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oPgUIN\ SAN JOAQUIN COUNTY
<br /> .• C,
<br /> ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 1868 East Hazelton Avenue, Stockton, CA 95202-3029
<br /> Telephone:(209)468-3420 Fav:(209)468-0333 Web:www.sjoov.org/ehd
<br /> SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST
<br /> SITE LOCATION: 1 f40-v f /97Dl N, ,D+,SLk 12,4, tucKt ;,.*W
<br /> PAM Pf7-��jopl ZO
<br /> REPORT DATE: -1-13 - 11,
<br /> S = Sufficient
<br /> I = Insufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12
<br /> S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION
<br /> 13" ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information.
<br /> P'� 2 • 4G-g0
<br /> 3'_ ❑ 1.2 Descri ption oeproposed development.
<br /> [v]� ❑ 1.3 Parcel location map.
<br /> 15 ❑ 1.4 Site map showing location of all items on parcel. (Examples: structures, drives,well, septic systems, large trees,
<br /> pastures, pools, natural drainage courses, ponds, waterways, etc.)AI,,le-r1�„ z.
<br /> Re1'2^'W'k 1 4'41--
<br /> 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION
<br /> Ef ❑ 2.1 Discussion of past, present and proposed future uses at the site to assp§s potential problems. (Example sources
<br /> of information: current and/or previous property owners, historical maps, Insurance maps, previous land use
<br /> applications, etc.)
<br /> 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION
<br /> ❑ ❑ 3.1 Discussions of the methods used to research and investigate the potential or known.bove and belowground'6 1_7
<br /> sources of contamination at the project site. (Examples: Database search, EHD records search, agricultural
<br /> chemical,a�pl�Nvon se rch�I�ted4e�pnn�aiss �ce and surveys etc)
<br /> E� ❑ 3.2 Description of all past on-site potential and/or known above and below 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, ponds/lagoons,vehicle/machine repair/painting, buried or
<br /> stockpiled solid waste, etc.) '� o
<br /> [1 ❑ 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). j-i O
<br /> P] ❑ 3.4 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.) . z,'' 1171
<br /> E� ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination
<br /> identified in the area of the project site.
<br /> 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED
<br /> AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION
<br /> [✓� ❑ 4.1 Evaluation of each potential and/or known source of contamination identified (in 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. 7,',✓SI
<br /> 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION
<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 soil/water samples)and/or mitigative measures (i.e., clean up of
<br /> surface wastes). All recommendations for future work must include a time frame for implementation.
<br /> Ful ❑ 5.2 The report was inclusive(i.e. all information referenced was included in this report—report should not reference
<br /> other reports).
<br /> EA ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional.
<br /> ❑ ❑ 5.4 The report was pr pare +.hs�o1f the date of the s bmittal of,the land use application.
<br /> L US _ 'Ippl,C k f'C- hd within six months
<br /> c,.:i,yi1' ¢f Pr� r. . :I• I f;../,
<br /> [� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report.
<br /> Reviewed By: Oct eK, Akr, tel Reviewed Date:
<br /> EHD 26-01 Page I of 2 Surface&Sub Checklist
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