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SAN JOAQUIN COUNTY •.i ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3"d Floor Stockton • CA 95202-2708 (209)468-3420•Fmv:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 15709 Trethway Road Lodi, CAPA#: 03-244 REPORT DATE: 5/1/2003 J S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION El ✓� 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. 1-1 7 1.2 Description of proposed development. ✓❑ F1 1.3 Parcel location map. El 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.) 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION El ✓❑ 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 ✓❑ F-1 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.) 3.2 Description 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.) 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). ✓� 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 DBCP/Nitrate groundwater impact, etc.) ❑✓ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination identified in the area of the project site. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION contamination fied n the above section)for any real 4.1 Eva/or otent al threat totial humann/or health and he envknown source ironment. This evalulation(should take into consideration the and/or p proposed future uses of the project parcel. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION El 5.1 Discussion of?oh?nibOate or abatle any rreal orrule potential th eats ident fied. Recommepotential ndationsthreat may include further actio 9 additional site assessment(i.e. collection of soil/water samples)and/or mitigative measures(i.e.,clean up o surface wastes). All recommendations for future work must include a time frame for implementation. El5.2 The report was inclusive(i.e. all information referenced was included in this report—report should not reference other reports)- El ✓Z 5.3 The report was signed, dated and stamped by a qualified environmental professional. Z0 5.4 The report was prepared within six months of the date of the submittal of the land use application. 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. R1 0 Reviewed By: Lisa Medina, Sr, REHS Reviewed Date: 7/9/2003 Page 1 of 2 Surface&Sub Checklist EHD 2602-001 � 7/14 2003