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SAN JOAQUIN COUNTY lot ENVIRONMENTAL HEALTH DEPARTMENT 600 Fast Main Street, Stockton, CA 95202-3029 Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: �[� • I /a/ `� V PA#: N '�� c'✓_, vl :. REPORT DATE: S = u icm Ins = InsutTicirnt San Joaquin County Development Title Chapter 9-905,Section 9-905.12 S I 1.0 INTRODUCTION $ PROPOSED DEVELOPMENT SECTION M ❑ 1.1 Descriptio1 n 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. , ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures, drives,wells,septic systems, large trees, pastures, pools, natural drai2age courses, ponds, waterways, etc.) 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION fil ❑ 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.) L 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.) __ M ❑ 3.2 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, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) -1,_ 7 ® ❑ 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). 7, 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: Close proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) J9 ® ❑ 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. -7 - ) 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. 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 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. ® ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: c 1 s a - Reviewed Date: ERD26-m Pagel oft — S.K.&s.ncho,k1W