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SAN JOAQUIN COUNTY � ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 ,�...;.. F Telephone:(209)468-3420 Fac:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST i SITE LOCATION: � �3 S /�Sr REPORT DATE: S = Insufficient Sufficient I = Insufficient 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. ® r�l❑ 1.2 Descri ron of proposed development. El 1.3 Parcel Cation map. ❑ 1.4 Site map showing location of all liitems on 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.) Q&f 12 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 a plication search, site reconnaissance and survey,etc.) (. E] 3.2 DescriptionWal?past on-site potential and/or known above and below ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storageluse, abovegroundlunderground tanks, septic systems, injection wells, unsealed wells, pondstlagoons,vehiclelmachine repair/painting, buried or stockpiled solid waste,etc.) X73 ® ❑ 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). Q ❑ 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.) ❑ 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. I 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. 5.0 CONCLUAONS 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. E. ❑ 5.2 The report wastclusive(i.e.all information referenced was included in this report—report should not reference other reports). I a ❑ 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: Reviewed Date: _zzi Erin zb-ot Page I of surface&sub Checklist