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�Pq� N. SAN JOA UIN COUNTY '��.caG Q lENVIRONMENTAL HEALTH DEPARTMENT I 304 E Weber Avenue 3rd Floor Stockton • CA 95202-2708 cP.. (209)468-3420 • Far:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd ��1FOR� SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: L/,1 7 /V - A-le-4-5 4,•e o-1C PA#: IgCe-Z7,3 REPORT DATE: = Sufficient I Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 = S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ® ❑ 1.1 Description of site (report must addr ss all arcels), including current and/or proposed zoning information. ® ❑ 1.2 Description of proposed development. ® ❑ 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.) 2.0 PAST, PRESENT AND PROPOSED 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, 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.) -- N ❑ 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 ® ❑ 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 ® ❑ 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 .— Z ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report—report should not reference other reports).,-- N eports).✓® ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. i ® ❑ 5.4 The report s prepared within six mon hs of the date/9f the submr�littal of the land use application. Afil� c01'h� rd- Ace,—C - r6t /2 —IC—"'/, ® ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: l�a}rsw �l+,ti_�� Reviewed Date: EHD 26-02-001 Pagel of2 Surface&Sub Checklist