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f SAN JOA UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT �.. j.. ' ,..- `. 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax.(209)464-0138 Web:www.Sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST q C, r� PA#: j — o27D Lt *g) SITELOCATION: 1 ! ��) S) aI L) - ��/( � REPORT DATE: 5 = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.92 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. [�] ❑ 9.2 Desbription of proposed development. ❑ 1.3 Par el/location map. ❑ ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,wells,septic systems,large trees, pastures, pools, natttyal d inage courses, ponds,waterways,etc.) 2.0 PAST, PRESENTAND PROPOSED FUTURE USES OF THE SITE SECTION t [ ❑ 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 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 chemiI application search,site reconnaissance and survey,etc.) ® ❑ 3.2 Descrion 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, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste,etc.) fy 2- 3.3 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). ,'I- 3.4 'I-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 D, �P/Nitrate groundwater impact,etc.) ® ❑ 3.5 Description of all current off-site potential andAnown above and below ground sources of contamination identified in the area of the project site. (�r '2 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 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. +6 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 recommendations for future work must include a time frame for implementation. y i ❑ ❑ 5.2 The report was incl&ive(i.e.'all information referenced was included in this report—report should not reference other reports). 3 ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional. a ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. i — ❑ 5.5 The attachments/appendices contain sufficient documentation-to-suppoft claims made in report. ReviewedBy:_ -Date: EHD 26-01 Page I of 2 Surface$Sub Checklist