1. Jurisdiction: __________________________________________________________________________________________
2550 SW Hillsboro Highway • Hillsboro, Oregon 97123 • Phone: (503) 681-5100 • Fax: (503) 681-4439 • www.cleanwaterservices.org
Sensitive Area Pre-Screening Site Assessment
3. Owner Information
Name: _________________________________________
Company: ______________________________________
Address: _______________________________________
City, State, Zip: __________________________________
Phone/Fax: _____________________________________
E-Mail: _________________________________________
5. Applicant Information
Name: _________________________________________
Company: ______________________________________
Address: _______________________________________
City, State, Zip: __________________________________
Phone/Fax: _____________________________________
E-Mail: _________________________________________
2. Property Information (example 1S234AB01400)
Tax lot ID(s): _______________________________________
__________________________________________________
__________________________________________________
Site Address: _______________________________________
City, State, Zip: _____________________________________
Nearest Cross Street: ________________________________
4. Development Activity (check all that apply)
o Addition to Single Family Residence (rooms, deck, garage)
o Lot Line Adjustment o Minor Land Partition
o Residential Condominium o Commercial Condominium
o Residential Subdivision o Commercial Subdivision
o Single Lot Commercial o Multi Lot Commercial
Other _____________________________________________
__________________________________________________
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 the best of my knowledge and belief, this information is true, complete, and accurate.
Print/Type Name ________________________________________ Print/Type Title ___________________________________
Signature _______________________________________________________________________ Date ___________________
FOR DISTRICT USE ONLY
o 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.
o 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 07-20, Section 3.02.1. All required permits and
approvals must be obtained and completed under applicable local, State, and federal law.
o Based on review of the submitted materials and best available information the above referenced project will not signicantly 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
07-20, Section 3.02.1. All required permits and approvals must be obtained and completed under applicable local, state and federal law.
o This Service Provider Letter is not valid unless ______ CWS approved site plan(s) are attached.
o The proposed activity does not meet the denition of development or the lot was platted after 9/9/95 ORS 92.040(2). NO SITE ASSESSMENT OR
SERVICE PROVIDER LETTER IS REQUIRED.
Reviewed by _________________________________________________________________ Date ______________________
Clean Water Services File Number
6. Will the project involve any off-site work? o Yes o No o Unknown
Location and description of off-site work _____________________________________________________________________
7. Additional comments or information that may be needed to understand your project _____________________________
_____________________________________________________________________________________________________
