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pq iv SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, 3`I Floor, Stockton, CA 95202-2708 Telephone:(209)468-3420 Fax:(209)464-0138 Web:wwwsjgov.org/ehd FORK SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: a�]a7a . L �rcc_`Zi A.� �Se.(�v� 553ZSJ Pp'#• — DOS— ,$ tils� REPORT DATE: = 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 epoort- rp}st addle all 1paarcels ,,i 3�ding current and/or proposed zoning information. ® ❑ 1.2 Description of propos dOvCelJQpmen1./ ® ❑ 1.3 Parcel location map.�2 ® ❑ 1.4 Site map showing loc n of all items on parcel. (Examples:structures, drives,wells, septic systems, large trees, pastures, pools, natural drainage courses, ponds,waterways, et A) 2.0 PAST, PRESENT AND PROPOSED FUTURE USES O HE 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 pre vioi property owners, Istoric I maps, insurance maps, previous land use applications, etcX P_!— m �r G�e&< 3.0 IDENTIFICAT\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, EHR record search, gricultural chemical application search, site reconnaissance and survey, etc.)/,q-� / C4identip( *„p) F] urce 3.2 Description of all past on-site potential and/or known above and below groundlSas o contamination fied at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks, septic systems, injection well unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) F-13.3 Description of all current on- . potential and/or known above and below ground sources of contamination identified at the project site(see examples above( -8)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.) ( COF-13.5 Description of all current off-site potential an or known above and below ground sources o contamination identified in the area of the project site. *c1) 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION [a ❑ 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 c ME environment. This evaluation should take into consideration the proposed future uses of the project parcel. 5.0 CONCLUSIONS AND RECOMATIONS SECTION ® ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend / y-,further action to mitigate or abate any real or potential threats identified. Recommendations may include 6'i /additional site assessment(i.e. collection of soil/water samples)and/or mitigative measures(i.e., cleprn up of surface wastes). All recommendations for future work must include a time frame for implementation ,to ®- ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report-report should not reference other reports). ❑ 5.3 The report was signed, dated and stamped by a qualified environmental profession>;I. �/1,2 ®- ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. JZ ❑ 5.5 The attachments/andice .contain sufficient documentation to support claims made in report. Reviewed Byl_ � ae> Reviewed Date: � R2 EHn 26-01 Page I of 2 Surfc.&Sub Checklist /