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mt /x- '`� , SAN'JOAQUIN.COUNTY y ENVIRONMENTAL HEALTH DEPARTMENT 304 E Weber Avenue 3"Floor Stockton•CA 95202-2708 ': J1 .(209)448-3420•Far:(209)464-0138•Jreb:vrvw.co_san-joaquin.ca.us/ehd �Q SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT,CHEGKLIST SrTS LocAmON: L U S , 1 t' V� PA#: b b© Z ry z REPORT DATE: [� i S = Sufl"icirnt I - insufficient q County Development San Joaquin Coun Title Chapter 9-905,Section 9-905.12 S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ ® 1.1 Description of site(report must address all parcels),including current and/or.rwoposed zoning information / El 1.2 Description of proposed development Z P y3o /2Z AY&O ® ❑ 1.3 Parcel location map. P , 1 A Site ma � Elp showing location of all items on parcel. (Examples:Structures,drives,welts,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.) N z 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,EHO records search,agricultural chemical application search,site reconnaissance and survey,etc.) 0-t Z ❑ 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 handfing/storage/use,aboveground/underground tanks, septic systems,injection wells,unsealed wells,ponds/lagoons,vehicle/machine.repairlpainting,buried or stockpiled solid waste,etc.) FA ❑ 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 examplet above). Pct y C ki- pM �/ ❑ 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 proxiru to a former land611lformmer gasoline station,in area of known OBCP/Nitrate groundwater impact,etc.) Pq �, ,, to �l ❑ 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. M-L m-,w c Q ,N t= c) 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED AT OR'NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION ® ❑ 4.1 Evaluation of each potential and/or known source of Contamination identified(in the above section)for arty real and/or potential threat to human health and the environment. This evaluation should take Into consideration the proposed future uses of the project parcel. Pt 2. 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to reoommend f"i further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e.collection of soiUrrater samples)andfor mitigative measures(i.e.,dean up of surface wastes). All recommendations for future woek must include a time frame for implementation.. p., z-. ® ❑ 5.2 The report was inclusive(i.e.all information referenced was included in thins report=report should not reference other reports). ® ❑ 5.3 The report was signed,dated and stamped by a qualified environmental professional. r_V � © ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By:_ �r _Reviewed Date: EHD 26-02.001 Page I of 2 surface do Sub Checklist $ 7114/,003