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SAN JOAQUIN COUNTY I ? ENVl ,U.AMENTAL HEALTH DEPARTMETn' 304 E Weber Avenue 3rd Floor Stockton - CA 95202-2708 (209)468-3420 - Fax:(209)464-0138 - Web:www,co.san joaquin.ca.us/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST PA: 04-301 (MS) SITE LOCATION: 23800 N.JACKTONE RD., ACAMpO, CA REPORT DATE: MAY, 2004 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. ® ❑ 123 - Parcel location map. ❑ ® 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.)- 3 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION El ®�.V 2.1--Discussion of past, preset acid 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.) I 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION r _ ❑ ® '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.) ❑ '�®_ '12 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, abovegroundlunderground tanks, septic systems, injection wells,unsealed wells, ponds/lagoons, vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) ❑ <®� 13.3 Description of all curFent on-site potential and/or known above and below ground sources of contamination identified at the project site (see examples above). ❑ 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 landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) ❑ Z— -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 1 ❑ 4.1 Evaluation of each potential and/or known source of contamination identified (in the above section)for any real t 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 ❑ ® 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. ® ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: Lisa Medina Sr. R.E.H.S. Reviewed Date: 7/12/2004 EHD 26-02-001 Page 1 of 2 Surface&Sub Checklist