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> °4- SAN JOAQUIN COUNTY I `j ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3"Floor Stockton-CA 95202-2708 (209)468-3420• Far:(209)464-0138 • IVeb:www.co.saia-joaquin_ca.Us/chd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST FsrTE Locnnor+: c c; J f �,y �� P F �� PA#: Co�-o a e s-S- f=f' REPORT DATE: S-//y o� S - Imufficient ic 1 � InsuSan Joaquin County Development Title Chapter 9-905,Section 9-905.12 _ e S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION EA ❑ 1.1 De�,scription of site(report must address all parcels),including current and/or proposed zoning information. Z P L ❑ 1.2 Description of proposed development �5 y ❑ 1.3 Parcel location map. Aper/ A ❑ 1.4 Site map stowing location of all items on parcel. (Examples:structures,drives,wells,septic systems, large trees, pastures, pools,natural drainage courses,ponds,waterways, etc.) lhl'x"a,x 14- 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.)'6;�l 2 _//Y 3 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 chenucal application search,site reconnaissance and survey,etc.) /-� 3 El ❑ 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 harldlingfstorage/use,aboveground/underground tanks, septic systems,injection wells,unsealed wells,pondsliagoons,vehicle machine repair/painting,buried or stockpiled solid waste,etc.) V r' ❑ 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).,,r�'y f ,," © ❑ 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 IandfiWformer gasoline station,in area of known DBCP/Nitrate groundwater impact,etc.) ,0V s- ❑ ❑ 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 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 ,t ❑ 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 soillwater samples)and/or mitigative measures(i.e.,dean up of surface wastes). All recommendations for future work must include a time frame for implementation. ❑ 5.2 The report was inclusive(.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. ❑ ❑ 5.5 The attachmentsiappendices contain sufficient documentation to support claims made in report. Reviewed By: /� — Reviewed Date: 26 EHD 7602-001 Page I of 2 surfxe&sub Cn«test 7114-%13