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SAN JOAQUIN COUNTY z_ ENVIRONMENTAL HEALTH DEPARTMENT rQ: •' 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 3.2 5 LI S_ IC E-Y �� RE (t - o o Z.'3�( (e"C) REPORT RT DATE: llcG 12\ Zm�1 S = iciem Insu = Insufficirnt San Joaquin County Development Title Chapter 9-905,Section 9-905.12 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. 2-- 1.3 1.3 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.)4 r 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 2, / r,1 c.7]b)7 09(f Z )y� /-/ 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.) 1 t 4,'l )5 6 � ❑ 3.2 Description of alt'past on-site potential and/or known above and below ground sources of contamination identified at the project sit&-(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 tc.) 7) ❑` ❑ 3.3 Description of all curre on-site potential and/or known above and below ground sources of contamination identified at the pr ' site(see examples above). 7 2 [,q ❑ 3.4 Description of al a off-site potential and/or known above and below ground sources of contamination identified in the area of the oject s fe 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.) 7 g ❑ 3.5 Description of ajYcurrenoff-site potential and/or known above and below ground sources of contamination identified in the arehe project site. 7 b 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION I� ❑ 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 parce`7 S 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). g] ❑ 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: eviewed Date: R 3 Y EHD 2"1 Page 1 ofSurface&Sub Checklist