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4� `s SAN JOAQUIN COUNTY z ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)464-0138 Web:wwwsjgov.org/ehd ��FORr. SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST F ITE LOCATION: '.\\ ` ` o C PA#: 0 7 I ��'Vb N�2e��nw �I'�' L-S�OIi� REPORTDATE: = sufficient I Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 = S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ) ❑ 1.1 Des�nptioni�f site(report must address all parcels), including current and/or proposed zoning information. ( �} ❑ 1.2 Description of proposed developmerff�� ® ❑ 1.3 Parcel location 71 ❑ 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.) CA-1,�'1 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION 0- ❑ 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, et _) Ca L)3 ) A j,(, �f ) Av t—) 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: Dal a�search, EHD records searchpppagricultur 1 chemical application search, site reconnaissance and survey,et ��'j ) t, fj 6 $ 0 s ❑ 3.2 Description of all past on-site potential and/or known above and low ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks, septic systems,injection wells,unsled wells,ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste,etc.) ( ) ❑ 3.3 Description of all current on-sjteotential and/or k wn�ve and below ground sources of contamination identified at the project site(see examples above) �C ❑ 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,etc.) 66 ® ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination identified in the area of the project site. (r 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 and the environment. This evaluation should take into consideration the proposed future uses of the project parcel. l� 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTIONrt;7- 2L ❑ 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 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. ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. Jg_-_ ❑ 5.5 The attachments/appendic suffici mentation to support claims made in report. Reviewed B Reviewed Date: ERD 2601 Pa Surface&Sub checklist