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T OP N C :.z; •.� SAN JOAQUIN COUNTY 'II ENVIRONMENTAL HEALTH DEPARTMENT 1 �l 304 E Weber Avenue 3' Floor Stockton • CA 95202-2708 \c P/ (209) 468-3420 • Fmv: (209) 464-0138 • Web: www.co.san-joaquin.ca.us/ehd �9 �./FpR/ SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST G PA #: SITE LOCATION: , 5 (Q ter- J M y1"L REPORT DATE: A2_0Zd S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 1 = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION Q pN. J\ °oma 6 (o - �- ❑ ❑ 1.1 Description of site (report must address all parcels), including current and/or proposed zoning information. ��_ '1L0 ❑ ❑ 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.) poN�t�cti� '"(i'O-t 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.) LQSS b1; • Pry VM 6A& 4�AWS DWNPNP1F -1 two aVF -& f -D ,DP- 13 6060q F-]❑ 3.2 Description of all past on- ite potential and/or known above and below ground sources of contamination ld ntified 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.) 2 S S �e �� 6P+• �./� Q �-�Gb � Q� PSS � � E..P O Q..T S A`�� T� R- SA s_Z� `-�- o rr V oA ❑ ❑ 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). R�pr.gNp oI.-LVA. \�-Q . EHD 26-02-001 Page 1 of 2 Surface & Sub Checklist 7/14/2003