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U SAN JOAQUIN COUNTY s ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd � o � SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST 1� �. � PAM `3 - oo til l /"Ise l SITE LOCATION: (�`1� 6 5 5c REPORT DATE: $ S = SuffiInsufficent ient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION [5 ❑ 1.1 Descriptio of site (report must address all parcels),including current and/or proposed zoning information. ❑ 1.2 Description f proposed development. ❑ 1.3 Parcel location map. a ❑ 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.) ,A t _- _ f,� 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION M ❑ 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.) 2 _6 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.) 2 -C ]- ❑ 3.2 Description ofas - potential and/or known above and below ground sources of contamination identified at the projects es: Agricultural chemical handling/storage/use,abovegroundlunderground tanks, septic systems,injection wells, unsealed wells, pondsllagoons, vehicle/machine repair/painting,buried or stockpiled solid waste etc.) 7- E] ❑ 3.3 Description of a current on-s a potentia and/or known above and below ground sources of contamination identified at the see examples above). 7 [� ❑ 3.4 Description of 6ast aff- tential and/or known above and below ground sources of contamination identified in the area of the a sl a 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.) ❑ 3.5 Description of current off-s'a potential and/or known above and below ground sources of contamination identified in the are act 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 andlor 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. 9 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 recommndations for future work must include a time frame for implementation. ❑ 5.2 The report was inclusive (i.e�ll 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. [E�- ❑ 5.5 The attach apper s contain sufficient documentation to supPort claims made in report. Reviewed By: viewed Date: �7 EHD 2&01 Page 1 of 2 Stat'ace&Sub Checklist