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Ul SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3" Floor Stockton • CA 95202-2708 . P . (209)468-3420 • Fax:(209)464-0138 • Web:www.co.san-joaquin.ca.us/ehd ro SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION:�1 L1 `� �' y - \,k o,ii,4.J PA#: REPORT DATE: 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 zoning information. LoN'�'C. .u-) :mac �'-�. c� = GC—•cL� `.A / 6�,',e �7- 2.'�— P,(_1 - � ❑ 1.2 Description of proposed development. 5 U�_8 CID �-v ;,s Lo N�) sb Y R-L��-S / 0�,c.v`A Q,Q CA 9--iia" [�] ❑ 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.) - SNI ,�— �.' .w �-"c °a F w`�c c:�`^ t`' r"r ' 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION I ❑ 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.) [e�] ❑ 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.) ❑ 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. EHD 26-02-001 Page I of 2 Surface&Sub Checklist 7/14/2003