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SAN JOAQUIN COUNTY N: ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone: (209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST PAM SITE LOCATION: �� 6ija,p (/q�,{ j7 A REPORT DATE: 4 S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 1 = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description of site(report must address all par els), including current and/or proposed zoning information. ®� ❑ 1.2 Description of proposed developmen 3� ®� ❑ 1.3 Parcel location map. 4141� �c ❑ 1.4 Site map showing location of all items on parcel. (Examples: structur drives,wells,septic systems, large trees, pastures, pools, natural drainage courses, ponds,waterways, etc.) A +-rte 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 owners, historical maps, insurance maps, previous land use applications, etc.) C) 3.0 IDENTIFICATIO OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION ,K]' ❑ 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 recor s search, agricultural J� chemical application search, site reconnaissance and survey, etc(j 11r5��17) e, y '4pb JE]/ ❑ 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 wellsyn sealed wells, ponds/lagoons, vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) ( ] ❑ 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 ab�6e�8� ®� ❑ 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 groundwater impact,et 4-",❑ 3.5 Description of all current off-site potential and/or known above and below BrDund sours�of contamination identified in the area of the project site. ! s.- B-) 4.0 EVALUATION OF PAST AND CURRENT 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 anal-the environment. This evaluation should take into consideration the proposed future uses of the project partnc�7-g 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION �, F-15.1 Discussion of the above evaluation to either rule out each source as a real o ntial 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 wastes). All recommendations for future work must include a time frame for implementation. ��- ❑ 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. 9 - ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. � ❑ 5.5 The attachments/ nd' s contain sufficient documentation to support claims made in report. Reviewed By: Reviewed Date: 7 �� EHD 26-01 Pagel of 2 Surface&Sub Checklist