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state of California-California I onm ntat Protection Agency Departi of Toxic substances Control <br /> TIERED PERMITTING PHASE I ENVIRONMENTAL ASSESSMENT CHECKLIST <br /> SECTION III: FACILITY IIISTORY <br /> Instructions: Complete this section regarding facility history based on reasonably available knowledge of the <br /> facility. This section will determine past operating practices and significant historical events that occurred at the <br /> facility that may indicate areas of contamination. Employees or retired employees who know about the facility's <br /> past operating practices can be an asset in completing this section of the checklist. <br /> YES NO <br /> 1. Has an environmental assessment and/or a site investigation report ever been completed <br /> for the facility? If YES, list the date and name of the report, and agencies receiving the YES <br /> report. Include a copy of the reports not submitted to the Department. <br /> 03/23/93: SITE ASSESSMENT BY ALEX SCHEFLO P.E. <br /> S.J.C. ENVIRONMENTAL HEALTH <br /> -D 15C <br /> 2. Do you know if the facility has ever been flooded due to natural or man made causes? NO <br /> 3. Do you know if the facility has ever been damaged by an earthquake that could cause <br /> contamination? NO <br /> 4. Do you know if the location for the facility was used for industrial purposes prior to use <br /> as a hazardous waste facility? If YES, then indicate the type of industry that the location NO <br /> was used for (i.e. warehouse, food processing etc.). <br /> 5. Do you know of past incidents of spilling, pouring, emptying, pumping, discharging, <br /> leaching, dumping, injecting, burying, detonating, or disposing of hazardous chemicals or <br /> hazardous wastes at the facility? If YES, these areas should be evaluated by the facility <br /> owner/operator and addressed in the FACILITY WALK-THROUGH INSPECTION NO <br /> section. <br /> 6. Do you know if the facility has ever had electrical transformers, capacitors, or hydraulic <br /> equipment, including but not limited to elevators and auto lifts, at the facility? If YES, YES <br /> these areas should be evaluated by the facility owner/operator and addressed in the <br /> FACILITY WALK-THROUGH-INSPECTION section. <br /> If YES, was the equipment ever tested for the presence of PCBs? Vc-5 <br /> 7. Do you know if there have ever been groundwater wells installed at the facility? NO <br /> If YES, <br /> a) State the average ground water depth for the upper most aquifer: feet below - โ€” <br /> surface grade. <br /> b) Have the wells ever been tested for possible contamination. If YES, attach the latest <br /> copy of any sampling or monitoring reports <br /> Please indicate total number of pages: Page 4 ofโ€” <br /> DISC 1151 (6/94) WORKSHOP DRAFT 9 <br />