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P II t Y.
<br /> SAN JOAQUIN COUNTY
<br /> ?� ENVIRONMENTAL HEALTH DEPARTMENT
<br /> 1868 East Hazelton Avenue, Stockton, CA 95202-3029
<br /> • / Telephone:(209)468-3420 Fax:(209)468-0333 Web:www.sjoov.org/ehd
<br /> SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST
<br /> SITE LOCATION: 23 S
<br /> REPORT DATE: `/-z 9'iy
<br /> = Sufficient
<br /> I = Insufficient
<br /> San Joaquin County Development Title Chapter 9-905,Section 9-905.12
<br /> S I 1.0 INTRODUCTION & PROPOSED DEVELOPMENT SECTION
<br /> E✓f ❑ 1.1 Description of site(report must address all parcels), including current and/or proposed zoning information. f 1
<br /> 0 ❑ 1.2 Description of proposed development.
<br /> [v]� ❑ 1.3 Parcel location map. p 3 R P n c, of r x ,4
<br /> F ❑ 1.4 Site map showing location of all items on parcel. (Examples: structures, drives,wells, septic systems, large trees,
<br /> pastures, pools, natural drainage courses, ponds,waterways, etc.)
<br /> 2.0 PAST, PRESENT AND PROPOSED FUTURE USES OF THE SITE SECTION
<br /> [3' ❑ 2.1 Discussion of past, present and proposed future uses at the site to assess potential problems. (Example sources
<br /> of information: current and/or previous property owners, historical maps, insurance maps, previous land use
<br /> applications, etc.) pc-,- 3 e,'5drn<<.-A, Fs,, 1.4 � x ,:.> '�• . � S►•b
<br /> 3.0 IDENTIFICATION OF ALL PAST AND CURRENT SOURCES OF CONTAMINATION
<br /> 0 ❑ 3.1 Discussions of the methods used to research and investigate the potential or known above and belowground
<br /> sources of contamination at the project site. (Examples: Database search, EHD records search,agricultural
<br /> chemical application search, site reconnaissance and survey, etc.) 0, IJP F pDjSPYJa{!S� GOA^}/a�(�w� E r2S
<br /> ❑ 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.) 1h:YE;' - !,, ' :f`>r'+s • '`o OD'T, P-7'/—,S
<br /> r
<br /> ❑ ❑ 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). P,�,,_ r
<br /> ❑ ❑ 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 ground)�ater impact, etc.) Ft9 s P'•� �� ' " r�o -
<br /> -1"� 11y co✓rpt•
<br /> F-13.5 Description of all current off-site potential and/or known above anld;elow ground sources k contamination
<br /> identified in the area of the project site. 1;'
<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. r�- f
<br /> 5.0 CONCLUSIONS AND RECOMMENDATIONS SECTION
<br /> E?r ❑ 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 wor {m}u$t include a time frame for implementation.
<br /> E� F15.2 The report was inclusive(i.e. all information referenced Ways included in this report—report should not reference
<br /> other reports).
<br /> ❑ 5.3 The report was signed, dated and stamped by a qualified environmental professional. �G
<br /> ❑ 5.4 The report was prepared within six months of the date of the submittal of the land use application.
<br /> [� ❑ 5.5 The attachments/appendices contain sufficient documentation to support claims made in report.
<br /> Reviewed By: Reviewed Date:
<br /> EHD 26-01 Page I of 2 Surface&Sub Checklist
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