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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Avenue 3" Floor Stockton • CA 95202-2708 <br />(209) 468-3420 • Fax: (209) 464-0138 •Web: www.co.san-joaquin.ca.us/ehd <br />�FOR <br />SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST <br />SITE LOCATION: PA #: L` 00 1— S _j n <br />�• 1� �N� \W�� t ���� REPORT DATE: <br />S = Sufficient <br />1 = Insufficient <br />San Joaquin County Development Title Chapter 9-905, Section 9-905.12 <br />S <br />I <br />1.0 <br />INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br />[/� ❑ <br />❑ <br />1.1 <br />Description of site (report must address all parcels), including current and/or proposed zoning information. <br />[/J <br />❑ <br />1.2 <br />Description of proposed development. <br />chemical application search, site reconnaissance and survey, etc.) <br />❑ <br />1.3 <br />Parcel location map. <br />❑ <br />1.4 <br />Site map showing location of all items on parcel. (Examples: structures, drives, wells, septic systems, large trees, <br />septic systems, injection wells, unsealed wells, ponds/lagoons, vehicle/machine repair/painting, buried or <br />pastures, pools, natural drainage courses, ponds, waterways, etc.) <br />2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION <br />[� ❑ 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 />EHD 26-02-001 Pagel o1`2 Surface & Sub Checklist <br />7/14/2003 <br />3.0 <br />IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION <br />[/� ❑ <br />3.1 <br />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 />[77� ❑ <br />3.2 <br />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 />Ed ❑ <br />3.3 <br />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 />[� ❑ <br />3.4 <br />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 />[]� ❑ <br />3.5 <br />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 />EHD 26-02-001 Pagel o1`2 Surface & Sub Checklist <br />7/14/2003 <br />