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- /r-t' 5 r ;A4/1 — cr / o ? 1,. 5 c'3 7 6 d-LI /4 I� �) cK r? f_ I I 01/01/2006 00:06 5038350662 CUSTOM VIEW CONTRAC GE 01/01 6. -- ;E ;;f (^ 'JUL 0 5 2011 ! ' 11,1 i' ;, ' II ` cle4S4 rQirvli' { IDNumber ii i I ' i.,,,A( ' l. 1, 1 I , I l. lh :I ON 1 , Ii CleanWater Services tjy _wait' Area Pre-Screening Site Assessment 1. Jurisdiction': 0. ©( Tt , 2. Property Itt:fomis Lion (example 1 S234A801400) 3. Owner Information Tax lot ID(sI:_ 'LS∎tt ckC14,g00 Name: Rywo Swicuv . Company: ,- Address: 151 3 - 7 L- - Site Address: „•_ i 5`17 Std tiEl c G {tL� City, State, Zip: l fI or 7 City, State, Zip: •Tt� Or 91242.4 Phone /Fax: _ 503 - - 13. - S - - Sq s c LL ( • Nearest Cross St eet: ___ jalsaju ,.•. i c1 , E -Mail: 4. Development Activity (check all that apply) S. Applicant Information )3( Addition to Sirgie Family Residence (rooms, deck, garage) Name: e L I FrtQ [J Lot Line Adjustment ❑ Minor Land Partition ' Company: Cue „, tdLj, _1. ► , �. L L.c . U Residential ondominium ❑ Commercial Condominium q Address: 4`1,2 t 5 E R ic L t o . In Residential 9ubdIvision la Commercial Subdivision pi Single Lot Commercial Li Multi Lot Commercial City, State, Zip: a '110 Other Phone/Fax: Sol - Vi E- Mail:( iOvvt tovJ •a, .. - 4 m•anA” QVin 6. Will the project Involve any off-site work? pl Yes X No ❑ Unknown Location and de iption of off -site work . 7. Additional Corn ents or information that may be needed to understand your project C a.d2V, # I. 4 y.40.1.1u A i(Z -) " f ' tna,,. S•D 5 or _ 1141.. ., lt� r. ca.(cee.., o.,.,J ba-ti • g . S I. ✓t' 6 No .,l • . 4. . This applic does , OT replace Grading and Erosion Control Permits, Connection Building Permits, SIto.Development Permits, DEQ. -- _ . 1200 -C Permit ar other permits as Issued by the Department of Environmental Quality, Department of State Lands andfor Department of the Army COE. All required penttlts and approvals must be obtained and completed under applicable local, state, and federal law. By signing this form, the or Owner's authorized agent or representative, acknowledges and agrees that employees of Clean Water Services have authority to enter the project site 4t all reasonable times for the purpose of inspecting project site conditions and gathering information related to the project site. I certify ! that I am familiar with the information contained in this document, and to the best of my knowledge and belief, this information is true, complete, and accurate. Printtlype Name E. L 't Fr to con Print/Type Title C-o a -c- -- C.J C. 11 ' Signature ,_ I... . A, • . C.". ` ( % Tic A .. Ll_C_ • pate S ' 18" 1 1 FOR DISTRIC USE ONLY 0 Sensitive areas pot- tlalty exist on site or within 200' of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE OF A SERVICE PROVID R LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties, a Natural Resources Assessment Report may also be requir. d. Based on review o • the submitted materials and best available information Sensitive areas do not appear to exist on site or within 200' of the site. This Sensitive Area Pre reening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered. This d umeni will serve as your Service Provider letter as required by Resolution and Order 07.20, Section 1021 All required pe its and approvals must be btalned and completed under applicable local, State, and federal law. jpr via c:iv,ta -� ¢o Le. C f , ID Based on review o the submitted materials and best available information the above referenced project will not significantly Impact the exiting or potentially sensitive areas) fond near the site. This Sensitive Area Pm- Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality senstive ar e if they are subsequently discovered. This document wit serve as your Service Provider letter as required by Resolution and Order 07 -20, Section 3.0 ,1, All required permits and approvals must be obtained and completed under applicable local, state and federal law. ❑ This Service Prov er Letter is not valid unless CWS approved site plan(s) are attached. C] The proposed act i ty does not meet the definition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR SERVICE PROV rr R LEVER I - QUIRED, Reviewed b - I1E`1!i Date 5 -L 5 ✓ t( Aim _ AC' Hx 1r, u! tV I l I- Llcri, NIryhw q • i - gi-I-Io,n, e - i rt7 ,; Phoii (`.i0 ).�St• 'IUL1 F,iz: (5(i', (:2i ,'1�i v 4/IL ,U: rai,;lrll' ile,Qirtrvlr' s of.q 1 Page 1of1 Custom View Contracting • From: "Laurie Harris" < HarrisL @CleanWaterServices.org> To: <customviewcontracting @frontier.com> Sent: Wednesday, May 25, 2011 7:13 AM Attach: 15937 SW Kreick PI 11- 002223.pdf Subject: 15937 SW Kreick PI (CWS File No. 11- 002223) Hello Eli: Attached is the completed Pre - Screen form which becomes your Service Provider Letter. Please submit the attachment to the City of Tigard. If you have any follow up questions, please contact me at 503 -681- 3639. Thank you, Laurie Harris Environmental Plan Review Clean Water Services 2550 Southwest Hillsboro Highway Hillsboro, Oregon 97123 ph: (503) 681 -3639 fax: (503) 681 -4439 e -mail: harrisl @cleanwaterservices.org 6/29/2011