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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTIWr NT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)464-0138 Web:v .sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 17,4151 /`�Shc �YH PA#: 'J6-OJ32 e 1 REPORT DATE: "*)Lf S = sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 I = Insufficient ' .dS, I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTI( CI. ❑ 1.1 Description of site(repprt must address all parcels), including current and/oPProposed zoning information. ® ❑ 1.2 Des�rip'onof developmerf ® ❑ 1.3 Parcel location map ® ❑ 1.4 Site map showing lova of�l son 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.) �, oa Y� , /' 3.0 IDENTIFICATION OF ALL II 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.) 0 ❑ 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, pondsllagoons, vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) (� r0 )1 ® ❑ 3.3 Description of all current on-site pote4al 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.) ) ) 13 (� F-13.5 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'; JI ? 1 Z- 13 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. �2 .�l)") l l� ))6 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 Q surface wastes). All recommendations for future work must include a time frame for implementation. ;,d j_-F U�y ® ❑ 5.2 The report was inclusive(i.e. all information referenced was included in this report—report should not referent U WI other reports). ® Ele report was signed, dated and stamped by a qualified environmental professional. - (A> ��J .BAF 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 documentatio to support claims made in report. Reviewed By - Reviewed Date:L 1/ EHD 26-01 Pagel of 2 Surface&Sub Checklist