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SAN JOAQUIN COUNTY %v ENV*PKONMENTAL HEALTH DEPARTML-KT 304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST E�� ATION: REPORT DATE: S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 I = Insufficient 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.6pf ) [� ❑ 1.3 Parcel location map. 4,,,-13 [� ❑ 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.) P /� k.'") 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, histo cal maps, insurance maps, previous land use applications, etc.) 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.) ( r� 5 ) 6):7 ) (l�PJ�"^�x r -0)U F-] 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�'anseale�wells, ponds/lagoons, vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) C 1"� 1? ❑ 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). (_ �6 S ❑ 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.) (' d' t ❑ 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. < << r> 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 environrllent. This evaluation should take into consideration the proposed future uses of the project parcel. ( ,t s ) 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 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 l surface wastes). All recommendations for future work must include a time frame for implementation. Lft q 1 ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report-report should not reference other reports). /Ig ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. Ing ic) ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use applicatio [� ❑ 5.5 The attach ments/ap endices contain sufficient documentation to support claims made in report. Reviewed By:� �'^ Reviewed Date: EHD 26-01 Pagel of 2 Surface&Sub Checklist