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Hazardous Materials Inventory Statement, dated November 11, 2018RECEIVED NOV 0 8 2018 CITY OF FEDERAL WAY DEPARTMENT OF COMMUNITY DINMMWt1WQR4F5k&MENT A1 33325 8`h Avenue South CITY OF PO Box 9718 Federal Way WA 98063-9718 FederaI Way 253-835- 607;w.ch Fax 25 ralwa 2609 tV w w.Ci tYnf Fcdc ral way.cnm 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 City Code (FWCC), Chapter 18, "Environmental Protection." 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 Project Name VILLAGE GREEN PHASES II & III - EXTENSION © Applicant VILLAGE GREEN OF FEDERAL WAY, A RETIREMENT CAMPUS LLC p Project Location 15T AVENUES & SW 356TH STREET Tracking No. 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 5 (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 < 5 per week (21) Metals (hazardous e.g. arsenic, copper, chromium, lead, mercury, silver, etc.) (22) Paints, pigments, dyes, stains, varnish, sealers. 10 (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. Bulletin #056 — November 24, 2004 Page 2 of 3 k:\14andouts\Ilazardous Materials Inventory Statement VILLAGE GREEN VILLAGE GREEN OF FEDERAL WAY, Pra ect Name PHASES II & III - EXTENSION Appli=t,___. A RETIREMEhIT CAMPUS LLG Project Location 'IST AVENUE S & SW 356TH STREET Tracking No, IV. F[RTHEItINFORMA'[ION Provide the approximate quantity of fill and source of fill to be imported to the site. Auvroximate Quantity of Imported Fill Source of Fill None NIA 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 -wbmances listed above. #2 [ ] Above ground storage tanks, having a capacity of — gallons will be installed, #3 [ 7 Constmetion vehicles will berefacled on site. Storage within wholesale and retail facilities of hazardous materials, or other dclewnnus #4 [ ] substances, will be for sale in original containers with a capacityof — gallons liquid or _--_pounds solid. The presence of chemical substances on this parcel is/will be for "temporary" non -routine #5 [A ] maintenance or repair of the facility (such as paints and paint thinners) and are in individual containers with a capacity of 10 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 [t] 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 #S [ } Leak detection devices, training for employees for use of hazardous materials, self-contained machinery, etc. SIGNATURE V14Signattue Print Name 1111 Fr 1O If you have any questions about filling out this application form, please call the Department of Community Development Services at 25M35-2607. Please be advised that an application for a development permit lacking the required information will not be accepted. 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