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<br /> SAN JOAQUIN COUNTY
<br /> J
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 304 E Weber Avenue 3rd Floor Stockton•CA 95202-2708
<br /> (209)468-3420•Far:(209)464-0138 • Web:www.co.san-joaquin_ca.US/ehd
<br /> SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST
<br /> SITE LOCATION: �7vv L /.3-l-A S, PA#: 0;Z
<br /> REPORT DATE:
<br /> S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905-12
<br /> 1 - IasutTicient
<br /> S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION
<br /> F1 ❑ 1.1 Description of site(report must address all parcels),including current and/or proposed zoning information.
<br /> F1 ❑ 1.2 Description of proposed development.
<br /> 41 ❑ 1.3 Parcel location map. A*,,.,u, , A
<br /> El ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,wells,septic systems, large trees,
<br /> pastures,pools,natural drainage courses, ponds,waterways,etc.) :aF.ti, y ,'
<br /> 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION
<br /> El ❑ 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.) p�,Z_ _/f/
<br /> A17u4,,a, Y A A' C
<br /> 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION
<br /> ❑ 3A 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.)
<br /> R ❑ 3.2 Description of all past on-site potential and/or known above and bek)w 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,pondsAagoons,vehiclelmachine repair/painting, buried or
<br /> stockpiled solid waste,etc.) P -� 4,9 " ;
<br /> El ❑ 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 examples above). 12' -;�,) v,e if/-I,*-— ,sa-i s rc- *�
<br /> El3.4 Description of all past off-site potential 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 known DBCP/Nitrate groundwater impact,etc.) nP,,rev S
<br /> n ❑ 3.5 Description of all current off-site potential andlor known above and below ground sources of contamination
<br /> identified in the area of the project site./'S �� vis f Who c."" tj �
<br /> 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED
<br /> AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION
<br /> El ❑ 4.1 Evaluation of each potential and/or known source of contamination identified(n 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.
<br /> 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION
<br /> El
<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 soiltwater samples)and/or mitigative measures(Le.,dean up of
<br /> surface wastes). All recommendations for future work must include a time frame for implementation. p Y
<br /> ❑ F— V f r,,-i S{, fU,/ t�r.':ti��'r.+.v,rfv"ina r it/J 1- ,."A
<br /> 5.2 The report was inclusive(.e.all information referenced was induded in this report-report should not reference
<br /> other reports).
<br /> FRI ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional.
<br /> r ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application.
<br /> ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report.
<br /> Reviewed B Reviewed Date: � 11.161 -
<br /> Y: �
<br /> EHD 2602-001 Page I o f 2 Surface&Sub Checklist
<br /> 7/14,1003
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