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�� COUNTY ~.O0NTY ENv IRONMENTAL HEALTH DEPARTMENT ANA / m 3O4l�l�eber��veouc3 FboorB0ocktoo ^ CA95202-2700 (2O9)468'342O^Fax:(2O0)464'0l38 ^ xyeb/vmnnv.co.ouo-jougubu.cu.vo/ebd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST u ~ oufoc/ont I ~ Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 S D 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION �� �� 11 D000riptionofoihe(nepo�mua�addneaao||pame|a) ino|udingourmntand/orpmp000dzoninginformation �� . . 12 Description ofproposed development. E] 1.3 Parcel location map. 1�4 Site map showing location of all items on parcel. (Examples:structures, drives,wo||o.septic systems, large trees, ^ ' pastures, pools, naturaldrainage dwaterways, etc.) . ^' 2.0 PAST, PRESENT AND PROPOiE'D FUTURE USES OF THE SITE SECTION 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 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,nto.) f� �� 3.2 DuoohptionofoUpast on-site potonda|and/or known above and below gmundsources ofoontsminadonidondfied�� a1the project site. (Examples: Agricultural chemical hand|ing/o0onage/uao.abovagmund/undonground tanks, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) Fj F� 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination identified otthe project site (see examples obove). F_� 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified inthe area ofthe project site that has ormay impact the project site. (Examples: Close proximity 0oaformer landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) [l �� 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination identified inthe area ofthe project site. 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMUNATUO IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION 7 F-1 4.1 Evaluation of each potential and/or known source of contamination identified (in the above section)for any real and/or potential threat tohuman health and the environment. This evaluation should take into consideration the proposed future uses ofthe project parcel. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION F� F-1 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend further action tomitigate orabate any real orpotential 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. F� F� 5.2 The report was inclusive(i.e.all information referenced was included in this report-report should not reference other reports). F� F-1 5.3 The report was signed, dated and stamped by a qualified environmental professional. �� F-1 5.4 The report was prepared within six months of the date of the submittal of the land use application. 5.5 The attach ments/appendices contain sufficient documentation to support claims made in report. Reviewed Lisa Medina, Reviewed Date: ell auom-0z-0n/ Pugelnf2 Surface aSub checuist