22-100630-Hazardous Materials Inventory Statement-02-10-2022-V1CITY O ,m
Federal way
DEP"TmimT of Cotmowff DEvo opmoa SratvicEs
33325 8' Avenue South
Federal Way, WA 98003-6325
253-835-2607;Fax 253-835-2609
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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 H 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.
H. 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[21)
• 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 i F-co+ JAyot Fe erd WAV Applicant JfiC
Project Location Tracking No.
�/1V15
M. 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
(3 1) 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 — January 1, 2011 Page 2 of 3 k:\Handouts\Hazardous Materials Inventory Statement
Project Name"� ��Y Applicant"-�'
p —
Project Location _ -�r Trucking No.
TV. F u'RTHER NFoR>tiAno-N
Provide the upproxintute quantity of fill and source of fill to be imported to the site.
Approximate (jttantity 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) 3#2
through #5 (and fill in appropriate blanks) of the below table if they apply to your facility or activity.
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 [ } .shove -,round storage tanks, having a capacity of ballons will be installed.
#3 [ 1
#41 1
Construction vehicles will be refueled on site.
Storage within wholesale and retail facilities of hazardous materials, or other deleterious
substances, aill he for sale in original containers with a capacity of _ gallons liquid or
_. __pounds solid_
The presence of chemical substances on this parcel islwill be for "temporary" non -routine
n5 ] ] maintenance or repair of the fa6lity (such as paints and paint thinners) and are in individual
containers --ith 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 [
} Stonnw•ater 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
-#-' l
] a Cathodic protection --ells
#4 (
J water wells, monitoring wells, resource protection wells, piezometers
#SL
leak detection devices. training_ for employees for use of hazardous materials, sela contained
maehmer., etc.
SIGNATURE
Signature Date
Print Name
If you have any questions about filling out this application form, please call the Department of Community
Development Services at 253-835-2607. Please be advised that an application fora development permit
lacking the required information will not be accepted.
Bulletin #056 — January I, 2011 Page 3 of 3 k:UiandoutsiHazardous Materials Inventor• Statement