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SAN JOAQUIN COUNTY EN'IRONMENTAL HEALTH DEPARTN-.�NT '` 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 SITE LOCATION: PA#: C)-,,- G0181 /� �b�i s. L�'�c � �� > /�� !/ 1/ y REPORT DATE: // - / I ,(�•�%� S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 1 = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description of site port�ust address all parcels), including current and/or proposed zoning information. ecipti [9 ❑ 1.2 Dron of propor(d development. ® ❑ 1.3 Parcel location map.(44h- Ff ❑ 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 2.0 PAST, PRESENT AND 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. /U� 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION FI ❑ 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 C plica)tio �, site reconnaissance and survey, etc.) V] F13.2 Descripti �t on-sl((te 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.) �j7gy ❑ ❑ 3.3 Description of all current on-site p ntial and/or known above and below ground sources of contamination identified at the project site(she examples above). ❑ ❑ 3.4 Description of all past off-siteWential 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 gasol• a station, in area of known DBCP/Nitrate groundwater impact, etc.) ® ❑ 3.5 Description of all cuW off-site potential and/or known above and below ground sources of contamination identified in the area, of t ie project site. 4.0 EVALUATION Q/F_�PlIA1IST 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 he project parcel. 5 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). PtH r5e5,c$Tmendations for future work must include a time frame for implementation. ® F-15.2 The report was incake(.e. all information referenced was included in this report-report should not reference other reports). ;f ,1 J�1 � ❑ 5.3 Th�repo as signed, dated and stamped by a qualified environmental professional. ❑ 5.4 The r ortvlyly prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The a ments/appe'ndices contain sufficient documentation to support claims made in report. Reviewed By: /� l'�Iio vu S • - Reviewed Date: _.... _ - EHD 26-01 Pagel of 2 Surface&Sub Checklist -1-1