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T. � SAN JOAQUIN COUNTY <br /> z ENVIRONMENTAL HEALTH DEPARTMENT <br /> w.. 304 E Weber Avenue 3`d 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: ` ���b �� qo� �Q-®tit RCr.� �p . PA#: <br /> REPORT DATE: <br /> S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 <br /> I = Insufficient <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 /> L/J ❑ 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 /> ❑ 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.) �p ��,5��S� ���S NeF �(�'f (J P`���E• <br /> IWT. a- 1i0M - C(9MPL_n+'1VLF <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.) Q b �S (150' _-r'_0biT3�-" Ko')t G\%Q-1N4 <br /> - 'Q C-S_ SEdfr,LC r_ti��S <br /> �+ 7- q r r.✓/t r K- Gi e - <br /> E] 3.3 Description aT c 'Xirit on-Site pot�tial and/or(nown abol e Fid below'✓groundsources of contamination <br /> identified at theroject site(see examples above). r00 E3 Ajor D&V n�� <br /> A.&I' HA� u ldq&T'E , f4Ft2MA-1_1 wRbr-� TLS 5T6�Aa,�. <br /> [� �] 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 /> I C11 <br /> F <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 /> EHD 26-02-001 Page 1 of 2 Surface&Sub Checklist <br /> 7/14/2003 <br />