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opo IN .c SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT y°. 1868 East Hazelton Avenue, Stockton, CA 95205-6232 c, P Telephone: (209)468-3420 Fax:(209)464-0138 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST SITE LOCATION: Z l SPAM J800E9 I \ REPORT DATE: n f O\f I 5 = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 N�Q : P.. JEO dZ6, C�\ I = Insufficient L( ./ W S ✓mac✓ a R+ �1� S 1 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION � p//Gly 4-ko ❑ 1.1 Description of site(report must address all parcels), including current and/or proposearning information. " T�"4,1 ❑ 1.2 Description of proposed development. �/� 011, �y ❑ 1.3 Parcel location map. J Q 7_q ( �Q [� ❑ 1.4 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, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION L}' ❑ 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.) 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 records search, agricultural �/ chemical application search, site reconnaissance and survey, etc.) L� ❑ 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 handling/storage/use, aboveground/underground tanks, septic systems, injection wells, unsealed wells,ponds/lagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc.) M/ ❑ 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). 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified B W in the area of the project site that has or may impact the project site. (Examples: Close proxJ.mity to.a fo[rneerr� landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.)Q�p I�Ng6�/Sl) Ley,// 3.5 Description of all current off-site potential and/or known above and below ground sources of contaminati(_on�°ST��G YI identified in the area of the project site. llr-� �ZU " k Sr�ay— J 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATIO IDENTIFIED d'1 AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTIONd r� ❑ 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 environmen This evaluation should take into consideration the \ proposed future uses of the project parcel. 40 A�� rGO' JJ AQ i 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION (6P ❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat ort mend 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. ❑ 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 V� /D Vo 5.4 The report was prepared within six months of the date of the submittal of the land use app/i - ❑ 5.5 The attach nts/app n ices contain sufficient-documentation to support claims made in report. Reviewed B ' � �4 _ l Reviewed Date:C z Z8 EHD 26-014121,12 Page 1 of 2 SURFACE&SUB CKLST