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<: SAN JOAQUIN COUNTY EhViRONMENTAL HEALTH DEPART'V NT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Far:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: t 7 u G+ (4 ('S PA#: GG- 0,::) 3'2-7 SLi l t \ l�C-\ ��t REPORTDATE: _5Q } I Z.f,4 I = t�fflt ccimt San Joaquin County Development Title Chapter 9-905, Section 9-905.12 S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION 66 . W _L ® ❑ 1.1 Description of site(report must addr s all parcels), including current and/or pro sed zoning information. �t ((�� 1 2- 4, l y� ❑ 1.2 Description of proPLl;6t1 deZament. 1,[��J//,/AZ,,lrj ❑ ❑ 1.3 Parcel location meth ) 6� I ')OVA) A) ❑ 1.4 Site map showing I on of all items on parcel (Examples:strictures,drives,wells, septic systems, large trees: pastures, pools, natural drainage courses, Ponds, waterways,etc.) 4 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF 7HE 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). /sy 3 ��) 3.0 IDENTIFICA/ION 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.) fD $ 9 " ,) 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.) Me y lo .3 Description of all current on-site potehtial land/or known above qand below ground sources of contamination identified at the project site(see examples above). .9 t I 10 t 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: Gose proximity to a former landfill/former gasoline station, in area of known DBC21Nifr�te grc�undwater impact, etc.) Description of all current off-site potential and/or 1 ado/I and below ground sources of contamination j identified in the area of the project site. TG 61.1 . 4.0 EVALUATION OF PAST AND CURRELT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION on identified n the 4.1 Evaluation fathreaten and/or and the sourceown of cnmentln This evaluation 1should above intotconsideration ion)for any real and/or potentialt parcel. proposed future us o�a projgc nd 5.0 CONCLUSION ND RECOMMENDATIONS SECTION include real or potential threats identified. Recommendations may ❑ action to mitigate or abate any andlor mitigative measurei�? fol�n up of 5.1 DISCUCL of the above evaluation to either rule out each source as a real or potential threat or to dude e ® further a report should not reference recornm ndations for future work must include a time frame for imp additional site assessment(i.e.collection of soillwater samples) surface wastes). 7 0 11, 5.2 The report was i ve e.a I information for f referenced was included in this report- ❑ ed by a qualified environmental professional. other reports). ❑ 5.3 The report was sign dated and stamp useapplication' w4 prepared within six months of the date of the submittal°�Via' S made nP report. ❑ 'l 5.4 The rePoff to sup(>o f{ S attachme app contain suffident documentati. Reviewed Date: