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HomeMy WebLinkAbout3521 172ND ST NE_BLD1669_2026 COMMERCIAL MECHANICAL • PERMIT APPLICATION ING��� Department of Community&Economic Development City of Arlington • 18204 59th Ave NE•Arlington,WA 98223 • Phone(360)403-3551 THIS APPLICATION MUST BE ACCOMPANIED BY TWO (2) SETS OF CONSTRUCTION DRAWINGS AND ALL OTHER INFORMATION OUTLINED IN THE MECHANICAL PERMIT SUBMITTAL REQUIREMENTS, IF APPLICABLE. Type of Permit: New installation Replacement t' Alteration Project Address: 35�lZ C /d����li7`'�� Parcel#: Project Description: ,(:/A/g- /�' �'GL �i}��f Valuation: Od6 Owner: ' S ,2 io LE v Phone#: Address: �l?!31 /'2G�i/���� City: ,,✓i2 �'"J� State�f, Zip: Email Address: A&4a;7ia o/Y� Contact Person: Phone#: q Address: I Z? 2 d12L Cltylri 't Statl-, Zip: Email Address: Contractor Name: "t-)G Phone#: _zsjr-Z1/ Contractor Address:a �i,V L=? City:'!iZ J Stater11 Zip: Email: d, Al/ 02411_U_ e7 Contact Person: '4VIA 'G,e-rlc � Contractor License Number: lYeJ oe�tlel 9G�! /��' Expiration: Please indicate type of number of appliances: FURNACE CONDENSING UNIT GAS PIPING OUTLET BOILER HEAT PUMP(multi-split) UNIT HEATER CHILLER HEAT PUMP(mini-split) PAINT BOOTH COOLER HEAT PUMP(other) TYPE I HOOD AC(air cooled) HEAT REJECTION EQUIP TYPE II HOOD AC(water cooled) VENTILATION SYSTEM AST AC(evaporator) PACKAGED UNIT UST AC(VRF) DRYER OTHER I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the above- described property will be in accordance with the laws, rules and regulation of the State of Washington. Applicants Signature: Date 2) Appli .Printed Name I�0 FOR STAFF USE ONLY Received Permit# Acceff By Amount Received Receipt# Da e'RecEl4b L U 7 6/16LP Page 7 of 7 OPERATING ` PERMIT APPLICATION Department of Community & Economic Development City of Arlington• 18204 59th Ave NE*•Arlington,WA 98223•Plumc(360)403-3551 Part I Applicant/Building Information Applicant's Name: Applicant's Address: S�Z� ll =_:f S- Ile- G�,yl� ,�; Gt 1 t i Contact Person ~ � ��;,, �, Telephone: 2s�s`Z`�/• dZl Address of Premises for which Operating Permit is requested: D-game as above ❑ Other(specify): Tax Parcel ID#: !©_S'�f�,*��� ��' Current Occupancy Class: Part II Type of Operating Permit An Operating Permit is required to conduct any activity or to use any class of building listed below. Please indicate the type(s)of Operating Permit(s)requested by checking each applicable box. (If you require assistance, or would like more information, contact the City of Arlington Building Department at 360-403- 3551.) ❑ Manufacturing, storing or handling hazardous materials in quantities exceeding those listed in the Fire Code (see Appendix A.)Identify the materials and quantities and describe the manner in which the materials will be manufactured, stored or handled(attach additional sheets if necessary): Revised 4/l/08 Page 1 of 4 Part H(cont'd) ❑ Conducting a hazardous process or activity, including, but not limited to, any commercial or industrial operation which produces combustible dust as a byproduct, fruit and crop ripening,waste handling, spray operations, and high-piled storage (see Appendix B.)Describe the process(es)or activity(ies)to be conducted(attach additional sheets if necessary): ❑ Use of pyrotechnic devices in assembly occupancies (see Appendix C.)Describe the devices to be used and type of event(attach additional sheets if necessary): ❑Aboveground Storage Tank(AST) (see Appendix D) ❑ Removal ❑ Decommissioning ❑ Temporary tank closure ❑ Changes in service ❑ Permanent tank closure Brief description: 0 t!nderground Storage Tank(UST)(see Appendix D) ❑ Removal ❑ Decommissioning ❑ Temporary tank closure ❑ Changes in service ❑ Permanent tank closure Brief description: V' �//..; — /t�i�7 G/K/,�`/ � 4 1A ❑ Temporary Membrane Structures, including tents and canopies (see Appendix E.)Brief description of structure and use: Cc: Fire Department Page 2 of 4 Part II(cont'd) ❑ Special Event Operating Permit-An Operating Permit is required for any special event that takes place within an occupied building, or an outdoor mass gathering,which is outside the scope of the permitted use(see Appendix F.)Brief description of type of gathering proposed: Part III Premises/Building Information 1. Date of last inspection of Premises: 2. Has a Certificate of Occupancy been issued for the premises?❑ Yes ❑No Type: ❑ Permanent ❑ Temporary Date of Issuance: _ 3. Are there currently any open Building Permits associated with the premises? ❑ Yes ❑No If yes, please describe (attach additional sheets if necessary): 4. Additional Comments: SIGNATURE OF APPLICANT I herby certify that the foregoing information(and all information in attached sheets, if any) is true and complete. Signature of Appl ica►it or Authorized Representatives Signature Date Name and Title (if applicable)of person signing Application(Please print) Cc: Fire Department Page 3 of 4 Part IV To be completed by the City of Arlington Building Department Inspection Required: ❑ Yes ❑No Inspections Performed: ❑ Yes ❑No Date of Inspection: Tests or Reports required verifying compliance? ❑ Yes ❑No If YES,have Tests or Reports been received? ❑ Yes ❑No Application(s) Approved: ❑ Yes ❑ No Operating Permit Issued by: Date Operating Permit Issued: Date Operating Permit Expires: Type/Description of Operating Permit: Conditions of Operating Permit(list conditions here AND in the space provided in the Operating Permit): Additional Comments: (Attach additional pages if needed) Cc: Fire Department Page 4 of 4 OPERATING PERMIT APPLICATION Appendix D Removal of Aboveground and Underground Storage Tanks Department of Community& Economic Development City of Arlington•18204 59th Ave NE•Arlington,WA 98223•Phone(360)403-3551 • An Operating Permit is required prior to the removal and/or decommissioning of any aboveground storage tank(AST) or underground storage tank(UST), unless specifically exempted per the WAC 173. ■ An Operating Permit is required for any temporary tank closure, change in service,and permanent tank closure for all AST's or UST's. ■ The following is required prior to the issuance of any AST Operating Permit: o Site Check/Site Assessment Checklist,DOE form ECY 010-158. o Removal plan for all hazardous materials. o Appropriate certifications and insurances of contractor(s). ■ The following is required prior to the issuance of any UST Operating Permit: o Appropriate DOE forms. o Closure and Site Assessment Notice. 0 30-Day Notice. o Site Check/Site Assessment Checklist,DOE form ECY 010-158. Revised 5/12/2008 Facility Name: ARLINGTON ARCO AM/PM Tag(s): A4286 SITE INFORMATION ARLINGTON ARCO AM/PM RESP UNIT:NORTHWEST COUNTY:SNOHOMISH IUSTID:100010 3521 172ND ST NE LAT:48.1528091514039 IFSID:14518124 ARLINGTON,WA 98223 LONG:-122.182427373895 TANK INFORMATION TANK NAME: REGULAR 91 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT: INSTALL DT:12/01/1988 UPGRADE DT:11/09/1998 PERMIT EXPIRATION DT:06/30/2018 TANK PIPING� MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: SFC*at TANK: RELEASE DETECT:Interstitial Monitoring SFC*at DISP/PUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY: CAPACITY RANGE:10,000 to 19,999 Gallons SFC=Steel Flex Connector COMPARTMENT •' • SUBSTANCE USED CAPACITY 1 A Leaded Gasoline A Motor Fuel for Vehicles TANK NAME: SUPER#3 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT: INSTALL DT:12/01/1988 UPGRADE DT:11/09/1998 PERMIT EXPIRATION DT:06/30/2018 TANK c MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: SFC*at TANK: RELEASE DETECT:Interstitial Monitoring SFC*at DISP/PUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY: CAPACITY RANGE:10,000 to 19,999 Gallons SFC=Steel Flex Connector COMPARTMENT# SUBSTANCE STORED SUBSTANCE USED CAPACITY 1 B Unleaded Gasoline A Motor Fuel for Vehicles TANK NAME: UNLEADED#2 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT: INSTALL DT:12101/1988 UPGRADE DT:11109/1998 PERMIT EXPIRATION DT:06/30/2018 TANK PIPING MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: SFC*at TANK: a • 9/25/2017 RELEASE DETECT:Interstitial Monitoring SFC*at DISPIPUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY:12000 CAPACITY RANGE:10,000 to 19,999 Gallons '5FC=Sfuul Flux Cwina,lur COMPARTMENT • 1 B Unleaded Gasoline A Motor Fuel for Vehicles 12000 UST SiteTankDataSmry2014 ProgramToxics Cleanup RETROFIT/REPAIR CHECKLIST FOR UNDERGROUND STORAGE TANKS DEPARTMENT OF This checklist certifies that retrofit/repair activities were performed and conducted in accordance ECOLOGY with Chapter 173-360 WAC.Instructions arefound on the backpage. state of Washington -11.. UST FACILITY 111. [CC SERVICE PROVIDER Facility Compliance Tag#: 4286 Service Provider Name: Kevin Wilkerson UST ID#: 100010 Company Name: NES, Inc. Site Name: Arlington Arco AM/PM Address: PO Box 1583 Site Address:3521 172nd Street NE City: Sumner State: WA. Zip:98390 City: Arlington,WA.98223 Phone: (253 )241 -6213 Email: nesinc@hotmail.com County: Snohomish Certification Type: ICC Phone: ( 874 745- 1563 Certification Number: 874113 Exp. Date: 2018 Name: Phone: - Email: S and S Petroleum ( ) a Address: 11232 120th Ave NE City: Kirkland State:WA. Zip: 98033 Tank ID: Tank ID: TanklD: Tank ID: 1.Tank ID#(tank name registered with Ecology) 2 2. Date installed 1988 3.Tank capacity in gallons 12000 4.Tank material (specify for each tank): Steel (ST); Steel Clad w/Corrosion Resist(CLAD); CLAD Fiberglass Reinforced Plastic(FRP);STIp3 S.Tank construction (specify for each tank): DW Single wall (SW); double wall (DW);compartment(COMP) 6. Piping material (specify for each tank): Steel (ST); Fiberglass Reinforced Plastic(FRP); FLEX Flexible Plastic(FLEX); Other(specify): 7. Piping construction (specify for each tank): Single wall (SW); Double wall (DW) DW 1 ECY 070-71 (Rev.January 2013) V. TANK RETROFIT/REPAIRO. C. .. .. RELEASE DETECTION Tank ID: Tank ID: Tank ID: Tank ID: 1. Install/ Repair of release detection equipment(specify): Automatic tank gauge(ATG); Probe; Interstitial monitor(IM); Interstitial sensor(IS);Other(specify): CORROSION PROTECTION 1. Install/ Repair internal lining 2. Install/Repair impressed current rectifier 3. Addition of supplementary anodes 4.Addition of boots to metal flex connectors 5. Other repair(specify): SPILL/OVERFILL PREVENTION EQUIPMENT 1. Install/ Repair spill bucket 2. Install/ Repair of overfill prevention device (specify): Auto Shutoff(AUTO); Overfill Alarm (ALM); Ball Float Valve (BFV) OTHER REPAIR 1. Install/ Repair containment sump 2. Install/ Repair(specify): Turbine Pump(TP); Riser Pipe(RP);Tank Structure(TS) Other(specify): Other Repair not Listed and/or Additional Comments: PIPING Retrofit/Repair . • (circle INSTALL or REPAIR for each . . completed) RELEASE DETECTION Tank ID: Tank ID: Tank ID: Tank ID: 1. Install/Repair release detection equipment(specify): Sump Sensor(SUMP);Automatic Line Leak Detector(ALLD); Other(specify): OTHER REPAIR 1. Install/ Repair under dispenser containment(UDC) 2. Repair piping(<50%of piping run) (specify): FLEX ST FRP FLEX Other(specify): 3. Replacement of piping(>50%of piping run, must install DW) (specify): DW ST FRP FLEX Other(specify): Other Repair not Listed We are changing the existing unleaded slave tank to Diesel and replacing (6)dispensers. (3)3+0 an and/or Additional (3)3+1.All original vapor piping is staying attached Comments: 2 ECY 070-71 (Rev.January 2013) The following items shall be Initialed by the Certified Supervisor whose YES NO N/A signature appears below. 1. Have all items checked above been installed, repaired, or replaced per code and manufacturer's requirements and in accordance with federal and/or state kw regulations? 2. Has the owner/operator been provided with written documentation of the item(s) installed, repaired or replaced? kw Date work was completed: I hereby attest, that I have been the Certified Supervisor present on site during the above listed retrofitting/repair activities, and to the best of my knowledge they have been conducted in compliance with all applicable state and federal laws, regulations and procedures,pertaining to underground storage tanks. PERSONS SUBMITTING FALSE INFORMATION ARE SUBJECT TO FORMAL ENFORCEMENT AND/OR PENALTIES UNDER CHAPTER 173-360 WAC. Date Signat a of ICC Certified Provider Print or Type Name Date Signature of UST Owner/Operator Print or Type Name 3 ECY 070-71 (Rev.January 2013) RETROFIT/REPAIR CHECKLIST FOR UNDERGROUND STORAGE TANKS INSTRUCTIONS • This Underground Storage Tank(UST) checklist is required for retrofit and repair activities on regulated USTs. Completing this checklist documents and certifies the activities are performed and conducted in accordance with Chapter 173-360 WAC. • This checklist must be filled out completely by an International Code Council (ICC) certified provider for Installation and Retrofits of USTs within 30 days following the completion of the retrofit and repair activity. • A copy of the completed form must be provided to the tank system owner/operator. • The owner/operator is responsible for submitting a copy of the completed checklist to Ecology within 30 days of completing the activity. I. UST Facility: Complete this section about the UST facility and use the Facility Compliance Tag# (License Plate) and/or UST ID# (if known)to help identify the location. II. ICC Certified Provider: Complete this section about the ICC certified supervisor and service provider company. III. UST Owner/Operator: Complete this section about the owner or operator of the UST facility. IV. System Information: This section should be completed based on field observations. Use the bolded abbreviations,where applicable. V. Tank Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed, complete"Other"and provide additional information in Comments section. Use the bolded abbreviations, where applicable. VI. Piping Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed, complete"Other"and provide additional information in Comments section. Use the bolded abbreviations,where applicable. VII. Checklist: Initial in the appropriate box to answer the questions. VIII. Sip-natures: The ICC Service Provider must sign and date the completed form. Mail Checklist to: Department of Ecology Underground Storage Tank Section PO Box 47655 Olympia, WA 98504-7600 If you need this document in a format for the visually impaired call the Toxics Cleanup Program at 360-407-7170. Persons with hearing loss,call 711 for Washington Relay Service. Persons with a speech disability,call 877-833-6341. 4 ECY 070-71 (Rev.January 2013) ' CITY OF ARLINGTON 238 N. OLYMPIC AVE - ARLINGTON, WA. 98223 PHONE; (360)403-3551 BUILDING PERMIT Address:3521 172nd Street NE Permit#:1669 Parcel#:31052100302900 Valuation:22000.00 OWNER APPLICANT CONTRACTOR Name:SSA PROPERTIES LLC Name:NW Environmental Solutions,Inc. Name:NW Environmental Solutions,Inc. Address:29305 TERRENO LANE Address:P.O.Box 1583 Address:P.O.Box 1583 City,State Zip:VALENCIA,CA 91354 City,State Zip:Sumner,WA 98390 City,State Zip:Sumner,WA 98390 Phone: Phone:253-211-6213 Phone: MECHANICAL CONTRACTOR PLUMBING CONTRACTOR Name:NW Environmental Solutions,Inc. Name: Address:P.O.Box 1583 Address: City,State,Zip:Sumner,WA 98390 City,State,Zip: Phone:253-211-6213 Phone: LIC#:NWENVES964MB EXP: LIC#: EXP: JOB DESCRIPTION PERMIT TYPE: Commercial Mechanical CODE YEAR: 2015 STORIES: 0 CONST.TYPE: DWELLING UNITS: 0 OCC GROUP: BUILDINGS: 0 OCC LOAD: PERMIT APPROVAL I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOING THE WORK AUTHORIZED THEREBY; NO PERSON WILL BE EMPLOYED IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. THIS APPLICATION IS NOT A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID. IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. IBC110/IRC110. SALES TAX NOTICE-Sales tax relating to construction and construction materials in the City of Arlington must be reported on your sales tax return form and coded City of Arlington#3101. Signature Print Name Date Released By Da CONDITIONS MUST PROVIDE PRESSURE TEST VERIFICATION OF NEW SUPPLY LINE OR CALL FOR VISUAL INSPECTION. THIS PERMIT AUTHORIZS ONLY THE WORK NOTED.THIS PERMIT COVERS WORK TO BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC DOMAIN(CURBS,SIDEWALKS,DRIVEWAYS,MARQUEES,ETC.)WILL REQUIRE SEPARATE PERMISSION. PERMIT FEES Date Description Fee Amount 9/27/2017 Mechanical Permit Base Fee $25.00 9/27/2017 Mechanical Plan Review Fee $25.00 9/27/2017 Processing/Technology Fee $25.00 Total Due: $75.00 Total Payment: $0.00 Balance Due: $75.00 CALL FOR INSPECTIONS BUILDING(360)403-3417 When calling for an inspection please leave the following information: Permit Number,Type of Inspection being requested,and whether you prefer morning or afternoon Part IV To be completed by the City of Arlington Building Department Inspection Required: Fj 1 e ❑No Inspections Performed: ❑ Yes 2 No Date of Inspection: Tests or Reports required verifying compliance? 2 Yes ❑No If YES, have Tests or Reports been received? ❑ Yes 2<0 Application(s) Approved: � Yes ❑ No Operating Permit Issued by: �. Date Operating Permit Issued: -7Z� � Date Operating Permit Expires: '0li Type/Description of Operating Permit: "t Conditions of Operating Permit(list conditions here AND in the space provided in the Operating Permit): fwi/1 DC- --�"V-c <5 s I vr:e 1 k<k k-1 e--'r Additional Comments: (Attach additional pages if needed) Cc: Fire Department Page 4 of 4 CITY OF ARLINGTON 238 N. OLYMPIC AVE - ARLINGTON, WA. 98223 PHONE; (360)403-3551 BUILDING PERMIT Address:3521 172nd Street NE Permit#:1669 Parcel#:31052100302900 Valuation:22000.00 OWNER APPLICANT CONTRACTOR Name:SSA PROPERTIES LLC Name:NW Environmental Solutions,Inc. Name:NW Environmental Solutions,Inc. Address:29305 TERRENO LANE Address:P.O.Box 1583 Address:P.O.Box 1583 City,State Zip:VALENCIA,CA 91354 City,State Zip:Sumner,WA 98390 City,State Zip:Sumner,WA 98390 Phone: Phuut:253-211-6213 Phone: MECHANICAL CONTRACTOR PLUMBING CONTRACTOR Name:NW Environmental Solutions,Inc. Name: Address:P.O.Box 1583 Address: City,State,Zip:Sumner,WA 98390 City,State,Zip: Phone:253-211-6213 Phone: LIC#:NWENVES964MB EXP: LIC#: EXP: JOB DESCRIPTION PERMIT TYPE: Commercial Mechanical CODE YEAR: 2015 STORIES: 0 CONST.TYPE: DWELLING UNITS: 0 OCC GROUP: BUILDINGS: 0 OCC LOAD: PERMIT APPROVAL I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUCTION AND IN DOING THE WORK AUTHORIZED THEREBY; NO PERSON WILL BE EMPLOYED IN VIOLATION OF THE LABOR CODE OF THE STATE OF WASHINGTON RELATING TO WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27. THIS APPLICATION IS NOT A PERMIT UNTIL SIGNED BY THE BUILDING OFFICIAL OR HIS/HER DEPUTY AND ALL FEES ARE PAID. IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFICATE OF OCCUPANCY HAS BEEN GRANTED. IBC110/IRC110. SALES TAX NOTICE:Sales tax relating to construction and construction materials in the City of Arlington must be reported on your sales tax return fonn and coded City of Arlington#3101. Signature Print Name Date Released By Da CONDITIONS MUST PROVIDE PRESSURE TEST VERIFICATION OF NEW SUPPLY LINE OR CALL FOR VISUAL INSPECTION. THIS PERMIT AUTHORIZS ONLY THE WORK NOTED.THIS PERMIT COVERS WORK TO BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THE PUBLIC DOMAIN(CURBS,SIDEWALKS,DRIVEWAYS,MARQUEES,ETC.)WILL REQUIRE SEPARATE PERMISSION. PERMIT FEES Date Description Fee Amount 9/27/2017 Mechanical Permit Base Fee $25.00 9/27/2017 Mechanical Plan Review Fee $25.00 9/27/2017 Processing/Technology Fee $25.00 Total Due: $75.00 Total Payment: $0.00 Balance Due: $75.00 CALL FOR INSPECTIONS BUILDING(360)403-3417 When calling for an inspection please leave the following information: Permit Number,Type of Inspection being requested,and whether you prefer morning or afternoon Part IV To be completed by the City of Arlington Building Department Inspection Required: 0 Ycs ❑Now Inspcctions Pcrformcd: ❑ Yes ❑"Nc7 Date of Inspection: Tests or Reports required verifying compliance? Ye ❑No If YES, have Tests or Reports been received? ❑ Yes❑No Application(s) Approved: E Yes ❑ No Operating Permit Issued by: _ kn' Date Operating Permit Issued: Date Operating Permit Expires: '(/ r5 Type/Description of Operating Permit: _� ,� �;Upwy U4e- Conditions of Operating Permit(list conditions here AND in the space provided in the Operating Permit): K d5f" We--U I Q!5- V-E <51ST i W:e--r,Qd Or d - l IJM(�f Additional Comments: (Attach additional pages if needed) Cc: Fire Department Page 4 of 4 • • • Site9/25/2017 Facility Name: ARLINGTON ARCO AM/PM Tag(s): A4286 SITE INFORMATION ARLINGTON ARCO AM/PM RESP UNIT:NORTHWEST COUNTY:SNOHOMISH USTID:100010 3521 172ND ST NE LAT:48.1528091514039 FSID:14518124 ARLINGTON,WA 98223 LONG:-122.182427373895 TANK INFORMATION TANK NAME: REGULAR#1 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT: INSTALL DT,12101/1988 UPGRADE DT:11/09/1998 PERMIT EXPIRATION DT:06/30/2018 TANK PIPING MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: -SFC*-at TANK: RELEASE DETECT:Interstitial Monitoring SFC*at DISP/PUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY: CAPACITY RANGE:10,000 to 19,999 Gallons 'SFC=Steel Flex Connector COMPARTMENT •' 1 A Leaded Gasoline A Motor Fuel for Vehicles TANK NAME: SUPER#3 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT, INSTALL DT:12/01h988 UPGRADE DT:11109/1998 PERMIT EXPIRATION DT:06/30/2018 TANK PIPING MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: SFC*at TANK: RELEASE DETECT:Interstitial Monitoring SFC*at DISP/PUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY: CAPACITY RANGE:10,000 to 19,999 Gallons *SFC=Steel Flex Connector COMPARTMENT •' 1 B Unleaded Gasoline A Motor Fuel for Vehicles TANK NAME: UNLEADED#2 STATUS:Operational STATUS DT 08/06/1996 PERMANENTLY CLOSED DT: INSTALL DT:12/01/1988 UPGRADE DT:11109/1998 PERMIT EXPIRATION DT:06130/2018 TANK PIPING MATERIAL:Steel Clad with Corrosion Resistant Composite MATERIAL:Fiberglass CONSTRUCTION:Double Wall Tank CONSTRUCTION:Double Wall Pipe CORROSION PROT:Corrosion Resistant CORROSION PROT:Corrosion Resistant MANIFOLDED TANK: SFC*at TANK: 0 ME r 0 MOM f ME 0 Ika r MINE . ■ J ' ' i - 1 ■ ■ =11WIE ■ JMOM ' - '■ - - - • - - • • -- MOM ■ ■ ME'EE ■ ■ or ■ ■ ■ ■ MEMO - ■ 1 0 - - - 1 - 1 ■ 1 ■ ■ - ■ 1 • 'MOM i,, MEW WA .AT _ :w 32S ' . ■ ■ . ■ - ■ ■ rm — ■ ■ ■ ■ 0 MOM ME 0 ■ ■ - ME ■ . ■ - ■ ■ ■ ME AN - ■ ■ , - ■ 0 ECOLOGY 'QST Site Tank Data Sumn!., ?A � RELEASE DETECT:Interstitial Monitoring SFC at DISP/PUMP: TIGHTNESS TEST: 1ST REL DETECT:Automatic Line Leak Detector(ALLD) SPILL PREVENTION:Spill Bucket/Spill Box 2ND REL DETECT: OVERFILL PREVENT:Overfill Alarm PUMPING SYSTEM:Pressurized System ACTUAL CAPACITY:12000 CAPACITY RANGE:10,000 to 19,999 Gallons SFC=Shrol Flux Coneector COMPARTMENT •' 1 B Unleaded Gasoline A Motor Fuel for Vehicles 12000 UST SlteTankDataSmry2014 RETROFIT/REPAIR CHEL KLIST FOR UNDERGROUND STORAGE TANKS DEPARTMENT OF This checklist certifies that retrofit/repair activities were performed and conducted in accordance ECOLOGY with Chapter 173-360 WAC. Instructions arefound on the back page. State of Washington �Y Facility p g Compliance Ta #: 4286 Service Provider Name: Kevin Wilkerson UST ID M 100010 Company Name: NES,Inc. Site Name: Arlington Arco AM/PM Address: PO Box 1583 Site Address:3521 172nd Street NE City: Sumner State: WA. Zip:98390 City: Arlington,WA.98223 Phone: (253 )241 -6213 Email: nesinc@hotmail.com County: Snohomish Certification Type: ICC Phone: ( 874 745- 1563 Certification Number: 874113 Exp. Date: 2018 Name: S and S Petroleum Phone: ( ) - Email: Address: 11232 120th Ave NE City: Kirkland State:WA. Zip: 98033 Tank ID: Tank ID: Tank ID: Tank ID: 1. Tank ID#(tank name registered with Ecology) 2 2. Date installed 1988 3. Tank capacity in gallons 12000 4.Tank material (specify for each tank): Steel (ST);Steel Clad w/Corrosion Resist (CLAD); CLAD Fiberglass Reinforced Plastic(FRP);STIp3 5.Tank construction (specify for each tank): DW Single wall (SW); double wall (DW); compartment(COMP) 6. Piping material (specify for each tank): Steel (ST); Fiberglass Reinforced Plastic(FRP); FLEX Flexible Plastic(FLEX); Other(specify): 7. Piping construction (specify for each tank): Single wall (SW); Double wall (DW) DW 1 ECY 070-71 (Rev.January 2013) RETROFIT/REPAIRV. TANK INFORMATION (circle INSTALL or,REPAIR for each . . RELEASE DETECTION Tank ID: Tank ID: Tank ID: Tank ID: 1. Install/ Repair of release detection equipment(specify): Automatic tank gauge(ATG); Probe; Interstitial monitor(IM); Interstitial sensor(IS); Other(specify): CORROSION PROTECTION 1. Install/Repair internal lining 2. Install/Repair impressed current rectifier 3. Addition of supplementary anodes 4.Addition of boots to metal flex connectors 5. Other repair(specify): SPILL/OVERFILL PREVENTION EQUIPMENT ` 1. Install/Repair spill bucket 2. Install/Repair of overfill prevention device (specify): Auto Shutoff(AUTO); Overfill Alarm (ALM); Ball Float Valve (BFV) OTHER REPAIR 1. Install/ Repair containment sump 2. Install/Repair(specify): Turbine Pump (TP); Riser Pipe (RP);Tank Structure(TS) Other(specify): Other Repair not Listed and/or Additional Comments: RELEASE DETECTION Tank ID: Tank ID: 1 Tank ID: Tank ID: 1. Install/ Repair release detection equipment(specify): Sump Sensor(SUMP); Automatic Line Leak Detector(ALLD); Other(specify): OTHER REPAIR 1. Install/Repair under dispenser containment(UDC) 2. Repair piping(<50%of piping run) (specify): FLEX ST FRP FLEX Other(specify): 3. Replacement of piping(>50%of piping run, must install DW) (specify): DW ST FRP FLEX Other(specify): Other Repair not Listed We are changing the existing unleaded slave tank to Diesel and replacing (6)dispensers. (3)3+0 an and/or Additional (3)3+1.All original vapor piping is staying attached Comments: 2 ECY 070-71 (Rev.January 2013) The following items shall be Initialed by the Certified Supervisor whose YES NO N/A signature appears below. 1. Have all items checked above been installed, repaired, or replaced per code and manufacturer's requirements and in accordance with federal and/or state kw regulations? 2. Has the owner/operator been provided with written documentation of the kw item(s) installed, repaired or replaced? Date work was completed: V111. SIGNATURES I hereby attest, that I have been the Certified Supervisor present on site during the above listed retrofitting/repair activities, and to the best of my knowledge they have been conducted in compliance with all applicable state and federal laws, regulations and procedures,pertaining to underground storage tanks. PERSONS SUBMITTING FALSE INFORMATION ARE SUBJECT TO FORMAL ENFORCEMENT AND/OR PENALTIES UNDER CHAPTER 173-360 WAC. Date Sighat a of ICC Certified Provider Print or Type Name Date Signature of UST Owner/Operator Print or Type Name 3 ECY 070-71 (Rev.January 2013) i i M RETROFIT/REPAIR CHECKLIST FOR UNDERGROUND STORAGE TANKS INSTRUCTIONS • This Underground Storage Tank(UST) checklist is required for retrofit and repair activities on regulated USTs. Completing this checklist documents and certifies the activities are performed and conducted in accordance with Chapter 173-360 WAC. • 'Phis checklist must be tilled out completely by an International Code Council (ICC) certified provider for Installation and Retrofits of USTs within 30 days following the completion of the retrofit and repair activity. • A copy of the completed form must be provided to the tank system owner/operator. • The owner/operator is responsible for submitting a copy of the completed checklist to Ecology within 30 days of completing the activity. I. UST Facility: Complete this section about the UST facility and use the Facility Compliance Tag# (License Plate) and/or UST ID#(if known)to help identify the location. II. ICC Certified Provider: Complete this section about the ICC certified supervisor and service provider company. III. UST Owner/Operator: Complete this section about the owner or operator of the UST facility. IV. System Information: This section should be completed based on field observations. Use the bolded abbreviations, where applicable. V. Tank Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed, complete "Other"and provide additional information in Comments section.Use the bolded abbreviations, where applicable. VI. Piping Retrofit/Repair Information: Complete all sections that apply. If work performed is not listed, complete "Other" and provide additional information in Comments section. Use the bolded abbreviations,where applicable. VII. Checklist: Initial in the appropriate box to answer the questions. VIII. Signatures: The ICC Service Provider must sign and date the completed form. Mail Checklist to: Department of Ecology Underground Storage Tank Section PO Box 47655 Olympia, WA 98504-7600 If you need this document in a format for the visually impaired call the Toxics Cleanup Program at 360-407-7170. Persons with hearing loss, call 711 for Washington Relay Service.Persons with a speech disability,call 877-833-6341. 4 ECY 070-71 (Rev.January 2013) i OPERATING PERMIT APPLICATION . Appendix D Removal of Aboveground and Underground Storage Tanks Department of Community&Economic Development City of Arlington•18204 59th Ave NE•Arlington,WA 98223•Phone(360)403-3551 ■ An Operating Permit is required prior to the removal and/or decommissioning of any aboveground storage tank (AST) or underground storage tank (UST), unless specifically exempted per the WAC 173. ■ An Operating Permit is required for any temporary tank closure, change in service, and permanent tank closure for all AST's or UST's. ■ The following is required prior to the issuance of any AST Operating Permit: o Site Check/Site Assessment Checklist, DOE form ECY 010-158. o Removal plan for all hazardous materials. o Appropriate certifications and insurances of contractor(s). ■ The following is required prior to the issuance of any UST Operating Permit: o Appropriate DOE forms. o Closure and Site Assessment Notice. 0 30-Day Notice. o Site Check/Site Assessment Checklist, DOE form ECY 010-158. Revised 5/12/2008 q . T � 4 ` Permit Information Date 9/26/2017 Permit Number 1669 Project Name Arco Applicant Name NW Environmental Solutions,Inc. Applicant Address P.O.Box 1583 City,State,Zip Sumner,WA 98390 Contact Kevin Phone 253-211-6213 Email kevin@nes-test.com Permit Type Commercial Mechanical Site Address 3521 172nd Street NE Valuation 22000.00 Status Applied Permit Issued Permit Expires Square Feet 0 Type of Construction/Occupancy Load Number of Stories 1 Proposed Use Pump replacement Assigned To Launa Peterson Property Parcel Address Subdivision Lot Owner 31052100302900 3521 172ND ST NE SSA PROPERTIES LLC Contractors Contractor Name Primary Contact Phone Email Contractor Type License License# VW Environmental Solutions,Inc. cevin@nes-test.com CONTRACTOR Labor&Industries JNWENVES964MB Review Date Type Description I Target Date Completed Date Assigned To Status 9/26/2017 lCommercial Mechanical 3/27/2017 J<evin Olander Iln Review Fees Fee Descri tion Notes Amount Mechanical Permit Base Fee 322.10.00.00 $25.00 Mechanical Plan Review Fee 322.10.00.00 $25.00 Processin /Technolo Fee 341.43.00.02 $25.00 Total $75.00 Uploaded Files Upload File_ Date File Uploaded B 1 9/26/2017 3:58:44 PM I669 App,Opc :t,DOC.pdf Aerson,Launa I x ! �aY COMMERCIAL MECHANICAL • PERMIT APPLICATION INc,��2 Department of Community&Economic Development City of Arlington • 18204 59th Ave NE•Arlington,WA 98223 • Phone(360)403-3551 THIS APPLICATION MUST BE ACCOMPANIED BY TWO (2) SETS OF CONSTRUCTION DRAWINGS AND ALL OTHER INFORMATION OUTLINED IN THE MECHANICAL PERMIT SUBMITTAL REQUIREMENTS, IF APPLICABLE. Type of Permit: New Installation EJ Replacement U0 Alteration Project Address: :J� • �7T�� _1k,.r,-7-4kf Parcel#: � 60 6(f) . d Project Description: A)h 1-1,AIZ- f'1��;Ai- Valuation: Owner: 7 S ,��/7so G�v Phone#: Address: l?!3� /2!S�iltJ�A� City: , /L �^� State�__J6— Zip: 9s96-? -? Email Address:' 0 oM Contact Person: Phone M Address: /f 7? 2 A70 AV �A/ City:��� � �� State• Zip: Email Address: C Contractor Name: 4_/�. -110 G Phone#: Contractor Address:����� /�'d 7 City:E , i�� State_Zip: � Email: d Contact Person: 14- V/,-/ (� Contractor License Number: ,A/!.J //ef-I 9 6�/ 1,S Expiration Please indicate type of number of appliances: FURNACE CONDENSING UNIT GAS PIPING OUTLET BOILER HEAT PUMP(multi-split) UNIT HEATER CHILLER HEAT PUMP(mini-split) PAINT BOOTH COOLER HEAT PUMP(other) TYPE I HOOD AC(air cooled) HEAT REJECTION EQUIP TYPE II HOOD AC(water cooled) VENTILATION SYSTEM AST AC(evaporator) PACKAGED UNIT UST AC(VRF) DRYER OTHER I hereby certify that the above information is correct and that the construction on, and the occupancy and the use of the above- described property will be in ac rdolke:with the laws, rules and regulation of the State of Washington. Applicants Signature., 'l! Date' // '� .-� Applicants Primed Nartla' I I FOR STAFF USE ONLY Rece1Ved it '0 n Permit# Acce By Amount Received Receipt# Da a ecElv@ib L U) 6/16LP Page 1 of 1 OPERATING ' PERMIT APPLICATION _ Department of Community& Economic Development City of Arlington-18204 59th Ave NE-Arlington,WA 98223-Phone(360)403-3551 Part I Applicant/Building Information Applicant's Name: 4 �/6 Applicant's Address: 3 le- �N(' ,� _ Contact Person-- ,,�� ,� �. Telephone: �S s` Z�1• �2 l Address of Premises for which Operating Permit is requested: E2-§ame as above ❑ Other(specify): Tax Parcel ID#: > 1© 5'•Z/n,n :,1, WU6 Current Occupancy Class: Part II Type of Operating Permit An Operating Permit is required to conduct any activity or to use any class of building listed below. Please indicate the type(s)of Operating Permit(s)requested by checking each applicable box. (If you require assistance, or would like more information, contact the City of Arlington Building Department at 360-403- 3551.) ❑ Manufacturing, storing or handling hazardous materials in quantities exceeding those listed in the Fire Code (see Appendix A.) Identify the materials and quantities and describe the manner in which the materials will be manufactured, stored or handled(attach additional sheets if necessary): Revised 4/l/08 Page 1 of 4 Part H(cont'd) ❑ Conducting a hazardous process or activity, including, but not limited to, any commercial or industrial operation which produces combustible dust as a byproduct, fruit and crop ripening, waste handling, spray operations, and high-piled storage(see Appendix B.)Describe the process(es)or activity(ies)to be conducted (attach additional sheets if necessary): ❑Use of pyrotechnic devices in assembly occupancies (see Appendix C.)Describe the devices to be used and type of event(attach additional sheets if necessary): ❑ Aboveground Storage Tank(AST)(see Appendix D) ❑ Removal ❑ Decommissioning ❑ Temporary tank closure ❑ Changes in service ❑ Permanent tank closure Brief description: []'l�'nderground Storage Tank(UST)(see Appendix D) ❑ Removal ❑ Decommissioning ❑ Temporary tank closure ❑ Changes in service ❑ Permanent tank closure Briefdescrip 'on: , .4ZG i ❑ Temporary Membrane Structures, including tents and canopies(see Appendix E.)Brief description of structure and use: Cc: Fire Department Page 2 of 4 Part II (cont'd) ❑ Special Event Operating Permit-An Operating Permit is required for any special event that takes place within an occupied building, or an outdoor mass gathering,which is outside the scope of the permitted use(see Appendix F.)Brief description of type of gathering proposed: Part III Premises/Building Information 1. Date of last inspection of Premises: 2. Has a Certificate of Occupancy been issued for the premises?❑ Yes ❑No Type: ❑Permanent❑ Temporary Date of Issuance: 3. Are there currently any open Building Permits associated with the premises? ❑ Yes ❑No If yes, please describe(attach additional sheets if necessary): 4. Additional Comments: SIGNATURE OF APPLICANT I herby certify that the foregoing information(and all information in attached sheets, if any) is true and complete. ? 75 - Signature of Applicant Authorized Representatives Signature Date Name and Title (if applicable)of person signing Application (Please print) Cc: Fire Department Page 3 of 4 Date: 04/10/2026 Perm t#: 1669 Permit Date: 09/26/2017 Review Date: 09/26/2017 Perm it Type: COMM IRCIAL MECHANICAL Review Type: COMM 1RCIAL MECHANICAL Target Date: 09/27/2017 Scheduled Time 00:00 Com pleted Date: 09/27/2017 Description: Must provide piping pressure test Review Status: Assigned To: BUILDING Tim eln: 00:00 Time O it: 00:00 H curs: 0.0 Property Information Parcel#: 31052100302900 S SA PROPERTIES LLC SSA PROPERTIES LLC 2 9305 TERRENO LANE 3521 172ND ST NE V ALENCIA, CA 91354 Zoning: 549 Other Retail Trade -Food NECLot: Block: Permit#: 1669 Permit Date: 09/26/17 Permit Type: COMM IRCIAL M ECHANICAL Project Nam a Arco Applicant Nam a NW Environm mtal Solutions, Inc. Applicant Address: P.O. Box 1583 Applicant, City, State, Zip: Sum mr,WA98390 Contact: Kevin Phone: 253-211-6213 Em al: kevin@nes-test.com Scope of Work: Pum preplacem mt Valuation: 22000.00 Square Feet: 0 Num ber of Stories: 1 Construction Type: O xupancy G ioup: ID Code: Permit Issued: Permit Expires: Form Permit Type: Status: LASERFICHE Assigned To: Launa Black Property Parcel# Address L egat Description O wner Nam e Caner Phone Zoning 31052100302900 3 521 172ND ST NE SSA PROPERTIES 549 Other Retail LLC Trade-Food NEC Contractors Contractor P rim ay Contact P hone A ddress C ontractor Type L icense License# NW Environm aital P.O.Box 1583 CONSTRUCTION Labor&NWENVES964MB Solutions,Inc. CONTRACTOR Industries Plan Reviews Date R eview Type D escription A ssigned To R eview Status 09/26/2017 COMMIRCIAL Must provide piping pressure test B UILDING MECHANICAL Fees Fee D escription N otes A m cunt Mechanical Base P erm i Fee $ 25.00 Mechanical Com m mial Plan Review T able 4-1 $ 25.00 Processing/Technology $25.00 Total $75.00 Attached Letters Date Letter D escription 09/27/2017 Building Perm i Paym acts Date Paid By D escription P aym art Type A ccepted By A m cunt 09/27/2017 Kevin Wilkerson 6 6609375 c c $75.00 O ttstanding Balance $0.00 Notes Date Note C reated By: 12/12/2019 Perm i not signed.Filed under address R aelynn Jones Uploaded Files Date File Nam e 09/26/2017 2653250-1669 App,O en rating,DOE.pdf