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{ 'oaa u yni� 2 �G2 SAN JOAQUIN COUNTY y ; ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 `�R aha Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST ESITEOCATION: PA#: AX —a a �1_7 (M r) / REPORTDATE: a+2� � ' s = sufciTt 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 development. ❑ 1.3 Parcel location map.r Q s ®. ❑ 1.4 Site map showing location of all Mems on parcel. (Examples:structures,drives,wells, septic systems,large trees, pastures, pools, natural drainage ooyrses,ponds, waterways, etc.)'� 2.0 PAST, PRESENT AND OlkOED FUTURE USES OF THE SITE SECTION l� ❑ 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 R ❑ 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.) y_0, 1 ❑ 3.2 Description of all past onsite potential and/or known above and below ground sources of contamination identified ] at the project site. (Examples: Agricultural chemical handling/storageluse, aboveground/underground tanks, I septic systems,injection wells, unsealed wells, ponds/lagoons,vehiclelmachine repairlpairding, buried or stockpiled solid waste,etc.) 5-11 ® ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination � -tl identified at the project site(see examples above). I ® ❑ 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 landfllllformer gasoline station, in area of known DBCPINitrate groundwater impact, etc.) 0—Ir ® ❑ 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. a --11 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. 0 -11 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(Le.collection of soil/water samples)and/or mitigative measures(i.e.,clean up of surface wastes). All recomm_end4tions 5o}future work must include a time frame for implementation. ❑ 5.2 The report was inclusive(i.e.all infodnation 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. [� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: eviewed Date: EW 26-01 Pagel of 2 renin Surface&Sub Checklist