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SAN JOAQUIN COUNTY 2 '2 ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, 95205 qP • (209)468-3420 - Fax:(209)464-0138 - Web:www.sjgov.ora/ehd ��FORN SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 14953 EAST TOKAY COLONY ROAD, LODI SR0082252 REPORT DATE: 06-10-2020 S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION 1.1 Description of site (report must address all parcels), including current and/or proposed N ❑ zoning information. • Split to two equal parcels, • two existing houses, each has own well and septic system ® ❑ 1.2 Description of proposed development. • Zone reclassification to limited agriculture 5 acre minimum ® ❑ 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.) • Residence and grazing land for last 10 years 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). • Leaky underground storage tank 5000 away, case closed. ® ❑ 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.) ® ❑ 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 EHD 26-02-001 Page I of 2 Surface&Sub Checklist 7/14/2003