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LAZ SAN JOAQUIN COUNTY SO r CpG" � a ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, P.Floor, Stockton, CA 95202-2708 I Telephone:(209)468-3420 Far:(209)464-0138 Web:www.sjgov.org/ehd `C!F ORa SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: /�(� /� /t��n � _I ��,-�.�f� REPORT DATE: 11pr J - 0-6 s = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I I = insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description of site (repRrt must address all parcels), including current and/or proposed zoning information. ®� ❑ 1.2 Description of proposed development. ❑ 1.3 Parcel location map. (�' ® � ❑ 1.4 Site map showing location of aH hems on parcel. (Examples: structure , drives welseptic systems, large trees, , pastures, pools, natural drainage courses, ponds,waterways, etc.} � 01/f/ 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION ❑ 2.1 Discussion of past, present and proposed future uses at the site to assess potential problems. (Example sources of information: current and/or previous property owner , historical maps, in urance maps, previous land use applications, et%A,�3„ .5) �/�,rrr�tna� 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION �� ❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural chemical application search, site reconnaissance and sury etc,15� , 1 .Z' ❑ 3.2 Description of all past on-site potential and/or known abov d below?r'ilouCr�d�!`ourcesof contamination identified . at the project site. (Examples: Agricultural chemical handling/storage/use, abovegroundlunderground tanks, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) �yl3� ❑ 3.3 Description of all current on-site potentind/or known above and below ground sources of contamination identified at the project site (see examples a--ove 1.�) [R/ ❑ 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified in the area of the project site that has or may impact the project site. (Examples: Close proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwa r imMo etc.) D� ❑ 3.5 Description of all current off-site potentiRREN2T d/or own above and belo g ouurces of contamination identified in the area of the project site.4.0 EVALUATION OF PAST AND SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION ❑ 4.1 Evaluation of each potential and/or known source of contamination identified (in the above section)for any real and/or potential threat to human health and the environment. This evaluation should take into consideration the proposed future uses of the project parcel. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e. collection of soil/water samples)and/or mitigative measures(i.e., clean up o surface wastes). All recommendations for future work must include a time frame for implementation. l!�—�� ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report—report should not reference other reports). / ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. rQ ❑ 5.5 The attachments/ en ' s contain sufficient documentation t claims made in report. Reviewed By: IX eviewed Date:7 �g EHD 26-01 Pagel of Z Surface&Sub Checklist