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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95202-3029 e '* Telephone:(209) ( � :www.sjgov.org/ehd 468-3420 Fax: 209 468-0333 Webov.org/ehd q Cl FSO R?% SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST A� q q PA#: SITE LOCATION: �35G3 S /Ytri�1'+�C4�� ?�cc� / � REPORT DATE: = Sufficient 1 = Insufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I 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. fz F-11.2 Description of proposed development.Z E] ❑ 1.3 Parcel location map. Aj, ® ❑ 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.) 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.) 2— 3 m5— 7 8 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.) e, �J ❑ 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.) r v❑ ❑ 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). 0—/,> ❑ 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 DBC Nitrate groundwater impact, etc.) [� ❑ 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. 8_/D 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. o _�U 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 wastes). All recommendations for future work must include a time frame for implementation. qp // ❑ 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. "r' ❑ 5.4 The report was prepared within six months of 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: Keviewect vate: _o zy ei�zv m Page 1 of 2 surface&sub Checklist