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City of Edmonds
DEVELOPMENT SERVTCES
PLUMBING, MECHAMCAL, TANK, & DEMOLITION
PERMIT APPLICATION
12l 5'r'Avenue N, Edmonds, WA 99020
Phone 425.77 l.OZ2O t Fax 425,77 LAZ2I
PLEASE REFER TO THE PLUMBING &, MECHANTCAL CHECKLIST FOR S(IBMTTTAL RESUIREMENTS
(Strtet, Suite #. City State, Zip):
9302 192nd St SW
PROJECTADDRESS
00434600005208
Pare!#:
lS THIS WORK ASSOCIATED WITH Á,NOTHER PROJECT? yes n No f]
Associated Permit #:
APPLICANT:
TANKS BY DALLAS
Phone:
206.365.0291
Fax:
26.361.0992
Add¡ess (Sheet, Ciry, State, Zip):
17552 BALLINGER WAY NE LFP, WA 9S155
E-Mail Address:
TAN KSBYDAL|ÁS@TAN KSBYDALLAS.N ET
PROPERTY OTVNER:
Bill Linlon
Phone:
425.418.5819
Fax
N/A
Address (Street, Ciry, State, Zip):
9302 192nd St SW, Edmonds, WA. 98020
E-Mail Address:
walinton@aol.com
LENDINGAGENCY:
NONE
Phone:Fax:
Address (Süeet, Ciry, State, Zip):E-Mail Address:
CONTRACTOR:*
TANKS BY DALI.AS
Phone:
20e.365.02S14
Fax:
206.361.0992
Address (Street, City, State, Zip):
17552 BALLINGER WAY NE tFP, WA 98155
E-Mail Address:
TAN KSBYDALLAS@TANKSBYDALLAS.NET
*contraaor must have a valid ciry of Edmonds å¡{s¡ness license príor to doìng work
in the City. Contad the City Clerk's Affice at 425.775.2525
DETAIL THE SCOpE OF WORK: Pump, Rinse, and Fill in place one (1) 3009 Home Heating Oil Tank with sand sturry mixh¡re
NR-026479
Date:
License #Æxp.
WA State License
TANKSD.OOlKF
PrintName: voN DALLAS GIGRICH I (specify):T
Signatüe:
Edmonds.
I declaru under penaily of perjury laws thort the ìntotmatìon I t ave pm vided on thisþmúapplìcatian is tttre, cotrect ønd complete,
and lhøl I un the property owner or daly øuthorized øgent otthe pmperty owner to submil apcrmìt applhatìon to the Cþ of
Von Gigrich Bi',f',v,ìBiå:,!,.':iLËH*
Owner
Date:
i,l li\,llI iIi) lr \ l( )\ ilrt
FORM C L:tsuitoing New Folder 2010\DONE & x-fened ro L-Building-New drive\Fonn C 20t4.docx Updâted: llnn0l4
Type of Gac/Alr/Vecuum System (new and relocated)Total#
Oxygen
Nitrous Oxide
Medtcal Air
Carbon Dloxide
Helium
Mdical - Surglcal Vacuum
Other:
TOTALOUTLETS
\ll l)l( \l (, \\. \lli. \ \( ( t \t
r
TANK#1 TANK#2
Method of Ab¡ndonment Method of Abandonment
Fill in Place fl p¡¡¡ ¡4¡1s¡¡4 sand $lunv Fill ln Place Flll Msterl¡l
Removal t]Re¡noval
Number of Gallons:3OO-GALLON Number of Gallons:
Crttic¡l Arcas Determination: Study Required f]ConditionalWaivern Waiver
l\\h
Type of shrrcturû to be demotíshed (e.g. house, shed, gamge, etc.);
Floor area ofstructure to be ft.
Critícal Areas Determination: Study Required Conditional Waiver tilaiver
PSCAA Case No.AHERA Survey done? (rrquirrd)
Addltional comments:
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FORM C LUuilOing New Folder 2010\DONE & x-fened to LBuiuing-New drive\Form C 20l4.docx Upd¡ted; llll¡2014
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TANK TIZE w T;nz FILL PIPE:t l)'lLf UIAMts I tsK
¡-t IlTOTAL A' LAY OFTANK-
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FILL GRADE .IO LENGTH l PI GROUND COVER PìI'I
CONTENTS OtL 20" WATER / OTHER yl ïoTAL )ot'
OFFICE NOTES:
FIELD NOTES:¡J¡
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