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SAN JOAQUIN COUNTY I/: K ENVIRONMENTAL HEALTH DEPARTMENT ��,��I� �, 1868 East Hazelton Avenue, Stockton, CA 95202-3029 QP Telephone: (209)468-3420 Fax:(209)468-0333 Web:www.sjgov.org/ehd SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST / PA#: /6 - eD 2.`Z SITE LOCATION: /�j � 7p,r`j�. REPORT DATE: S = Sufficient SanJoaquinCounty Development Title Chapter 9-905, Section 9-905.12 1 = Insufficient S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION 2 ❑ 1.1 Description of site(report must address allparcels), including current and/or proposed zoning information. ® ❑ 1.2 Description of proposed development. ❑ 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.) eC 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.) 1 y-r�y7 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 applicatiojEt: h, site reconnaissance and survey,etc.) r 1--4/7 ® ❑ 3.2 Description of all pn-s'a potential and/or known above and below ground sources of contamination identified at the project site. les: 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.) "I _ t17 ® ❑ 3.3 Description of all curreton- to potential and/or known above and below ground sources of contamination identified at the project see examples above). 4 k _ &47 ❑ ❑ 3.4 Description of all pa ff- ite potential and/or known above and below ground sources of contamination identified in the area of the pro c site that has or may impact the project site. (Examples: Close proximity to a former landfill/former gasoline on, In area of known DBCP/Nitrate groundwater impact, etc.) /lf—4 �] ❑ 3.5 Description of all cur nt o - ite potential and/or known above and below ground sources of contamination identified in the area project site. �Zi _ ,-, 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. q 13 — 5 / 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION �j ❑ 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. [ ❑ 5.2 The report was inclusi*)i.e.alllInformation 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. ®� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report. Reviewed By: �>�� Reviewed Date: EHD 26-01 Page I of 2 Surface&Sub Checklist