23-103808-Hazardousmaterial92523Project Namel�V�h/u, Applicant
Project Location W Tracking No.
III. TYPES AND QUANTITIES OF HAZARDOUS MATERIALS
Please provide the approximate quantity of the types of hazardous materials or deleterious
substances that will be stored, handled, treated, used, produced, recycled, or disposed of in
connection with the proposed activity. If no hazardous materials will be involved, please proceed to
Section IV.
MATERIAL
LI CID allons
SOLID (pounds)
(1) Acid or basic solutions or solids
(2) Antifreeze or coolants
(3) Bleaches, peroxides, detergents, surfactants,
disinfectants bactericides algaecides
(4) Brake, transmission, hydraulic fluids
(5) Brine solutions
(6) Corrosion or rust prevention solutions
(7) Cutting fluids
(8) Deicing materials
(9) Dry cleaning or cleaning solvents
(10) Electroplating or metal finishing solutions
(11) Engraving or etching solutions
(12) Explosives
(13) Fertilizers
(14) Food or animal processing wastes
(15) Formaldehyde
(16) Fuels, additives, oils, greases
(17) Glues, adhesives, or resins
(18) Inks, printing, or photocopying chemicals
(19) Laboratory chemicals, reagents or standards
(20) Medical, hospital, pharmaceutical, dental, or
veterinary fluids or wastes
(21) Metals (hazardous e.g. arsenic, copper,
chrom'um lead mercury, silver, etc.
(2 aints pigments, dyes, stains, varnish, sealers.
(23) Pesticides, herbicides or poisons
(24) Plastic resins, plasticizers, or catalysts
(25) Photo development chemicals
(26) Radioactive sources
(27) Refrigerants, cooling water (contact)
(28) Sludges, still bottoms
(29) Solvents, thinners, paint removers or strippers
(30) Tanning (leather) chemicals
(31) Transformer, capacitor oils/fluids, PCB's
(32) Waste oil
(33) Wood preservatives
Bulletin #056 — Januan 1. 2011 Page 2 of 3 k:\Handouts\Hazardous Materials Inventory Statement
Project Name Lts-"� rwll Applicant It �Vi. ✓J
Project Location ' �.� 3�I�rtft ► o.
(34) List o mER hazardous materials or JeIeterious
i
substances on a separate sheet.
��
IV. FURTHER INFORMATION
Provide the approximate quantity of fill and source of fill to be imported to the site.
Approximate Quantipy of Imported Fill
Source of Fill
Check box # 1 if you do not plan to store, handle, treat, use, produce, recycle, or dispose of any of the
types and quantities of hazardous material or deleterious substance listed in Section III. Check box(s)
#2 through #5 (and fill in appropriate blanks) of the below table if they apply to your facility or
activity.
#1 [ The proposed development will not store, handle, treat, use, produce, recycle, or dispose of any of
the types and quantities of hazardous materials or deleterious substances listed above.
#2 [ ]
Above ground storage tanks, having a capacity of gallons will be installed.
#3 [ ]
Construction vehicles will be refueled on site.
Storage within wholesale and retail facilities of hazardous materials, or other deleterious
#4 [ ]
substances, will be for sale in original containers with a capacity of _ gallons liquid or
_pounds solid.
The presence of chemical substances on this parcel is/will be for "temporary" non -routine
#5
maintenance or repair of the facility (such as paints and paint thinners) and are in individual
containers with a capacity o gallons liquid or _pounds solid.
Check any of the following items that currently exist or are proposed in connection with the
development of the site.
#1 [ ]
Stormwater infiltration system (e.g., french drain, dry well, stormwater Swale, etc.)
#2 [ ]
Hydraulic lifts or elevator, chemical systems, or other machinery that uses hazardous materials
#3 [ ]
Cathodic protection wells
#4 [ ]
Water wells, monitoring wells, resource protection wells, piezometers
#5 [ ]
Leak detection devices, training for employees for use of hazardous materials, self-contained
machinery, etc.
SI RE
Otg�na-t-ure
Print Name
r)
Date
Bulletin #056 —January 1, 2011 Page 3 of 3 k:\Handouts\Hazardous Materials Inventory Statement
Project Name
Project Locatio rA
If you have any questions about filling ou his application form, please contact the Department of
Community Development's Permit Center at 253-835-2607, or permitcenterCa;cityoffedealway.com.
Please be advised that an application for a development permit lacking the required information will
not be accepted.
Bulletin r056 -- .lanuar% I. 2011 Page 4 of 3 k:\Handouts\Hazardous Materials Inventory Statement