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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT lot >j 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: l PA#: // - co y2o�.r.l l REPORT DATE: J 3 ao 11 0 S = Su$icimt San Joaquin County Development Title Chapter 9-905,Section 9-905.12 t = Insunicimt 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 Descriptio of proposed development. EL ❑ 1.3 ParJ location map. A(,(, 0 ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,wells, septic systems,large trees, pastures, pools, natural drainagecourses, ponds,waterways,etc.) ra 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION 10 ❑ 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.) 7� 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.) H ❑ 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, pondstlagoons, vehide/machine repair/painting, buried or stockpiled solid waste,etc.) zj o[� ❑ 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). [ ❑ 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: Gose proximity to a former landfill/former gasoline station, in area of knowr DFP/Nitrate groundwater impact,etc.) FC] F] 3.5 3.5 Description of all current off-site potential aoriknown above and below ground sources of contamination identified in the area of the project site. G 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. b 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 as included in this report—report should not reference other reports). ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. d] ❑ 5.4 The report was f epared 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: 8 i EHD 26-01 Pagel of 2 Surface&Sub Checklist