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SAN JOAQUIN COUNTY IRONMENTAL HEALTH DEPARTiv.ENT 304 E Weber Avenue 3`d Floor Stockton • CA 95202-2708 (209)468-3420 •Fax:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST PA#: SITE LOCATION: —[� �'� Q'7'j REPORT DATE: S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 1 = Insufficient S I 1.0 INTRODUCTION $ PROPOSED DEVELOPMENT SECTION 9[ ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. J 1.2 Description of proposed development. ❑ 1.3 Parcel location map. 1.4 Site map showing location of all items on parcel. (Examples:structures, drives,wells, septic systems, large trees, pastures, pools, natural drainage courses, ponds,waterways, etc.) ra �s�~ saw a�•vra 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:curreWtd/ r previous property owners, historical maps, insurance maps, previous land use applications, etc.) yP* v4 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 survey,etc.) ❑ 3.2 Description of all past on-site potential and/or known above and below ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storage/use,aboveground/underground tanks, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste,etc.) ,1 ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination ! identified at the project site (see examples above). ❑ 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/fo r gasoline station, in area of known DBCP/Nitrate groundwaten impact, etc.) o4 ,�,,,,,.r 3.5 Description of all curre"n' off sife potential and/or known above and below ground sources o' contamRfOn"S' � identified in the area of the project site. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO 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 of surface w tes). All recommendations for future work must ilclude a ti lg frame for.implemen4Ption. •Sa'y�� .Y°�'i't�ra rua.7"9�„�A� v�r�, ��..,�"'"/'�" t9 '�?./ �/a'..w'iir/ MLI- ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report—repo 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 ss mo fhs bf the date of the submittal of the land use application. ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: Lisa Medina, Sr. R.E.H.S. Reviewed Date: 3/2104 I EHD 26-02-001 Pagel of 2 Surface&Sub Checklist