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SAN JOAQUIN COUNTY = ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax: (209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: lg500 / f PA#:REPORT DATE: S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ® ❑ 1.1 Description of site (report must address all parcels), including current and/or proposed zoning information. ® ❑ 1.2 Description of proposed development. ❑ 1.3 Parcel loco'on map. 11� [] 1.4 Site map m cation of all items on parcel. (Examples:structures, drives,wells, septic systems, large trees, pastures, pool , natur I drainage inage courses, ponds,waterways, etc.) 2.0 PAST, PRE ENT 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.) 3.0 IDENTIFICATION OF ALJ_ PAST AND C RRENT SOUS FgONNTAMINATION [ ❑ 3.1 Discussions bf the met>lods used to researc`fi` nd'' vesti•6te the potentia or known above and belowground i sources of contamination at the project site. ( xamples: Database search, EHD records search, agricultural 1 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 I 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.) ❑ 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/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) FIVI ❑ 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. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR �THE �SITE AND RECOMMENDATIONS FOR FURTHER ACTION ®` ❑ 4.1 Evaluation-66f_ valuation of-_4ach po'fential ander/o 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 CONCLU I�O�NS� rD� ECOMMEPATIONS SE TION5.1 Discussion tf he ab.W-e�Cialu�a�or,to ei a ut 4M source asa 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. 4 ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The attachments/a nd• contain sufficient documentation to support claims made in report. Reviewed ByAd//��544t-�JrZ _ -- � Reviewed Date: IOL,-'l EHD 26-01 Page 1 ofSurface Surface&Sub Checklisl —� 11. ,