21920 HWY 99Sr4t- 1;�-m]-S-H C-o.
42 Hi6q -FIRE'PREVENPON
WSPEPTION REPORT
Servi. Lurriunds, and
12425 Meridian Ave S eEDMONbs
Moiintlake Terrace Everett, WA 98208 0 BRIER
Phone (425) 551-1200 0 MOUNTLAKE TERRACE
[I UNINCORPORATED
FAC7 A JObJL%j JL. www.FireDistrict]-org Fax (425) 551-1272
LOCATION: 21920 Highway 99 98026
r- FREQUENCY
2017
I ST�01�V SHIFT)
Starbucks Coffee #3339
BUSINESS NAME:
4257754286
SCHEDULED Aug 2017
PHONE:
DATE DUE �
MAILING 21920 Highway 99, Edmonds, WA 98026
ADDRESS:
513
UFIR
BUSINESS OWNER:v-.,
HOME PHONE:
EMERGENCY-114naA��
HOME PHONE- -42-53117-3�
KEY ACCESS-2:
' 20
HOME PHONE:
CURRENT
CITY
YES NO
BUSINESS.
EMAIL:
LICENSE
r-
PERSON CONTACTED: �04'j 1,0%-)
-1-7
INITIAL INSPECTION DATE
NAME OF INSPECTOR:�,X -Mi-A le-1
42 1AP 4
- V-7
17
=IRE SYSTEMS: FE 12/13
1
;.."T 41�1-77
FIRE PREVENTION
INSPECTION REPORT
SNOHOIVIISH CO. ;-I *vinj Biiier,: Edinonds, and 12425 Meridian Ave S
�rrace Everett, WA 98208 0 BRIER
Mountlake-.,T
Ir
IE Phone (425) 551-1200 0 MOUNTLAKE TERRACE
4rimin 0 UNINCORPORATED
www.FireDistrict].org Fax (425) 551-1272
LOCATION:
BUSINESS NAME:21920 Highway 99 98026
MAILING Starbucks Coffee #3339
ADDRESS:
BUSINESS OWNER:21920 Highway 99, Edmonds, WA 98026
PHONE:
HOME PHONE:
4257754286
FREQUENCY STATION & SHIFT*'�
SC26jt&ED 20-B
DATE DUE 0
FIR 1 0 Aug 2016
EMERGENCY-1: HOME PHONE: CURRENT
KEY ACCESS-2: HOME PHONE: CITY ES NO
.SMAbrZeFeasa_ f BUSINESS.
EMAIL: LICENSE
C(Y2, 7 -7 f — qz- KA
PERSON CONTACTED: );VA INITIAL INSPECTION DATE
NAME OF INSP ECTOR: 5pvl<�"A- fi"
01114
CITY OF EDMONDS
121 5TH AVENUE N. - EDMONDS, WASHINGTON 98020 - (425) 771-0215
FIRE DEPARTMENT
4t� S t 89 Z
LOCAnON:
21920 Highway 99
BUSINESS NAME:
Starbucks Coffee #3339
MAILING
130 Box 34067
ADDRESS:
Seaftle
BUSINESS OWNER:
Starbucks Corp
EMERGENCY-1:
Smdh, Tereasa
KEY ACCESS-2:
Schwegel, Kat
FIRE PREVENTION
SAFETY SURVEY
PHONE: 4257754286
98124
HOME PHONE: 2063188705
HOME PHONE: 4253873341
HOME PHONE: 2063084308
FREQUENCY STAnON & SHIFT
365 16 A
SCHEDULED
DATE DUE 01
LIFIR 0- 169 1157
ACTIVE
PERSON CONTACTED: _T r tx's INITIAL INSPECTION DATE
NAME OF INSPECTOR: // /
FIRE FE-3 � M
SYSTEMS:
ANNUAL
HAZARDS FOUND AND LOCATIONS COMZMICATIONS ENTER CODE ONLY ONCE I�
'(N
VIOLATION CODE
2
2
3
3
4
4
5
5
6
6
7
7
8
8
In our continuing effort to promote fire safety and prevention within the community, your fire department conducts
regularly scheduled "Fire Safety Survey Inspections" of all businesses and multi -family occupancies in the City of
Edmonds.
You are to be congratulated on the relative good condition of your occupancy in regards to fire safety. Above you
will find the item(s) that were noted during our inspection which require attention to bring them into compliance
with the minimum standards adopted by the City of Edmonds.
Please call (425) 775-7720 within 30 days to schedule a reinspection.
Any overlooked hazards or violations of the fire regulations does not imply approval of such condition or violation.
If you require additional information or assistance, please contact this off ice by calling (425) 775-7720 between
the hours of 8 a.m. and 5 p.m., Monday through Friday.
BUSINESS COPY
5
i
APPLICATION FOR PERMIT
FOR MATERIALS OR PROCESSES
March 7, 2011
Please verify and correct the following information:
D U�-- �� I F- U V Lc-�
MAP, 2
EDMONDS FIRE DEPT.
Name of Company; DBA
Starbucks #3339
Edmonds Location
21920 Highway 99
In conformity with the terms of
Places of Assembly - Occupant Load: 67
the International Fire Code,
application is hereby made to
store, use or maintain the
following activity, storage or
processes:
Mailing Address:
Starbucks Corp.
P.O. Box 34442, S-TAX2
Seattle WA 98124
EFID LIFIR #:
16106701113157
(for office use)
Your Signature
Your Name (print)
Your Title
Please make corrections, atta $40 pa able to the City of Edmonds, and mail to:
Fire Marshal
Department of Fire Prevention
121-5 1h Avenue North
Edmonds, WA 98020
CITY OF EDMONDS
DEPARTMENT OF FIRE PREVENTION
PERMIT
January 1, 2011 161-067-01 B-1 57 December 31, 2011
Date of Issue UFIR Number Date of Expiration
I This PERMIT is issued to: I Starbucks #3339
I located at: 121920 Highway 99 1 Edmonds, WA
I To engage in the business, occupation or process of: -F I
And shall constitute permission to maintain, store, use or handle materials or to conduct
process which produce conditions hazardous to life or property or to install equipment used in
connection with such activities as follows:
Places of Assembly - Occupant Load: 67
I Allowed Occupant Load: 1 6
Pursuant to the provisions of the International Fire Code, any violation of the Code may be
grounds for the revocation of this PERMIT.
This permit does not take the place of any
license required by law and is not
transferable. Any change in the use or
occupancy of premises shall require a new
permit.
Firq)marshal,j
Debbrtment of Fire Prevention
This Permit Must Be Posted At All Times in The Premises Identified Above
City of Edmonds Community Development Code 19.25.020
FIRE PREVENTION
MIS11 Co. yu Serving Brier, Edmonds 12425 Meridian Ave S INSPECTION REPORT
OEDMONDS
FIRE Mountlake Terraceand Everett, WA 98208 0 BRIER
e Town of Woodway Phone (425) 551-1200 E]WOODWAY
0 MOUNTLAKE TERRACE
_D I S T R T w"ww.FireDistrictLorg Fax (425) 551-1272 0 UNINCORPORATED
FREQUENCY ATION & SHIF7"'
LOCATION: 21920 Highway 99 365 7 �16 6
BUSINESS NAME: Starbucks Coffee #3339 PHONE: 4257754286 SCHEDULED
DATE DUE 1' 01101112
MAILING PO Box 34067 LIFIR � 169 1157
ADDRESS: Seattle 98124
A
BLISkNESS OWNER: Starbucks Corp HOME PHONE: 2063188705
ACTIVE
EMERGENCY-1: Smith, Tereasa 4253873?41
HOME PHONE: CURRENT
KEY ACCESS-2: Schwegel, Kat HOME PHONE: 2063084308 CITY YES NO
BUSINESS
LICENSE 0 0
INITIAL INSPECTION DAT
PERSON CONTACTED: it/ E
NAME OF INSPECTOR: q0 912 1 1 __1 L
FIRE F�E:Lfff_ �
SYSTEMS: Al"INU4
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
3 ------ 3
5 __. 5
6 6
7 7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION 2nd RE -INSPECTION EXTENSION FINAL RE -INSPECTION VIOLATIONS
2ATE DUE DATE DUE: GRANTED TO: DATE DUE: CITED:
PERSON PERSON PERSON
CONTACTED: CONTACTED: CONTACTED:
LNLP�CTOR: INSPECTOR: INSPECTOR: 2
DATE: DATE: DATE: 3
VIOLATIONS VIOLATIONS CITATION ISSUED
PRE -CITATION 4
1 5 1 5 LETTER SENT NUMBER:
CODE 5
6 2 6 DATE: SECTION:
RETURN RECEIPT
RECEIVED 6
DISPOSITION:
7
4 8 DATE:
b YES NO]
—LETTER NEEDED 8
LETTER NEEDED E] YES M NO
FIRE DEPARTMENT COPY
Se)lijng Brier, Edmonds
Mountlake Terraceand
the Town of Woochvay
www.FireDistrictl.org
LOCATION: '21020- 0 , Ecimonds 98026
BUSINESS NAME: Starbucks Coffee AG339
MAILING IQ C4
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
E]WOODWAY
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY I STATION & SHIFF'�
Annual 20-C
SCHEDULED
DATE DUE � Aug.
UFIR 0
ADDRESS: 11 VT
1,2425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 4257754286
BUSINESS OWNER:
HOME PHONE:
Email:
EMERGENCY-1:
CURR NT
KEY ACCESS-2:
HOME PHONE:
CITY YES NO
BUSINESS
1:1 1-1
LICENSE
PERSON CONTACTED: I/
INITIAL INSPECTION DATE
NAME OF INSPECTOR:
FJRESYSTENIS� FE It /1Z,
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
I t' I - A / I I_ - A j. i
fl
2
3 1 3
6
5
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
Ist RE -INSPECTION
2nd RE -INSPECTION
FINAL RE -INSPECTION
EXTENSION VIOLATIONS
DATE DUE:
DATE DUE:
GRANTED TO: DATE DUE: CITED:
PERSON
PERSON
PERSON
CONTACTED:
CONTACTED:
CONTACTED: 1
INSPECTOR:
INSPECTOR: 2
DATE:
DATE: 3
DATE:
VIOLATIONS
VIOLATIONS
PRE -CITATION
1. 1
1
LETTER SENT NUMBER: 4
CODE 5
2 6
2
6
DATE: SECTION:
RETURN RECEIPT
3 7
r4
3
7
RECEIVED 6
DISPOSITION:
8
4
DATE: 7
I-EiTTERNEEDED YES NO
.18
LETTERNEEDED C] YES NO
8
FIRE DEPARTMENT COPY
[ SN
% Serving Briei; Edmonds, and
:)HOMISH
11R Mountlake Terrace
11S R 'T www.FireDistrictl.org
LOCATION: 2 1 02f) Hiql),Aay 92 08026
BUSINESS NAME: Starbuck-i Colicc �=O
MAILING
ADDRESS: 21020 1 lighAav 00, i-damri&, WA 0902E
BUSINESS OWNER:
EMEIRGENCY�1-�,M_�& w
KEY ACCESS-2:
EMAIL:
PERSON CONTACTED: f7 A 4-) A
NAME OF INSPECTOR: /J b
�-IRE SYB iEms: FE 11112
12 //,;
1,2425 Meridian Ave S
Everett, WA 98208
Phone (425) 551-1200
Fax (425) 551-1272
PHONE: 42-M5428
HOME PHONE:
HOME PHONE:
HOME PHONE:
FIRE PREVENTION
INSPECTION REPORT
0 EDMONDS
0 BRIER
0 MOUNTLAKE TERRACE
0 UNINCORPORATED
FREQUENCY I STATION& SHIF_1
Pulnual 20-13
E SCHEDULED Aua 2014
DATE DUE
LIFIR
'CURRENT
CITY YES NO
BUSINESS
LICENSE
INITIAL INSPECTION DATE
10 — 6 -- Al� 6 1 Li
HAZARDS FOUND AND LOCATIONS COMMUNICATIONS
2 A -r) 0 A)
2
3
3
4
4
5
5
6
6
7
7
I AGREE TO CORRECT THE ABOVE VIOLATION(S) IN THE NEXT 30 DAYS X
1st RE -INSPECTION
DATE DUE:
2nd RE -INSPECTION
DATE DUE:
EXTENSION
GRANTEDTO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED:
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR:
INSPECTOR:
2
DATE:
DATE:
DATE:
3
VIOLATIONS
1 5
VIOLATIONS
1 5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2
6
2
6
DATE:
CODE
SECTION:
5
3
7
3
7
RETURN RECEIPT
RECEIVED
6
.4
8
4
8
DATE�
DISPOSITION:
7
LETTER NEEDED [] YES NO
rLE77ER NEEDED El YES [:1 NO
8
FIRE DEPARTMENT COPY
11 .1 a all) RM
MEMO TO:
FROM:
PROJEC
TO:
DATE:
)IVISION
DEPARTMENT DATE
NEERING DWISION DATE
FLZAa SIGN
PLANNING DIVISION DATE
nZASE SIGN
SITE ADDRESS
PERMIT 9 2,00 -ADB# --DATE INSPECTED—�L
DESCRIPTION OF WORK TO BE INSPECTED ()5T-- )ZL,AtLV/+I-
3?c / 0/ 060 q af6r, �4 " . ...
A field inspection was conducted to determine compliance with approved plans. Final approval denotes that
there are no objections from the' above signed Department to the granting of
__��_Final approval of the described work
_Performance Bonds associated with the project may be released
_GRANT FINAL PROJECT APPROVAL
GRANT FINAL PROJECT APPROVAL WITH CONDMONS NOTED
I .
I —FAILED FINAL INSPECTION - OUTSTANDING ISSUES
I .
2.
3.
R -INSPECTED OUTSTANDING ISSUES -GRANT FINAL PROJECT APPROVAL
ocaprvl.doc.l:temp:bldg:forms6/98
MAY-22-2000 12:29 GLACIER ENVIRONMENTAL
ZGLAACIER
ENV I ROW MEN T A L
Fax
T_! Paul WestDhal
Glacier Environmental Services, Inc
12521 Evergreen Drive, Suite A
Mukilteo, WA 98275
Phone: (425) 355-2826
Fax: (425) 290-9186
-7 1 Tz' 0 H-t-vq 9 1
From Steve Miles
CMP. edmonds Fire Marshall pagew. 5 including this I
Ph=m oaw; May 22,2000
raw. (425) 775-7721 Rm Confined Space Entry at 22e & HWY 99
C] urgent x IF%w Review [:] Please Cmmnent [3 please Reply E] please Recycle
Sir,
Mike Holzschuh requested that I send you confined space tmining documents for our on -site personnel
at the referenced address. Please call me if you need further infornmition.
Please note that our work is being directed by a Certified Marine Chemist from Sound Testing, Inc.
Sincerely,
Steve Miles
P. 01/05
CROWLEY MARITIME CORPORATION
presents this certificate to
for your participation in
0 0
ud Competent Person Tranung
!Smpy
A Safety Seminar
Oider rhe Seal of
--I CROWLEY MARITIME CORPORATION
0
day of June 19N7
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Cate, 0 compfetton
This is to certify that
Ronald D. Stater
has satisfactorily completed
8 hours of tfaining in
Confined Space Entry
in compliatice with WAC 296-62-145 Part M, Confincd Spaces
OSHA 29 CFR 1910.146
:q
1711111111111
_Zj,
Sep 15,1998
Ce". # 98-08259
Conducted au.
4,0 A=-Wswltor
Prezant Associates
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Associated Builders Contractdrs -of Weste; n
1999 Safety Series
of
Tyier Moore
has attended a seminar on
Confined SPace
6 Hour Series
June 22, 1999
L 4-4 A 1,
Ka thlei--rl 4CO&I:y, Execullve
MAY-22-2000 12:2-9 GLACIER ENVIRONMENTAL P.02/05
ISSUE 12-13-90 0209
DATE ------ -N?
DaviO M. S S Tech I
NAME joia cLA$S
PSFSD East Marginal WaY
SION LOCATION
(=I 223-0500
is Cemilied as mmpetentio Porform citempro confined
FokX: spaCe entry, hot work an or in vessels 3F4 5paces and
(2051223-7791 lira oreaking iIn comptiancemm tederal, state and local
regulations.
12-15-91 -- ti MANAG
?TP-IqATM 6AM CORP, AFET I CBE #28ptCSSP 0142
ASSE-M. M3, WS .
IMPOATANT! - READ pESTIqICTIONS ON BACK OF -fHIS CARO
ERMIT EXPIRES
Wy OF EDMONDS
CONSTRUCTM PERNT APPLECATPON
OWNER NAME/NAME OF BUSINESS
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PROPER Y TAX ACCOUNT PA5�EL NO.
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C] NEW C] RESIDENTIAL 0 PLUMBING MECH
ADDITION COMMERCIAL COMPLIANCE OR
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THIS PERMif AUTHORIZES ONLY THE WORK NOTED. THIS PERMIT COVER� WORK TO
BE DONE ON PRIVATE PROPERTY ONLY. ANY CONSTRUCTION ON THEPUBLIC
DOMAIN (CURBS, SIDEWALKS, DRIVEWAYS, MARQUEES, ETC.) WILL REQUIRE
t:
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PERMIT APPLICATION: 180 DAYS
CL
PERMIT LIMIT. I YEAR - PROVIDED WORK IS STARTED WITHIN 180 DAYS
SEE BACK OF PINK PERMIT FOR MORE INFORMATION
to
"APPLICANT, ON BEHALF OF HIS OR HER SPOUSE, HE IRS, ASSIGNS AND SUCCESORS
uj
IN INTEREST, AGREES TO INDEMNIFY� DEFEND AND HOLD HARMLESS THE CITY OF
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2
EDMONDS, WASHINGTON, ITS OFFICIALS, EMPLOYEES, AND AGENTS FROM ANY AND
ALL CLAIMS FOR DAMAGES OF WHATEVER NATURE, ARISING DIRECTLY OR INDIRECTLY
x
FROM THE ISSUANCE OF THIS PERMIT. ISSUANCE OF THIS PERMIT SHALL NOT BE
a
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DEEMED TO MODIFY, WAIVE OR REDUCEANY REQUIREMENT OF ANY CITY ORDINANCE
0
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NOR LIMIT IN ANYWAYTHE CITY'S ABILITYTO ENFORCE ANYORDINANCE PROVISION..
f
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION: THAT THE INFORMATION
GIVEN IS CORRECT,�AND THAT I AM THE OWNER, OR THE DULY AUTHORIZED AGENT OF
THE OWNER. I AGREE TO COMPLY WITH CITY AND STATE LAWS REGULATING CONSTRUC-
TION; AND IN DOING THE WORK AUTHORIZED THEREBY, NO PERSON WILL BE EMPLOYED
IN VIOLATION OF THE LABOR 60DE OF THE STATE OF WASHINGTON RELATING TO
WORKMEN'S COMPENSATION INSURANCE AND RCW 18.27.
OWNER AG
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DAT7 IGNED
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PLAT NAME/.SUBDIVIsibN NO. LO NO.
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PUBLIC RIGHT OF WAY PER OFFICIAL STREET MAP TESCP Approved 0
RW Permit Required 0
Street Use Pe —it Req'd 0
EXISTING — PROPOSED Inspection Required 0
Sidewalk Required 0
Underground
EQUI RED DEDICATION FT ---7— Wiring required 0
METER SIZE LINE SIZE NO�'OF'FIXTURES PRV REQUIRED
YES 0 NO CI z
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REMARKS z
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"41—)—
APPLICATION APPROVAL
CALL
This application is not a permit until signed by the
FOR INSPECTION
Building Official or his/her Deputy: and Fees are paid. and
receipt is acknowledged in space provided.
OFFICIALS SIGNATURE DATE
771-0220
Egg -M;C-
DATE
ATTENTM90' EXT 333
IT IS UNLAWFUL TO USE OR OCCUPY A BUILDING OR STRUCTURE UNTIL
A FINAL INSPECTION HAS BEEN MADE AND APPROVAL OR A CERTIFI- 771-0221 ORIGINAL -FILE - YELLOW- INSPECTOR
CATE OF OCCUPANCY HAS BEEN GRANTED. UBC SECTION 109 FA x PINK - OWNER - GOLD - ASSESSOR
5/98
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EXPLANATION
FUEL DISPENSER
APPRO
PJREj/ DIE CANOPY BOUNDARY
N
-13 1 eta
APPROXIMATE AREA OF
UNDERGROUND STORAGE TANKS
HIGHWAY 99
0 30 60
APPROX. SCALE IN FEET
7-ELEVEN, INC.
FACILITY NO. 22346
21920 HIGHWAY 99
EDMONDS, WASHINGTON
xxxxx
DRAWN BY: K. KILDAY OATE:* 08-26-99
DRAFTED BY. DEN HOLMES DAT& 08-27-99
CHECKED BY-_ DATE --
SITE PLAN
FIGURE 2
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7-Ar p 1�1�-
RECirivrn
Form Approved OMB No. 2050-0072
Tier Two
EMERGENCY
AND
HAZARDOUS
CHEMICAL
INVENTORY
Specific
Information
by ChemIcal
Community Right -to -Know #: CRK�ocCo 1 2_2-10
Revised June 1090 (REQUIRED INFORMATION) MAR
Facility Identification
Name��
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Counly.SD h Sftko 1:56
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SIC Code Dun & Brad Emergency Contact. .
EIEE Number E M] Name �� a i za 5) � �� ���v 1; �1, I ___
FOR Date
OFFICIAL Received:
USE ONLY
Important, ReacIallinstructlons before complelin� form.
Chemical Description
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Phone (5b3 Ill 7 7 - 7 7 13 Ext.
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9' D 11 -e of Pressure Avg. Dally
Check all Reactivity ro_F� Amount (code)
that apply ED rKr 0 fysr ID ED Immediate (acute)
Pure _91—x Solid Liquid Gas EHS No. of Days
EHS Name Delayed (chronic% on -site (days)
CAS Trade
- _c) f�;l EEI IT] Secret Ire Max. Daily
F07M Amount (code)
Chern. Naino . Fre'rin i �-+Ylzra hL v4e vnleAded Sudden Release
lia5bliKIL of Pressure Avg. Dally
Check 11 __�7_ Reactivity FF Tal Amount (code)
11 F-1 N�r F-1 E]
that apply E] Immediate (acute)
Pure Mix ' Solid . ldquld Gas EHS No. of Days
EHS Name Delayed (chronic) 0n.s1te (days)
Certification (read and sign after completing all secil7n—s)
rage Codes and Locations
(Non-Confidentlal)
M
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3-3
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EMEN
-
Non
NEON
NON=
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I certify under penalty of law that I have personally examined and am famlllarwlth the Information submitted In pages one thru and that based
on my inquiry of these Individuals responsible for obtaining the Informal -1—
lon, I believe that Ile submIlled lnlormatlon Is true, accurale, and complete.
M h
Name and official title of owner/operator's ulhorIzed rept4sentative -2-6-q
Signature Date slaned
OPTIONAL ATTACHMENTS
I have attached a $110 plan
I have attached a list of site
coordinate abbreviations
I have attached a description ol
dikes and other 881eguard measures
FIRE PREVEN'1710N
SAFETY SURVEY
PHONE: -7-74-5-4-5-1
CITY OF EDMONDS
CIVIC CENTER 9 EDMONDS, WASHINGTON 98020 9 (425) 775-2525
FIRE DEPARTMENT
4�' t 8
LOCATION: 21920 Highway 99
BUSINESS NAME: 7-11 Store #2306-22346B
MAILING Z�91Z'-�' -f
ADDRESS: C_()rAojsjo� WA
r-, I cr m:j w,_ L"'ST OU40"-
BUSINESS OWNER: r A I I I Q u P_ cr is HOME PHONE: r7 -7 4 — 3 c)-7
EMERGENCY- 1: p u 12,E s t-A HOME PHONE: -7-7 so-7�L -- YES 10
KEY ACCESS-2: HOME PHONE: LETTER
16HMAo NEEDED
lo PERSON CONTACTED: fA r2 INITIAL INSPECTION DATE
NAME OF INSPECTOR: F-i K r 2 - -z G-
FREQUENCY I STATION 6 SHIFT
16 A
P c I 9(cf-�
HAZARDS FOUND AND LOCATIONS / COMMUNICATIONS
IE 0 'LA C, tc- cl t e7 cl f-i �2 -V L k.�:
to) p- I c
ENTER CODE ONLY ONCE 111-
VIOLATION CODE
rs-
2
2'
3
3
4
4
5
5
6
6
7
7
C- )1+'7
8
8
lst RE -INSPECTION
DATE DUE: 3-2,,6
(up 6 a-
f-60
2nd RE -INSPECTION
DATEDUE:
EXTENSION
GRANTED TO:
FINAL RE -INSPECTION
DATE DUE:
VIOLATIONS
CITED:
PERSON
CONTACTED: r-��Aj Z
PERSON
CONTACTED:
PERSON
CONTACTED:
1
INSPECTOR:
INSPECTOR: �41V
INSPECTOR:
2
DATE:
DATE:
DATE:
3
\AOLATIOUNS
VIOL IONS
5
PRE -CITATION
LETTER SENT
CITATION ISSUED
NUMBER:
4
2 N
11
v8tj
axtktL'
2
6
DATE:
CODE
SECTION:
5
3
"6
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7
3
7
RETURN RECEIPT
RECEIVED
6
4
8
4
18
DATE,
DISPOSITION:
7
8
k, LETTER NEEDED 5 YES F�(NO
LETTER NEEDED [3 YES 0 NO
FIRE DEPARTMENT COPY
FIRWA010
EFD EF98-1139
y -
Agcy EFD Run #
Snohomish County, Washington Page
Edmonds Fire Department 05/10/19.
FIELD INCIDENT REPORT
DISPATCHED INCIDENT
---------------------
EF98-1139 Incident Date 05/10/1998 Time 09:09:52
Location 21920 SR 99, EDMONDS, WA 98020
City Map 455B County Map Census Fire Block EF157
Coord: X Y
Jurisdictional Station STATION 16
Alarm Method TELEPHONE DIRECT TO FIRE DEPARTMENT
Alarm Level 1 This incident is owned by R Purge Date
Dispatch
Date
05/10/1998
Time
09:09:54
Enroute
Date
05/10/1998
Time
09:12:34
Arrival
Date
05/10/1998
Time
09:15:57
Clear
Date
05/10/1998
Time
10:55:08
Response Time: Minutes
6 Sec 3
Incident
Duration: Hours 1 Min 45
ALL INCIDENTS
---------------
Exp # 0
Location 21920 SR 99, EDMONDS, WA 98020
City Map 455B County Map Census Fire Block EF157
Coord: X Y
Shift B SHIFT
Investigation Status
Situations Found: 1 FLAMMABLE GAS OR LIQUID CONDITION
Actions Taken: 1 ACTION NOT CLASSIFIED/SEE NARRATIVE
2 NOTIFY OTHER AGENCIES/EMERG.AGENCIES ETC
General Property Use SALES USE
Specific Property Use AT FLAMMABLE LIQUID/GAS LOADING/UNLOAUlNG FAClLlT-y
Management
Occupancy Type
Structure Type
StructureStatus
Occupied at time of Inc
Number Responding: F.F. Career
Engines
Aerial
EMS
Rescue
-
6 F.F. Volunteer
2 Trucks
Command
Tankers
Hazmat
Me b� r/R Reporting EF1126 / SbUCY - JOSEPH P
� e epo � g ,
FIRWA010 Snohomish County, Washington Page
EFD EF98-1139 Edmonds Fire Department 05/10y195
FIELD INCIDENT REPORT
Officer in Charge EF1126 / SOUCY, JOSEPH P
Weather
Air Temperature
Wildland Haz Severity
Fire Service Casualties: Injuries Fatalities
Non -Fire Service Casualties: Injuries Fatalities
Aid Type NO AUTO/MUTUAL AID GIVEN/RECEIVED OR NOT REPORTED
Aid Agency NOT APPLICABLE
Multiagency Inc. No.
Special Studies: 1
UNIT INFORMATION
------------------
Unit EDMONDS - ENGINE 16
Role FIRST IN UNIT
Crew Action Taken: 1 NOTIFY OTHER AGENCIES/EMERG.AGENCIES ETC
2 ACTION NOT CLASSIFIED/SEE NARRATIVE
Distance Travelled Dispatch Date 05/10/1998 Time 09:09:54
PERSONNEL
-----------
Role UNIT OFFICER
DID EF1126
Name SOUCY, JOSEPH P
Condition
Role DRIV
DID EF1540
Name TURNER, AMY
Condition
Role CREW
DID EF1539
Name WHITE, DONALD
Condition
EQUIPMENT
-----------
Unit EDMONDS - ENGINE 20
Role SUPPORT UNIT
Crew Action Taken: 1
-
' bistahce Travelled' Dispatch Date 05/10/1 98 Time 09'- :151
FIRWA010 Snohomish County, Washington Page
EFD EF98-1139 Edmonds Fire Department 05/10y19c�:
FIELD INCIDENT REPORT
PERSONNEL
-----------
Role UNIT OFFICER
DID EF0447 Name HERYLA, MICHAEL
Condition
Role DRIV
DID EF1082 Name FLETT, THOMAS A
Condition
Role CREW
DID EF1531 Name KINDIG, WAYNE
Condition
Action INCIDENT CLOSED
Date 05/10/1998
Employee: DID
Name
Rank
Assignment
EF1126 05/10/1998
ENGINE 16
EQUIPMENT
-----------
SIGNATURES AND ACTIVITY
-------------------------
- STATISTICS SENT
EF1126
SOUCY.`JOSEPH P
NARRATIVE
---------
ENGINE 16-RESPONDED WITH ENG20 TO A GASOLINE SPILL AT 7-11, A
ARRIVAL, E16 ASSUMED COMMAND AND OBSERVED AN AMERICAN TRANSPORT TANK |RU�K iHA
HAD BURST
A 3 INCH FILL HOSE
SPILLING APPROX 15 GALLONS OF
GASOLlNL UN THE
GROUND. THE DRIVER HAD SHUT
VALVES OFF TO STOP THE FLOW OF
FULL. E1%161hE 16,
WITH HELP
FROM E-209 CONED THE
AREA OFF AND APPLIED 4 BAGS
OF AB�OHU�Nl -IL.) Ti
SPILL. ESCA WAS NOTTFIED. NO
FUEL ENTERED THE STORM DRAlNS.
TKANSPORT DRlV�H
CONTACTED
-
HIS SUPERVISOR WHO
-
RESPONDED TO THE SCENE. CO�TALl�
��6 N�uL WI|H i��
"�rLj �'"/ ,."^�^^"�~. �.`"^.`� ^" "". ~�^.`^ ''^ ^ ."`��"~
FIRWA010 Snohomish County, Washington
EFD EF98-1139 Edmonds Fire Department
FIELD INCIDENT REPORT
Page
05/10/1%,
COULD BE CLEANED UP, SCENE WAS RELEASED TO SUPERVISOR AND MANAGER OF 7/11.
ENGINE 16 RETURNED TO QUARTERS.
ACTING LT. JOE SOUCY
ALL FIRES
----------- // L/
STRUCTURE FIRE L/
----------------
PERSON INFORMATION
--------------------
Role OTHER
Name BROWN, STEVE (TRUCK DRIVER)
Sex MALE
Race
DOB Age Soc Sec #
Type INCIDEN Address 21920 HWY 99, EDMONDS, WA q8020
Type Address
Home # Work # Hrs
Note: DICK WALL (OPERATIONS) AMERICAN TRANSPORT INC. (206) 763-4393
10835 PACIFIC HWY S, SEATTLE,WA 98168 TRUCK #253
GENERAL EMS
-------------
DETAILED EMS INFORMATION
--------------------------
Role OTHER
Name BROWN, STEVE (TRUCK DRIVER)
Sex MALE
Race
DOB Age Soc Sec #
Type INCIDEN Address 21920 HWY 99, EDMONDS, WA 98020
Type Address
Home # Work # Hrs
~
Note: DICK WALL (OPERATIONS) AMERICAN TRANSPORT INC. (206) 763-4393
10835 PACIFIC HWY S, SEATTLE,WA 98168 TRUCK 4253
EMS SUPPLEMENTAL
------------------
NUN
�^ �
------ 7__7__7_-____�___--���-_
FIRWA010
EFD EF98-1139
HazMat Release: Area
Level
Snohomish County, Washington
Edmonds Fire Department
FIELD INCIDENT REPORT
FIRE SERVICE CASUALTY
-----------------------
HAZARDOUS MATERIALS INCIDENT
------------------------------
Page
05/10/199
ON/NEAR HIGHWAY, PUBLIC WAY, STREET, PAKKIN6 LUT
Release Factors: 1 OTHER PART FAILURE, LEAK, BREA6
Estimated No. Chemicals
Equipment Involved ROAD TRANSPORT VEHICLE
HazMat Action Taken: 1 ESTABLISH SAFE AREA
2 NOTIFY OTHER AGENCIES
3 REFER TO PROPER AUTHORITY
Disposition of Incident
HazMat ID Sources:
Personnel: 1
2
Fire Service: Injured Fatalities
Non -Fire Service: Injured Fatalities
HAZARDOUS MATERIALS DETAILS
-----------------------------
MOBILE PROPERTY
-----------------
���
k_����,�c�
05/10/98 12:00:03 PRINT REQUESTED BY
TERMINAL EFT020
Incident History for:
#EF98001139
Case Numbers:
$EF98001326
Received
05/10/98
09:08:14 BY
SCT001 SC734
Entered
05/10/98
09:09:52 BY
SCT001 SC734
Dispatched
05/10/98
09:09:54 BY
SCT004 SC710
Enroute
05/10/98
09:12:34
Onscene
05/10/98
09:15:57
Closed
05/10/98
10:55:08
Initial Type:
SPILL
Initial Alarm
Level: 1 Final Alarm Level: 1
Final Type:
SPILL
(HAZ MAT SPILL/LEAK
-SPLIT RESP) Pri: 2 Dispo:
Police BLK:
E009 Fire
BLK: EF157
Mop Page: 455B-7 Group: EF1 Beat: M001 �
c: 9
'
Low 21920 SR
99 ,EDM
7- 7-11 high xst:
220 ST SW (V)
Loc Info: SEVEN ELEVEN 22346, edm
Name: EMPL Addr: 21920 HWY 99 ,EDM Phone: 4257745457
/0909 (SC734 ) ENTRY
/0909 (SC710 ) DISP E16
/0909 $ASNCAS E16
/0909 ASST E20
/0910 (SC734 ) SUPP
/0912 (SC710 )
ENROUT
E16
/0912
ENROUT
E20
/0915
ONSCNE
E16
/0916
NEWLOC
E16
/0918
MISC
E16
/0920
MISC
E16
/0920
ONSCNE
E20
/0922
CHANGE
/0923
MISC
E20
/0929
MISC
E16
/0939
AOR
E20
/0940
MISC
E16
/1049
MISC
E16
/1050
OK
E16
/1055
AOR
E16
/1055 ~
CLOSE
E16
,GASOLINE SPILL APPROX 15-20 GALLONS BY GAS TA%
ER
#EF1126 SOUCY,JOSEPH
#EF1540 TURNER, AMY
,#EF1539 WHITE, DON - HAZMAT TECH
$EF98001326
#EF0447 HERYLA,MICHAEL
#EF1082 FLETT,THOMAS
#EF1531 KINDIG, WAYNE
TXT: AREA IS BEING BLOCKED OFF - NO lN3UClt5 W
THIS TIME
, [7/11 COMMAND] , WE OBSERVE THE SCENE
[7/11 COMMAND]
-,TO E20, ENTER PARKING LOT FROM THE H]6hwm/.
NOW HAVE 5-10 GALLONS ON THE GROUND. EVALW00
,NOTIFY ESCA. SPILL IS CONTAINED. NO! EwTtRuS �
Y WATERWAYS AT THIS TIME.
,ESCA PAGED
,APPLYING ABSORBENTS
,CELL PH FOR ESCA: 206 484-5861
,REMAINING NEXT 45 FOR 7/11 SUPERVISOR
,SUPERVISOR ON SCENE
,BREAKING DOWN COMMANU, RETURNIN6 TO 1HC1
HAZARDOUS MATERIALS INCIDENT COST RECOVERY FORM
Today's Date
Submitted City of
By: Edmonds Fire Department
Department:
5/28/98
Edmonds k�
Address: 121-5' Avenue North, Edmonds, WA 98020
Company or individual responsible for the spill:
Name: American Transport, Inc.
Address: 10835 Pacific Highway S., Seattle, WA 98168
Telephone and Fax Numbers (206) 763-4393 FAX: (206) 763-4927
Contact Person Dick Wall
Date, time and location of spill:
05-10-98 at 0909 hours at 21920 Highway 99
Brief details of spill: Gasoline spill (of approximately 15 gallons) by American Transport Tank
Truck.
Names of Responders:
Total Hours
@ $45 per hour
Joe Soucy
45.00
Amy Turner
45.00
Don White
45.00
Mike Heryla
45.00
Tom Flett
45.00
Wayne Kindig
45.00
Total
270.00
Apparatus Used:
Total Hours
Cost per Hour
Total Cost
Engine # 16
150.00
150.00
Engine #20
150.00
150.00
Expended Supplies
Replacement Cost:
Absorbent (4 bags @$ 10)
40.00
Damaged Equipment: Replacement Cost:
I TOTAL REIMBURSEMENT REQUESTED: 1 $ 610.001
Send list of expenses to ESCA, 23607 Highway 99, #3-C, Edmonds, WA 98026-9272
AMordtWordFonns 111/1i�MatCo 5/28198bc
CITY OF EDMONDS LAURA M. HALL
CIVIC CENTER - EDMONDS, WA 98020 - (206) 771-0215 - FAX (206) 771-0208 MAYOR
FIRE DEPARTMENT
8 9 0 - 1 9 C� -
February 3, 1994
Southland Corporation
7-Eleven Store 23.06-22346-B
1035 Andover Park West
Seattle, WA 98188
The requirement for a fire permit is generally found at the
time that a business license is processed. Other hazardous
processes/ circumstances in businesses are discovered during the
Fire Department's Annual Inspections. At this time, your business
has been found to require a fire permit for the following
potentially hazardous process(es)/circumstance(s):
*Storage and dispensing of Class 1 flammable liquids
A permit application is enclosed. Please sign and return the
application with the $5 annual permit fee to:
Edmonds Fire Department
250-5th Avenue North
Edmonds, WA 98020
This permit is valid only for the following location:
21920 Highway 99, Edmonds WA
If you have any questions, please call me at the Edmonds Fire
Prevention Office at 771-0215, #301.
JJW: be
hn JV Westflall
re Preventilon'Officer
* Incorporated August 11, 1890 *
Sister Cities International — Hekinan, Japan