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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM,-NT `z� ! 304 E Weber Avenue 3`d Floor Stockton CA 45202-2708 (204)468-3420.Fax:(209)464-0138 - Web:www.co.san-joaquin.cams/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: PA#: F � REPORT DATE: 5 - Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insuflicient 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 development. ❑ 1.3 Parcel location map. 1 - 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 J-�'[ / ❑ 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 i . applications, etc.) 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION cl .e'"�❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground F sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural chemical application search, site reconnaissance and survey,etc.) ['�- ❑ 32 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, f septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) ❑ 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). ca'� ^� ❑ 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. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED 7 AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION r� ❑ 4.1 Evaluation of each potential and/or known source of contamination identified(in the above section)for any real` Y and/or potential threat to human health and the environment. This evaluation should take into consideration the proposed future uses of the project parcel. i 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 F. further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e. collection of )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 was included in this report--report should not reference other reports). [ �❑ 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. J ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: Lisa Medina, Sr. R.E.H.S. Reviewed Date: E"12'1':11"-_ E}ID 26.02-003 Page 1 of 2 surface&sub checklist