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a°PQ moo, SAN JOAQUIN COUNTY <br /> x ENVIRONMENTAL HEALTH DEPARTMENT <br /> .. �.,. 600 E Main Street Stockton -CA 95202-3069 <br /> (209)468-3420 -Fay (209)464-0138- Web:www.co.san-joaquin.ca.us/ehd <br /> I.F_O R <br /> SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST <br /> PAM C�/��jr- <br /> SITE LOCATIOPI: �tya <br /> REPORT DATE: <br /> S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 <br /> I = Insufficient <br /> S I 11.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br /> @' ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. <br /> U2' ❑ 1.2 Description of proposed development. <br /> L2- ❑ 1.3 Parcel location map. <br /> ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,wells,septic systems,large trees, <br /> J pastures,pools, natural drainage courses, ponds, waterways,etc.) <br /> 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION <br /> (�" ❑ 2.1 Discussion of past,present and proposed future uses at the site to assess potential problems. (Example sources <br /> of information:current and/or previous property owners,historical maps, insurance maps,previous land use <br /> applications, etc.) <br /> 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION <br /> ❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground <br /> sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural <br /> chemical application search, site reconnaissance and survey,etc.) <br /> [— ❑ 3.2 Description of all past on-site potential and/or known above and below ground sources of contamination identified <br /> at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks, <br /> septic systems, injection wells, unsealed wells,pondstlagoons,vehiclelmachine repair/painting, buried or <br /> stockpiled solid waste,etc.) <br />' ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination <br /> identified at the project site(see examples above). <br /> a" ❑ 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified 1 <br /> in the area of the project site that has or may impact the project site. (Examples: Gose proximity to a former <br /> landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact,etc.) <br /> B— ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination <br /> identified in the area of the project site. <br /> 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED <br /> AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION <br /> ❑ 4.1 Evaluation of each potential and/or known source of contamination identified(in the above section)for any real <br /> and/or potential threat to human health and the environment. This evaluation should take into consideration the <br /> proposed future uses of the project parcel. <br /> 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION <br /> 0' ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend <br /> further action to mitigate or abate any real or potential threats identified. Recommendations may include <br /> additional site assessment(i.e. collection of soil/water samples)and/or mitigative measures(i.e.,clean up of <br /> surface wastes). All recommendations for future work must include a time frame for implementation. <br /> Er ❑ 5.2 The report was inclusive(i.e.all information referenced was included in this report—report should not reference <br /> other reports). <br /> By. ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional, <br /> ©y ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. <br /> L_.l ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. <br /> Reviewed By: Lisa Medina, Sr. R.E.H.S. Reviewed Date: <br /> EHD 26-02-001 Page 1 of 2 Surface&Sub Checklist <br /> 1!i F1'1M1M1'! <br />