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SAN JOAQUIN COUNTY ?` 2 Eiv VIRONMENTAL HEALTH DEPART'iviENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.Sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST PA#: pey—ca a..7� C� SITE LOCATION: a 1300 c.{ � �� C� SLC, �.. REPORT DATE: S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION a ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. p . do E] 1.2 De 1 ion Ofrpropo§ develo�pment. ❑ 1.3 Parcel-lolon map. ATv—&} -n ❑ 1A 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, PRESEPItuTali4ND 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.) Q 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 rgords search,agricultural chemical application search,site reconnaissance and survey,etc.��)+��,, ❑ 3.2 Description of all past on-site potential and/or known above and befbw ground sources of contamination identified at the project site. (Examples: Agricultural chemical handlinglstorage/use, abovegroundlunderground tanks, septic systems, injection wells, unsealed wells,pondsllagoons,vehicielmachine repair/painting, buried or stockpiled solid waste, etc.) r;5 G/– -7 ❑ 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). 41 _ 7 ❑ 3.4 Description of all past off-site potential and/or kon wn 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 proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact,etc.) P� ❑ 3.5 Description of all current off-site potential and/or known above an4 below ground sources of contamination identified in the area of the project site. --7 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION 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 any 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. /, , _?_ 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION B_ ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend further action to mitigate or abate any real or potential threats identified. Recommendations may include additional site assessment(i.e.collection of soil/water samples)and/or mitigative measures(i.e.,clean up of surface wastes). All recommendations for future work must include a time frame for implementation. �C ❑ 5.2 The report was inclusive(i.e. all information referenced was included in this report–report should not reference other reports). ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. E [� ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. �c ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: ��s� rL Reviewed Date: E14D 26-01 Pagel of 2 Surface&Sub Checklist -1