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?5',1'.5-SA/ -feM ex.'iEz, 44 /i1-S!�4if —et% Clean Water Services File Number '� �" C1eanWater\ Servicesisr- , Sensitive Area Pre-Screening Site Assessment ., 2 • 1. ur7sdiction• T�Ci �G I ��1 , CITY OF TIGARD) S 2. Property Information(example 1S234AB01400) 3. Owner Information Tax lot ID(s): �Sin 67(9 or) " r. v I.7uUy IM y A,D G DIVISION' Company: ( - Address: 1)5.$5 Std SOYini$& a—r, 0-2- '' Q@ Site Address: QS it 5 $t.J trriA m e.,2..Fill_to p,2. City,State,Zip: 'i 1&A2r, II,. 97 221 City,State,Zip: ► i 6,a,(-0 p/L 772.24 Phone/Fax: ,— Nearest Cross Street: E-Mail: 4. Development Activity(check all that apply) 5. Applicant information U Addition to Single Family Residence(rooms,deck,garage) Name: , it., ' --- , — 25,,-er �'aljy/AeJ ❑ Lot Line Adjustment U Minor Land Partition Company: Akt /-roe'.1 f /1-,otxyg /Au),1/4)i 'c�:) U Residential Condominium 13 Commercial Condominium Address: 124fb12/� (40 P-1 ^C- ❑ Residential Subdivision U Commercial Subdivision T CI Sin of Commercial E3 Multi Lot Commercial City,State,Zip: 614,44 ©n 97047-2 ( ) Other ] C Phone/Fax: (¢v3 � un-7Z 7 ' v • E-Mail:42e 1'Fvdc J2ro,nL vv4 f 1 Yn.ki ..Gvyi .j • 6. Will the project involve any off-site work? ❑Yes 4'No ❑Unknown Location and description of off-site work 7. Additional comments or information that may be needed to understand your project ,CR3 5 This application does NOT replace Grading and Erosion Control Permits,Connection Permits,Building Permits,Site Development Permits, DEQ 1200-C Permit or other permits as issued by the Department of Environmental Quality,Department of State Lands and/or Department of the Army COE. All required permits and approvals must be obtained and completed under applicable local,state,and federal law. By signing this form,the Owner or Owner's authorized agent or representative,acknowledges and agrees that employees of Clean Water Services have authority to enter the project site at 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 thebest of my knowledge and belief,this information is true,complete,and accurate. Print/Type Name L'._ klby,eya,&. / Print/Type Title Signature Ardir_ Date 7////if Ave FOR DISTRICT USE ONLY I❑ Sensitive areas potentially exist on site or within 200'of the site. THE APPLICANT MUST PERFORM A SITE ASSESSMENT PRIOR TO ISSUANCE 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. • ❑ Based on review of 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-Screening Site Assessment does NOT eliminate the need to evaluate and protect water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 17-05, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local,State,and federal law. In Based on review of the submitted materials and best available information the above referenced project will not significantly impact the existing or potentially sensitive area(s)found near the site.This Sensitive Area Pre-Screening Site Assessment does NOT eliminate the need to evaluate and protect additional water quality sensitive areas if they are subsequently discovered.This document will serve as your Service Provider letter as required by Resolution and Order 17-05,Section A.02.1. All required permits and approvals must be obtained and completed under applicable local,state and federal law. This Service Provider Letter is not valid unless / GWS approved site plan(s)are attached. ❑ The proposed activity 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 PROVIDER LETTER IS RE IRED. z: Reviewed by 2/.62,6Gr,yt�� Date o 7�Z��r Once complete, email to:SPLReview@cleanwaterservices.org • Fax: (503)681-4439 OR mail to: SPL Review, Clean Water Services, 2550 SW Hillsboro Highway, Hillsboro, Oregon 97123 Revised 6/2017