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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Avenue 3rd Floor Stockton - CA 95202-2708 <br />9 �e (209) 468-3420 - Fax: (209) 464-0138 - Web: www.co.san-joaquin.ca.us/ehd <br />�FOR <br />SURFACE AND SUBSURFACE CONTAMINATION REPORT REQUIREMENT CHECKLIST <br />SITE LOCATION: l3-) - r 9 r-, PA <br />3PA #: <br />1C S7 ��� REPORT DATE: I -1'14 2 <br />S = Sufficient San Joaquin County Development Title Chapter 9-905, Section 9-905.12 <br />I = Insufficient <br />S <br />I <br />1.0 <br />INTRODUCTION & PROPOSED DEVELOPMENT SECTION <br />[1S <br />❑ <br />1.1 <br />Description of site (report must address all parcels), including current and/or proposed zoning information. <br />[�J <br />❑ <br />1.2 <br />Description of proposed development. <br />[� <br />❑ <br />1.3 <br />Parcel location map. <br />[/� <br />❑ <br />1.4 <br />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 />[� ❑ 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.) <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 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.) <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.) 2 2'1 '7 0 J f -ATL T-1A✓� PV5014--� o , pst�T <br />t,Ut,o501rr- <br />A40APt(,fi l^, DM�*5 WkLt- 4- sF�Tf , � P �c e-(UkT_ <br />A <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). <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 groundwater impact, etc.) <br />[� ❑ 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 />EHD 26-02-001 Page 1 of 2 Surface & Sub Checklist <br />7/14/2003 <br />