Report 6-
Clean Water Services FH*Number
• 1 WN 2 () M6 CIeanWater Services 1 16- 000
Sensitive rea Pre-Screening Site Assessment
L __..__-- -- JAN 2 6 2 16
4va1. Jurisdlt tP T o
RD
2. Property Information(example 1S234ABOf400) 3. Owner Information I TY OF�(� `
p Jessica Joan PatinoArreola BUILDING I�I�� rC�N
Tax lot ID(s: Name:
],Sf 0, 1�,�QQ_YCompany:
Address:10 0 SW PARK ST.
SiteAddrees: 169150 SW PARK ST. City,State,Zip;GARDOR 4223
City,State,Zip:TIGARD OR 4W3. -? Aij Phone/Fax.(503)8 911
Nearest Cross Street: E-Mail: arreolelNeqotmatl.com
4. Development Activity(ohock all that apply) 5. Applicant Information
® Addition to Single Famiy,Residence(rooms,deck,garage) Name:MIKE MONTGOMERY
Q lot Line Adjustment ❑ Minor Land Partition Company:SIMPL HOME DESIGNS
❑ Residential Condominium Q Commercial Condominium Address:4931 SW 76TH AVE., PMB 211
❑ Residential Subdivision Q Commercial Subdivision PORTLAND OR 97225
❑ Single Lot Commercial (3 Multi lot Commercial City,State'Zip'_PORTLAND
Other INSTALLATION OF NEW COVER PORCH Phone/Fax:503-515-6495 0/503-7194625 F
E-Mail..mikernWzpermits.biz
6. VVIII the project involve any off-ette work? n Yes ®No ❑Unknown
Location and description of off-site work
T. Additional comments or Information that may be needed to understand your project
This appticetton does NOT replace Grading and Erosion Control Permits,Connection Permits,]Bullfrog Permits,Site Development Permits,DEO
1200-C Permit or other permits as issued by the Department of Ibnrironmental Quality,Department of State Lands andlor Blur tmont of the Army
COE.All required permits and approvals must be obtained and completed under applicable local,able,and federal leer,
By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and egress that employees of Clean Water Services have authority
to enter the protect site at all reasonable times for the nurnnm of inoiwsrno prr4M alto eonMona and pawodng Wormadon rdaod to rtw proj6d aRe. I ce*
that 1 am familiar wilh the Information contained h this document,and to the best of my knowledge and belief,this Information is We.complete,and accurate.
PrinMpe Name We Montgomery prinMpe Title Agent for owner
Signature Data Jan 19,2016
FOR DISTRICT USE ONLY
❑ Sensitive areas potentially exist on sine or within 200'of the site. THE APPLICANT MUST PERFORM A.31TE ASSE88MENT PRIOR TO NUANCE OF A
SERVICE PROVIDER LETTER. If Sensitive Areas exist on the site or within 200 feet on adjacent properties,a Natural Resources Assessment Report
may also be required.
[] Basad on review of the submitted materials and best available Information Senetdve areas do not appear to exist on site or within 200'of the site.This
Sensitive Area Fre-Soreening Site Assessment does NOT eliminate the need to evaluate and protect water quaaty sensalve areas if they are Subsequently
discovered.This document will serve as your Servtoe Provider letter as required by Resolution and Order 07-20, Section 3.02.1.Allrequired permits and
approvale must be obtalned end oompleted under appk*eble local,State,and federal law.
Bated on review of the submitted materials and best available information the above refsrermil project wig not signtlea*impact the existing or potentially
sensitive aras(s)found near the aIle.This SeneltiveAres Pre,Saeen%SasAseesernent does NOT eliminale the need lo evaluate and proles additional water
quality sensitive areas if they are subsequently d1wovered.This document will cisme as your Service Provider letter as required by Resolution and Order
07-20,Section 3.02.1. AN raquir wl permits and approvals must be obtained and completed under applicable local,state and federal law.
Q This Service Provider Letter Is rot valid unless CWS approved site plan(s)are attached.
The propos d activlt does nol*m4 not . the definition of development or the lot was platted after 9/9196 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE
? Ravi Date
Summary of Deposits to Key Bank 4412 on 01/26/2016 Deposit Summary 1/25/2016 6:09 PM
Chk No. PmtMethod Rcd From Memo Amount
—----------- --------- -------------------------------
2082 Check MATT HSIAO 2,471.33
Less Cash Back:
Deposit Total: 2,471.33
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