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oPgUIN\ SAN JOAQUIN COUNTY
<br />. • C,
<br />ENVIRONMENTAL HEALTH DEPARTMENT
<br />1868 East Hazelton Avenue, Stockton, CA 95202-3029
<br />Telephone: (209) 468-3420 Fav: (209) 468-0333 Web: www.sjoov.org/ehd
<br />•9��FOR%`
<br />SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST
<br />SITE LOCATION: 1f40-0 f /9?Dl /V ' Ii+SLS' 12,4, r%ucKt ;,tW
<br />PAM 84-19410 20
<br />REPORT DATE: -1-13-11,
<br />S = Sufficient
<br />I = Insufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12
<br />S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION
<br />13" ❑ 1.1 Description of site (report must address all parcels), including current and/or proposed zoning information.
<br />P'�2 • 4G -g0
<br />3'_ ❑ 1.2 Descri ption oeproposed development.
<br />[v]� ❑ 1.3 Parcel location map.
<br />15 ❑ 1.4 Site map showing location of all items on parcel. (Examples: structures, drives, well, septic systems, large trees,
<br />pastures, pools, natural drainage courses, ponds, waterways, etc.) AI,,le-r1 �„ z.
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<br />2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION
<br />Ef ❑ 2.1 Discussion of past, present and proposed future uses at the site to assp§s potential problems. (Example sources
<br />of information: current and/or previous property owners, historical maps, Insurance maps, previous land use
<br />applications, etc.)
<br />3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION
<br />❑ ❑ 3.1 Discussions of the methods used to research and investigate the potential or known.bove and belowground 461-7
<br />sources of contamination at the project site. (Examples: Database search, EHD records search, agricultural
<br />chemical, 7pl� Nvon se rch� I�ted4e�pnn�aiss �ce and surveys etc)
<br />E� E]3.2 Description of all past on-site potential and/or known above and below ground sources of contamination identified
<br />at the project site. (Examples: Agricultural chemical handling/storage/use, aboveground/underground tanks,
<br />septic systems, injection wells, unsealed wells, ponds/lagoons, vehicle/machine repair/painting, buried or
<br />stockpiled solid waste, etc.) '� o
<br />[1 ❑ 3.3 Description of all current on-site potential and/or known above and below ground sources of contamination
<br />identified at the project site (see examples above). j- i O
<br />P ] ❑ 3.4 Description of all past off-site potential and/or known above and below ground sources of contamination identified
<br />in the area of the project site that has or may impact the project site. (Examples: Close proximity to a former
<br />landfill/former gasoline station, in area of known DBCP/Nitrate groundwater impact, etc.) "% z, ''1171
<br />E� ❑ 3.5 Description of all current off-site potential and/or known above and below ground sources of contamination
<br />identified in the area of the project site.
<br />4.0 EVALUATION OF PAST AND CURRENT SOURCES OF CONTAMINATION IDENTIFIED
<br />AT OR NEAR THE SITE AND RECOMMENDATIONS FOR FURTHER ACTION
<br />[✓� ❑ 4.1 Evaluation of each potential and/or known source of contamination identified (in the above section) for any real
<br />and/or potential threat to human health and the environment. This evaluation should take into consideration the
<br />proposed future uses of the project parcel. 7, ',✓SI
<br />5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION
<br />❑ 5.1 Discussion of the above evaluation to either rule out each source as a real or potential threat or to recommend
<br />further action to mitigate or abate any real or potential threats identified. Recommendations may include
<br />additional site assessment (i.e. collection of soil/water samples) and/or mitigative measures (i.e., clean up of
<br />surface wastes). All recommendations for future work must include a time frame for implementation.
<br />Ful ❑ 5.2 The report was inclusive (i.e. all information referenced was included in this report — report should not reference
<br />other reports).
<br />EA ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional.
<br />❑ ❑ 5.4 The report was pr pared within six months of the date of the s bmittal of, the land use application.
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<br />[� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report.
<br />Reviewed By: Nr eK, Akr, tel Reviewed Date:
<br />EHD 26-01 Page I of 2 Surface & Sub Checklist
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