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SAN JOAQUIN COUNTY 4 ENVIRONMENTAL HEALTH DEPARTNizNT 304 East Weber Avenue, 3`a Floor, Stockton, CA 95202-2708 Telephone:(209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: 3D o` /y5l5 � !felt • PA#: W. REPORT DATE: VGt 2Q� S = Sufficient San Joaquin County Development Title Chapter 9-905,Section 9-905.12 I = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION [� ❑ 1.1 Description sciption e(re ortust address all parcels), including current and/or proposed zoning information.k 13 ®. ❑ 1.2 D ption propo4-6 development. ®- ❑ 1.3 Parcel location ma( � ® ❑ 1.4 Site map showing location of all items on parcel. (Examples:structures,drives,w IIs,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.)Cr��)) 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, EW records search,agricultural chemical application search, site reconnaissance and survey, etcC�Q) A,'-) 0 E] 3.2 Description of all past on-site potential and/or known above and b ow ground urces of contamination identified at the project site. (Examples: Agricultural chemical hand ling/storageluse, abovegroundlunderg round tanks, septic systems, injection wells, unsealed wells, ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) 7V ® E] 3.3 Description of all current on-si( otential and/or known above and below ground sources of contamination identified at the project site(see examples above). tv?,$)3.4 Description of all past off-site potential and/or knownove and below ground sources of contamination identified in the area of the project site that has or may impact the project site. (Examples: Cios proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, C. � - o ❑ 3.5 Description of all current off-site potential and/or known above and below ground sou s of contamination identified in the area of the project site 4.0 EVALUATION OF PAST AND URRENT 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 parcer 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 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 su wg I.)All recommendations for future work must include a time frame for implementation. ❑ 5.2 T report vias inclusive(i.e. all information referenced was included in this report—report should not reference other reports). E- ❑ 5.3 T e repiRrt was signed, dated and stamped by a qualified environmental professional. ❑ ® 5.4 777I[�1��a repoh was prepared within six months of the date of the submittal of the land use application. ❑ 5.5 The attachment /a endices contain sufficient docume tat io to support claims made in report. Reviewed Byx" Reviewed Date: y l EHn 26.01 Page I of 2 swram&s.b Checklist