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SAN JOAQUIN COUNTY EIYJIRONMENTAL HEALTH DEPARTNT 304 East Weber Avenue, 3r1 Floor, Stockton, CA 95202-2708 Telephone:(209)468-3420 Fax (209)464-0138 Web:wwwsjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: PA#: 104451- 44—� 4.1.1- REPORTDATE: Aj2-7 l j4 La S = Sufficient = Iffiuffx:im[ San Joaquin County Development Title Chapter 9-905, Section 9-905.12 S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 DepO�r of site(report must address all parcels), including current and/or proposed zoning information. �] ❑ 1.2 D ptio of proppsad development. [� ❑ 1.3 Parcello�at nJmaj�S�� ® ❑ 1.4 Site map showing lo,otion of all items on parcel. (Examples:structures,drives,wells,septic systems, large trees, past es, pools, natural drainage courses, ponds, waterways, etc.) 2.0 PAST PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION EL ❑ 2.1 Discussion of past, present and proposed future uses at the site to assess potential problems. (Example sources of information: curr t an previous property owners, historical maps, insurance maps, previous land use applications, etc. �JJ 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 s rcgg�, ''te :tZaN a9�and survey, etc.) ® ❑ 3.2 Description'l pas po ti a /Oinown 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,JJunseal wells, ponds/lagoons, vehiclelmachine repair/painting, buried or stockpiled solid waste, etc.) //r� 9� �, ❑ 3.3 Description of all current on-s potential and/or known above and below ground sources of contamination identified at the pr 'ectt�s1�a(see examples above). EX ❑ 3.4 Description of all t Difi 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 s I�t�in r kn° CP/ itrate groundwater impact, etc.) �J ❑ 3.5 Description of all cumen ff-sits and/or oewn above and below ground sources of contamination identified in the area of the project sit)a. 7) 4.0 EVALUATION OF PAST At 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 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 surfacewast )) All�r�/onyneWions for future work must include a time frame for implementation. E] 5.2 The report sFificlusife W. all information referenced was included in this report—report should not reference other reports). ❑ 5.3 The,Feport a g signed, dated and stamped by a qualified environmental professional. ❑ 5.4 The report wast prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The attachments contain sufficient documentation to support claims made in report. Reviewed By:,�� r Reviewed Date: EHD 26.01 Page I of 2 Sum&.Sub Cheddist