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u � SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95202-3029 <br />• a . Telephone: (209) 468-3420 Far: (209) 468-0333 Web: www.sjgov.org/ehd <br />SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST <br />/ PAM Z14)01A3LMS� <br />SITE LOCATION: 16A039) • bClT�. �✓� %ccc <br />REPORT DATE: y�2 9� 207 <br />= Sufficient <br />I =Insufficient <br />San Joaquin County Development Title Chapter 9-905, Section 9-905.12 <br />S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br />[� ❑ 1.1 Description of site (report must address all parcels), including current and/or proposed zoning information. <br />❑ 1.2 Description of proposed development. <br />[� ❑ 1.3 Parcel location map. <br />[� ❑ 1.4 Site map showing location of all items on parcel. (Examples: structures, drives, wells, septic systems, large trees, <br />pastures, pools, natural drainage courses, ponds, waterways, etc.) <br />2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION <br />[v� ❑ 2.1 Discussion of past, present and proposed future uses at the site to assess 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 above and belowground <br />sources of contamination at the project site. (Examples: Database search, EHD records search, agricultural <br />chemical application search, site reconnaissance and survey, etc.) <br />[+� ❑ 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.) <br />Q ❑ 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). <br />1+ ❑ 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.) <br />[� ❑ 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. <br />5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION <br />Q ❑ 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 />[v]A ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report — report should not reference <br />other reports). <br />d ❑ <br />Pl ❑ <br />ff ❑ <br />EHD 26-01 <br />5.3 The report was signed, dated and stamped by a qualified environmental professional. <br />5.4 The report was prepared within six months of the date of the submittal of the land use application. <br />5.5 The attachments/appendices contain sufficient documentation to support claims made in report. <br />Reviewed By: <br />Page I of 2 <br />Reviewed Date: 7-'06-?,0Zf <br />Surface & Sub Checklist <br />