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SAN JOAQUIN COUNTY I ? ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone:(209)468-3420 Far:(209)464-0138 Web: www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST PA#: � T, - o as fa SITE LOCATION: G F M K� ]O!� W, �ii�1H� )� - / v REPORT DATE: S = suffiInsu ici Insuffi 1 = cient San Joaquin County Development 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 proposed zoning information. t F1 ❑ 1.2 Description of proposed development. I ® ❑ 1.3 Parcel location map. 4, �'" ® ❑ 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 R ❑ 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.) I I Z ) 5 �I ll 12 i� I') 1 S, l 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION ❑d ❑ 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 earth, site reconnaissance and survey, etc.) [� F] 3.2 Description of all pa npotential and/or known above and below ground sources of contamination identified at the project site. (;;;Z: 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,Q c.) © ❑ 3.3 Description of all current -site potential and/or known above and below ground sources of contamination identified at the proj. rte(see examples above). fl ❑ 3.4 Description ofpa ff-site potential and/or known above and below ground sources of contamination identified in the area of th r ' ite that has or may impact the project site. (Examples: Close proximity to a former landfill/former gasoline_station, in area of known DBC /Nitrate groundwater impact, etc.) ,,E�, 5 Fy ❑ 3.5 Description of all current ff-site potential and/or known above and below ground sources of contamination identified in the area oft a project site.3 l S 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. 3 111 -s t 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION [d� ❑ 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 fpr rffuture work must include a time frame for implementation. F] 5.2 The report was inclusive (i.e. all igorrAatidn 441ced 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. 1- ® ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application. ® ❑ 5.5 The attachments/aypendic contain sufficient documentation to support claims made in report. Reviewed By: / r-- Reviewed Date � EHD 26-01 Page 1 of 2 Surface&Sub Checklist