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WETLAND DELINEATION / DETERMINATION REPORT COVER FORM <br />This form must be included with any wetland delineation report submitted to the Department of State Lands for review and <br />approval. A wetland delineation report submittal is not "complete" unless the fully completed and! signed report cover form and <br />the required fee are submitted. Attach the form to the front of an unbound report and submit to: Oregon Department of <br />State Lands, 775 Summer Street NE, Suite 100, Salem, OR 97301-1279 <br />Mail a copy of the completed form with payment of the required report review fee to: Oregon Department of State <br />Lands, P.O. Box 4395, Unit 18, Portland, OR 97208-4395. <br />For new credit card payment option see DSL web site <br />X Applicant X Owner Name, Firm and Address: <br />City of Eugene Public Works Parks and Open Space <br />ATTN. Eric Wold <br />1820 Roosevelt Blvd., Eugene, OR 97402 <br />❑ Authorized Legal Agent, Name and Address: <br />Business phone # 541-682-4842 <br />Mobile phone # (optional) <br />FAX # 541-682-4882 <br />E-mail eric.n.wold ci.eu ene.or.us <br />Business phone # <br />FAX # <br />Mobile phone # <br />E-mail: <br />I either own the property described below or I have legal authority to allow access to the property. I authorize the Department to access <br />the property for the purpose onfrming the informa~j'on in the report, after prior notification-to the primary c t ct. <br />Typed/Printed Name: r i e- IJ. we Signature: <br />Date:~J- ft y- p g Special instructions regarding site access: <br />Prnior4 and Ci•e 1.,i.....,..a:...- <br />- - - . . u wnyuuue, use centroia or site or start & end points of linear project <br />Project Name: Checkermallow Ditch Project Latitude: 44.0694-44.0640°N Longitude: 123.2098- <br />123.1998°W <br />Proposed Use: Fill recently excavated ditch Tax Map # 17-04-29-00 detail map 1 and 17-04-29-13 <br />Project Street Address (or other descriptive location): Township 17S Range 4W Section 29 QQ 13 <br />Park at Checkermallow Access lot (marked) on S side of Tax Lot (s) 1506 (17-04-29-00) and 101 (17-04-29-13) <br />Royal Ave. (1/3 mile E from intersection of Greenhill and <br />Royal) follow levee E and S, project is 1200' along N/ E Waterway: None River Mile: NA <br />side of levee <br />Ci : Eu ene Coun :Lane NWI Quad(s): Eugene West <br />Wetland Delineation Information <br />Wetland Consultant Name, Firm and Address: Phone # 541-822-1090 <br />Nancy Holzhauser of Environmental Solutions LLC Mobile phone # <br />55646 Drury Drive FAX # 541-822-1053 <br />Blue River, Oregon 97413 E-mail: nholz@envsol.net <br />The information and conclusions on this form and in the attached report are true and correct to the best of my knowledge. <br />Consultant Signature: Date: <br />-A" I August 20, 2008 <br />Primary Contact for report review and site access is X Consultant ❑ Applicant/Owner ❑ Authorized Agent <br />Wetland/Waters Present? x Yes ❑ No Study Area size: Approx 0.22 ac Total Wetland Acreage: 0.22 ac <br />Check Box Below if Applicable: Fees: <br />x R-F permit application submitted x Fee payment submitted $350.00 <br />❑ Mitigation bank site <br />❑ Wetland restoration/enhancement project (not mitigation) <br />❑ Industrial Land Certification Program Site <br />Other Information: <br />Has previous delineation/application been made on parcel? <br />Does LWI, if any, show wetland or waters on parcel? <br />DSL Reviewer: <br />Date Delineation Received: - / / <br />Scanned: ❑ Final Scan: ❑ <br />❑ Fee ($100) for resubmittal of rejected report <br />Name of Payor: City of Eugene <br />Y N <br />❑ x If known, previous DSL # <br />X ❑ <br />For Office Use On <br />Fee Paid Date: / / <br />DSL Project # <br />DSL WN # <br />DSL WD # <br />DSL Site # <br />DSL App. # <br />