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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fa_r:(209)468-0333 Web:www.sjcov.org/ehd �ClFp'R t� SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: PAM /9,ZW6B' REPORT DATE: Z 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 (report must address all parcels), including current and/or proposed zoning information. P"�r- t , I+Dgr j"X A [� ❑ 1.2 Description of proposed development. Rr ❑ 1.3 Parcel location map. © ❑ 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.) -J 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION Q ❑ 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 0 ❑ 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 EHp recos search, rch, agricu ltural chemical applicationgearch site rezonnaf ss nce and surv /etc.)_ kr.1" � ,�A-eS /��3- [ ❑ 3.2 Description of all past on-site potential and/or known above and below groffnd 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.) �'p' ' ` `/ [n' ❑ 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). ,,• ; V [� ❑ 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/ itrate ground�tater impacts etc.)A/' ❑ ❑ 3.5 Description of all current off-site potential and/or known above and below grounq sources of ontamination identified in the area of the project site. , �i/S�w �i t�/��, e',y4Nw�►�� ' ''i R"'�` �"P 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION 0 ❑ 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. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION Q ❑ 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. [2 ❑ 5.2 The report was inclusive(i.e. all information referenced was included in this report—report should not reference other reports). M ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. R ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. F� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: 14tn- Reviewed Date: EHD 26-01 Page I of 2 Surface&Sub Checklist