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q�!H SAN JOAQUIN COUNTY �o co ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue,3 d Floor, Stockton,CA 95202-2708 P Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST /Y%1a t / /.- 07- 0 6 y SITE LOCATION: 53 REPORT DATE: S = 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. ❑ 1.2 Description of proposed develop m� .)& 3 ❑ 1.3 Parcel location map(V��-"J ® ❑ 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.) 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.) 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. r biv ,4) © ❑ 3.2 Description of all past on-site potential and/or known above and b w ground sources of contamination identified at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks, septic systems, injection wells, sealed wells, pondsBagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) /� Clw® 6> ® ❑ 3.3 Description of all current on-si Aential and/or known above and below ground sources of contamination identified at the project site (see examples above)./d„ C) (�r ® ❑ 3.4 Description of all past off-site potential and known a ove 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,et c.) G ❑ 3.5 Description of all current off-site potential and/or known above and below ground source of cont9 min tion identified in the area of the project site. ( &('C 4.0 EVALUATION OF PAST AND CURRENT SO RCES 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 ano the environment. This evaluation should take into consideration the proposed future uses of the project parc . C��V, f6 2-7) 3D 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 �pirfror'tS)for' plementation. ❑ 5.2 The report was inclusive (i.e. all information referenced was include in thi9rep4rtp ort should not reference other reports). tea __ ��//,, � 5.3 The report was signed, dated and�tampiad bj�a qual ped environmental professional. ,}�y ® 5.4 The report was prepared within sis of the date of the submittal of the land use application. Y7/471 "[AA ❑ 5.5 The attachments/ ppendices contain sufficient documentation to support claims made in report. QthRZA viewed By: ��. �- Reviewed Date: �' 9 EHD 6)Z 07 " � �j Page%l of 2 Surface&Sub Checklist V ',