22-102749-UP-Hazardous Materials Inventory Statement-06-15-2022-V1
HAZARDOUS MATERIALS INVENTORY STATEMENT
CRITICAL AQUIFER RECHARGE AND WELLHEAD
PROTECTION AREAS
I. WHY SHOULD THIS INVENTORY STATEMENT BE FILLED OUT?
Critical Aquifer Recharge (CARAs) and Wellhead Protection Areas (WHPAs) are considered “critical
areas” pursuant to Federal Way Revised Code (FWCC) Title 14, “Environmental Policy.” This
inventory statement must be filled out by the applicant or agent for any proposed activity listed in
Section II of this handout, and which are located within Wellhead Capture Zones 1, 5, and 10 as shown
on the Critical Aquifer Recharge and Wellhead Protection Areas Maps. Please refer to the handout on
Critical Aquifer Recharge and Wellhead Protection Areas for a description of the review process.
II. ACTIVITIES GOVERNED BY CARA AND WHPA REGULATIONS
The inventory statement must be filled out for the following activities:
• Construction of any residential structure, including single-family development
• Construction of any barn or other agricultural structure
• Construction of any office, school, commercial, recreational, service, or storage building
• Construction of a parking lot of any size
• Other minor new construction (see WAC 197-11-800[2])
• Additions or modifications to or replacement of any building or facility (does not include
tenant improvements)
• Demolition of any structure
• Any landfill or excavation
• Installation of underground tanks
• Any division of land, including short plats
• Change of use, which involves repair, remodeling, and maintenance activities
• Dredging
• Reconstruction/maintenance of groins and similar shoreline protection structures
• Replacement of utility cables that must be buried under the surface of the bedlands
• Repair/rebuilding of major dams, dikes, and reservoirs
• Installation or construction of any utility, except for on-going operation and maintenance
activities of public wells by public water providers
• Personal wireless service facilities
DEPARTMENT OF COMMUNITY DEVELOPMENT
33325 8th Avenue South
Federal Way, WA 98003
253-835-2607; Fax 253-835-2609
www.cityoffederalway.com
Project Name Applicant
Project Location Tracking No.
Bulletin #056 – January 1, 2011 Page 2 of 3 k:\Handouts\Hazardous Materials Inventory Statement
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 LIQUID (gallons) 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,
chromium, lead, mercury, silver, etc.)
(22) Paints, 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
(34) List OTHER hazardous materials or deleterious
substances on a separate sheet.
Project Name Applicant
Project Location Tracking No.
Bulletin #056 – January 1, 2011 Page 3 of 3 k:\Handouts\Hazardous Materials Inventory Statement
IV. FURTHER INFORMATION
Provide the approximate quantity of fill and source of fill to be imported to the site.
Approximate Quantity 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.
#4 [ ]
Storage within wholesale and retail facilities of hazardous materials, or other deleterious
substances, will be for sale in original containers with a capacity of ___ gallons liquid or
____pounds solid.
#5 [ ]
The presence of chemical substances on this parcel is/will be for “temporary” non-routine
maintenance or repair of the facility (such as paints and paint thinners) and are in individual
containers with a capacity of ___ 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.
SIGNATURE
Signature Date
Print Name
If you have any questions about filling out this application form, please contact the Department of
Community Development’s Permit Center at 253-835-2607, or permitcenter@cityoffedealway.com.
Please be advised that an application for a development permit lacking the required information will
not be accepted.
2/28/2022
Joe Sheehy