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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton,CA 95202-3029 o- e% Telephone:(209)468-3420 Fax:(209)468-0333 Web:www.sjgov.org/ehd �i�iFoaN; SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST $ITE LOCATION: aCJ�DI C �e�wt A✓t ltd jr�. PAM 16 oea6� g) REPORT DATE: = Sufficient I = Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 S 1 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION ❑ 1.1 Description of site (report must address all parcels), including current and/or proposed zoning information. 1 2- 1.2 1.2 Description of proposed development. Z ❑ 1.3 Parcel location map. r4 CC (� ❑ 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.) P`C 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.) z 3 I L(\5,ti 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.) 2 - 6 ® ❑ 3.2 Description of all pa on- Ite potential and/or known above and below ground sources of contamination identified at the project site. (E mples: Agricultural chemical handling/storage/use, aboveground/underground tanks, septic systems, injection wells, unsealed wells, pondsAagoons,vehicle/machine repair/painting, buried or stockpiled solid waste, etc. S M ❑ 3.3 Description of all currenronAite potential and/or known above and below ground sources of contamination identified at the project&re (see examples above). o © ❑ 3.4 Description of all pas( ite 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 proximity to a former landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) ® ❑ 3.5 Description of all curre o site potential and/or known above and below ground sources of contamination identified in the area of�roject site. _ 4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION [o� ❑ 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 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 surface wastes). All recommendations for future work must include a time frame for implementation. �nl ❑ 5.2 The report was inclusive (i.e. ZII 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. ® ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. 4 ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: ) rzo 1 ar-we- -tL,.25 Reviewed Date: EHD 26-01 Page I of 2 surface&sub Checklist