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*-� c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue P Floor Stockton•CA 95202-2708 . �' '•: s t•;;� (209)468-3420•Far:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST nPA V: C? —mac U 163 SITE LOCATION: REPORT DATE: j ;Z S = Sufricicnt San Joaquin County Development Title Chapter 9-905,Section 9-905.12 1 Imufficient 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. ; \r ❑ 1.3 Parcel location map. �. { �� o ❑ 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.) 1 PFw` A,D 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE 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 previous property owners,historical maps•insurance maps, previous land use applications,etc.) , 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION ❑ ❑ 3.1 Digcussions 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.) tj 3 -y I '4&-t Y't- J) ❑ ❑ 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 handfing/storage/use,aboveground/underground tanks, septic systems,injection wells,unsealed wells, ponds/lagoons,vehiclelmachine repair/pai11 nting,buried or stockpiled solid waste,etc.)pcis4,LL li�wi f,Awl f`S, PV FX] ❑ 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). Yl� '/• ❑ ❑ 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.)py (/- V- 3.5 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. y y 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO 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. /!u 5-- 5.0 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 soiVwater samples)and/or mitigative measures C-e.,dean up of surface wastes). All recommendations for future work must indude a time frame for implementation./'y � L ❑ 5.2 The report was inclusive(.e.all information referenced was inducted in this report-report should not reference other reports). a ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional. ;-r 5.4 The report was prepared within six months of the date of the submittal of the land use application.Ad,'Ln L-r 1-1 © ❑ Sla%nM"bfrr/ 5.5 The attachments appendices contain sufficient documentation to support claims made in report- Reviewed Reviewed B =!� Reviewed Date: 1 y- LaLa EHD 26-02-001 Page I of 2 Surface&Sub Checklist 7/14,2003