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SAN JOAQUIN COUNTY <br /> ; . ENVIRONMENTAL HEALTH DEPARTMMT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> \C;_ Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd <br /> SURFACE AND SUBSURFACE /CONTAMINATION REPORT REQUIREMENT CHECKLIST <br /> SITE LOCATION: PA#: �%g C <br /> REPORT DATE: 2 r <br /> S = Sufficient <br /> 1 = Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 <br /> S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br /> 1Z ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. <br /> 4- <br /> F] ❑ 1.2 Description 9f pr9posed development. <br /> 3 <br /> F1 ❑ 1.3 Parcel locatiWA map. j ,> <br /> [ ❑ 1.4 Site map showing location of all items on parcel. (Examples: structures, drives,wells, septic systems, large trees, <br /> pastures, pools, natural drai age. ourses, 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 /> Jr <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.) t <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, ponds/lagoons, vehicle/machine repair/painting, buried or <br /> stockpiled solid waste, etc.) r` I <br /> F1 ❑ 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 re�x-'aWples above). <br /> [. ❑ 3.4 Description of all past off-site pol!ttf�tihl and/or known above and below ground sources of contamination identified <br /> in the area of the project site that has or may impact the project site. (Examples: Close proximity to a former <br /> landfill/former gasoline station, in area of knov1yn QSCR/Nitrate groundwater impact, etc.) <br /> fl ❑ 3.5 Description of all current off-site potentiad`/oti 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 CONTAMINATION 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. (�.I <br /> 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION <br /> [ ❑ 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 commendations for future work must include a time frame for implementation. <br /> qi:i ❑ 5.2 The report was iir !lusive(i.e. all information referenced was included in this report–report should not reference <br /> other reports).7 <br /> El ❑ 5.3 The r p%"s signed, dated and stamped by a qualified environmental professional. <br /> �— ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. <br /> ❑ 5.5 The attechments/ en Ices contain sufficient documentati to pport claims made in report. <br /> 11 <br /> Reviewed By: _ Reviewed Date:y <br /> EHD 26-01 Pagel of 2 ---- surface&sub Checklist <br />