HomeMy WebLinkAboutFill Source Statementrentonwa.gov/permitservices | developmentengineering@rentonwa.gov | 425-430-7240 5/1/2023 | Page 1 of 2
CITY OF RENTON Ι PERMIT SERVICES
FILL SOURCE STATEMENT
FOR PROJECTS IN THE AQUIFER PROTECTION AREA (APA)
A Fill Source Statement CERTIFIED BY A PROFESSIONAL ENGINEER OR GEOLOGIST licensed in the State of Washington
is required in the following circumstances:
•More than 50 cubic yards of fill will be imported to a project site located in Zone 1 of the Aquifer Protection Area
(APA) or
•More than 100 cubic yards of fill will be imported to a project site located in Zone 2 of the Aquifer Protection Area.
Exception: A Fill Source Statement is not required if documentation is provided that the fill to be imported comes from
a Washington State Department of Transportation approved source.
SPECIFIC CODE RELATED TO THIS DOCUMENT
RMC 4-4-060N Grading, Excavation, and Mining Regulation: Fills
INSTRUCTIONS
1.Determine if the project site is within the Aquifer Protection Area (apa). If you do not know if the project site is
within the APA, please contact Development Engineering at developmentengineering@rentonwa.gov or 425-430-
7240.
2.Acquire fill material sample at each Fill Source Site and provide sample(s) to laboratory to be analyzed to rule out
contaminations.
Note: A Fill Source Site may qualify for an ABBREVIATED FILL SOURCE STATEMENT ONLY if the source site has
never been filled, developed, or subjected to use that could have introduced chemical contamination to the site.
The abbreviated format does not require sampling and analysis of fill to detect contamination and, therefore,
reduces applicant costs.
3.Fill out the Fill Source Statement.
Note: If the Fill Source Site qualifies for an ABBREVIATED FILL SOURCE STATEMENT, only fill out page 1 and
complete the appropriate certification on page 2.
4.Submit an electronic copy of the completed Fill Source Statement and a SUMMARY ONLY of the results of sampling
and analysis of fill material from samples COLLECTED AT THE SOURCE SITE as required by RMC 4-4-060N4 for
projects located in Zone 1 and 2 of the Aquifer Protection Area. Follow sampling and analysis procedures specified
in N4 of regulations.
5.Upon submission of the completed Fill Source Statement, the City will review and determine if it is acceptable.
Note: The Department has the authority to request additional information regarding imported fill material and to
reject a source statement if it does not demonstrate that the fill material meets City standards or the Department has
reason to suspect that the fill material could be contaminated. Such requests or rejections shall be made in writing.
rentonwa.gov/permitservices | developmentengineering@rentonwa.gov | 425-430-7240 5/1/2023 | Page 2 of 2
FILL SOURCE STATEMENT
HAS THE FILL SOURCE SITE APPEARED ON THE FOLLOWING LISTS OF CONTAMINATED SITES?
a.Hazardous Sites List (per State Model Toxics Control Act)
b.National Priority List (Federal “Superfund” List)
Yes
Yes
No
No
IS THE FILL TO BE IMPORTED NATIVE TO THE FILL SOURCE SITE? Yes No
ENGINEER’S OR GEOLOGIST’S CERTIFICATION
I,___________________________________________________, a licensed professional engineer or geologist in the State of
Washington, certify that the above information is true and correct and that the fill to be imported to the project site meets
the City of Renton fill quality standards stated in the Renton Municipal Code 4-4-060N4a and b.
ABBREVIATED FILL SOURCE STATEMENT CERTIFICATION:
I, ___________________________________________________, a licensed professional engineer or geologist in the State of
Washington, certify that the above information is true and correct and that the source site does not appear on the Hazardous
Sites List (per State Model Toxics Control Act) or the National Priority List (Federal “Superfund List”). To the best of my
knowledge, fill to be imported to that project site meets that City of Renton fill quality standards state in the Renton
Municipal Code 4-4-060N4a and b and the source site has never been filled, developed, or subjected to use that could have
introduced chemical contamination to the site.
Signature: _______________________________________________________________________ Date: ____________________
Mailing Address: _____________________________________________________________Phone: ________________________
ENGINEER’S OR GEOLOGIST’S STAMP:
CURRENT AND ALL PREVIOUS LAND USES FILL SOURCE SITE: (attach additional information if necessary):
a._____________________________________________________________________________________________________
b._____________________________________________________________________________________________________
c._____________________________________________________________________________________________________
PROJECT SITE ADDRESS: PARCEL #:
IS THE PROJECT SITE LOCATED IN AQUIFER PROECTION AREA ZONE 1 OR 2? 1 2
CUBIC YARDS OF FILL TO BE IMPORTED PROJECT
PROJECT APPICANT NAME:
FILL SOURCE SITE ADDRESS & PARCEL #: