TRANSMITTAL of OMAHA LEAD SITE 

son - REMEDIATION FILE FOLDER 

SAID#: .^?^?'^. „ Date: ////f// / 

Address: . 9SS^ ^ /O ^ ^TT " 

Remediation Contractor: Coastal Environmental Group Year: ^^/ f 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

D 

Video of property (DVD) 

Executive Summary 

EPA-provided property sketch 

^ y \ Signed Access Agreement for subject property 

Signed Access Agreement(5) for adjacent property 

7 

y Restoration Agreemeni 

Settlement documents (i.e., for damage or to replace plants, etc.) 

Confirmation data 

Photographs ^^A(//fyraj(^yi ^ ^C^ypJw ^ "^ ^ 

< As-built sketch y 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Description of areas not meeting ROD cleanup criteria 

Utility clearances 

Property information from Douglas County Assessor's Oflice 

D y^ ­

n 

I Zf/fiLLpy 

ifs&y/ 

Signattfre / 

bate 

30261 688 

iillD lui n 

Superfund 
Property Access Checklist 

Propert). ID: Z^H?' i 

Property Addrws.- 2^' ^ CZ\[ 0 S f 

D

D

 WORK STARTED

 WORK COMPELTED

 ON: 

 ON: 

/ / 

j Owner QK I O f O'^OJIKO K Renter 

Phooe: 

[Hi ^ t=^^rAA-na •!: Y *-l U

OvnoJoft,, .Kye <f-gt&5 

Phone: 

Fax: 

j CclfPager: 

i PHX: 

Ctll/Pagtr: 

Additional Inlorraittion: 

D Notification Letter 

^ Access Agrixmnt 

^ Restoration Agreement 

1 D Topsoil Sampling (if applicable] 

O Disposai Sampling (if applicable} 

• Giirdcn Sampling (if applicable)' 

(S Wiiity Clearance

D Video/Photos (Before) 

D Video/Pbofos (During) 

n VIdeo/Pholos (After) 

D Video/Photos (30-Da.v) 

. 

5 Property Complelion Agreemeni 

Zl Final Report 

Sent: 1 1 

Signed:J^ / 2. 1 \ \ 

Signed: ^ 1 2 / [[ 

1 1 

1 1 

' ' 

 Called: J&. /\SL / V.\ 

On: / / 

On: / / 

On: / / 

On: / / 

Signed: «H A ^ /\ \ 

Issued: / / | 

B.v: 

By: 

By: 

By: 

By. 

By: 

By: 

By: 

By: 

By: 

By: 

By: 

By: 

Air Monitoring (as appiicabie 

D Community D Crew

Results: 

 Oo: yyi By: 

n Comrounit)'

Results: 

 CH Crew On: / / . By: 

ED Communifj'

Results; 

Q Crc>v On: / / Bv: 

Omaha Lead Site 
Douglas Countj' Account Intormation http://douglasne • •<ping-online.com/DouglasCoNe/static/accountin 

Db,uglas County, Nebraska Propert y Record - R1712780000 

Print Report 

View Interactive GIS Map Information is valid as of 2011-5-16 Treasurer's Tax Report 

New Feature -•'••* > Subdivision Sales Search 

Owner 

CITY OF OMAHA 

C/O PLANNING DEPARTMENT 

1819FARNAM ST #1111 

OMAHA NE 68183-0000 

Propert y Informatio n 

Key Number: 1278 0000 17 

Account Type: Ex Government 

Parcel Number: 1712780000 

Parcel Address: 2858 OHIO ST 

OMAHA NE 68111-0000 

Legal Description: MARION PLACE LOT 10 BLOCK 0 50 X 127 

Value Informatio n 

Land Improvement Total 

2011 $0.00 $0.00 $0.00 

2010 $0.00 $0.00 $0.00 

2009 $0.00 $0.00 $0.00 

2008 $500.00 $0.00 $500.00 

2007 $500.00 $0.00 $500.00 

2006 $500.00 $0.00 $500.00 

Show All Transactions 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6350.0 0.0 127.0 50.0 Yes 

I of 2 5/31/2011 1:38 P^ 
•• 

Uougias Count} Account Iniormalion 

http://douglasne.i|^ping-online.com/DouglasCoNe/static/accountinft 

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Map data ©2011 Google- Term»>ef.4deE^ 

The above map is powere d bv Google , and is intended to provide a general idea of a property's location If 

yoL require a more exact property location, you may use the Interactiv e GIS Mi aps that are maintained bv 

our office. 

2 of 2 

5/31/2011 1:38 PM 
in 28833 

Exterior Paint Noitl)Anaw Omaha Lead Site 

> • Good Site Sketch i • Poor 

Sampling Address: 2858 OHIO ST CylMot paint 

Sample Number Lead Concentration XRF LAB Samples Collected 

RYASCPXA-28833 Fl ppm B D Fimri:?£j:}t^3 A^t//^) / 

£LL 

RYBSCPXA-2883 Date: 16'/.^ . 2.0/ 0 3 F2 M2. ppm Q n RYCSCPXA-28833 B1 3aa. ppm B Time: ?''/6 ^.A4. 

D RYDSCPXA-28833 B2 ^h± ppm B D Samples Analyzed 

RDZOOPXA-2Q03

RQgOGPXA-20033—SS

3 BE ppm 

a D XRF Unit: IOR0li> Book: 2AS - ppm n D Date: 10 -ZO - ID nPZOOr)(A-20033 P i ppm a D Time: A M 

Numl)er of Samples = | ^ | \ Q | Staff: tlSlfl£ 

Legend: Fl = Front Left, F2 = Front Right, Bl = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla\ 

Al quadrants aie as viewed from the sb««t, fadng propeity 

-.JEiirTa 

1 JiH.;... 

6, i 1 

y ^ 

3SH 

BZ 

M l 1:5 201ft 

/IrbSi hf - : 1 

B3/ • 2JZ •

• 

•

• 

• 

.;=/..:.... . rz 

• 

• 

'• \ 5 0' 

; ; 

d^ii )' ^ ur Rev 2001 Cmtu t 14.Scp-IO a4470I.OI.U 
As-Built Drawing OLS#:25S23 

DATE EXCAVATED: 8/20/11 

DATE USEPA SIGNED OFF : 9/20/11 

COASTAL AREA SODDEN:1973 

Environmenta Omaha Lead Superfund Site l Group, Inc. 

liliiUllilllll 28833 

Extenor Patnl 

Site Sketch 

Omaha Lead Site 

• Good 

• Poor Sampling Address: 2858 OHIO ST P^ Klot paint 

Sample Number Lead Concentration XRF LAB Samples Collected 

RYASCPXA-28833 F1 aLL—ppfT i B D Fimi A€JCM ^ MAI^I ^ 

RYBSCPXA-28833 

RYCSCPXA-28633 

F2 

Bl 

2.12. ppm Q D 

D 

Date

Time

 ie-t.'i-2.B/ 0 

 9-/6 jt.M. 

RYOSCPXA-28833 

RDZOOPXA-20033 

82 

-BE 

31 ^ pom 

ppm 

B 

n 

D 

D Samples Analyzed 

KOZOGrXA-20033 -€2­ ppm n D XRF Unit \CfiUj , Book 2Jte> 

n!PgOOP)(A-20033 ppm D D Date

Time

 iO-2£>-I D 

 A M 

Numljer of Samples = | Z l | | Q | Staff MSW" 

Legend: Fl = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla\ 

A l quadrants are as viewed from (tie street, fadno property 

CONCRETE DRIP ZONE EXCAVATED QUADRANTS EXCAVATED 

AREA REPLACED WITH AREA LEFT BARE AREA REPLACED WITH SOD ROCK/MULCH 

CONTRACT #: EP-R7-09-06 COASTAL ENVIRONMENTAL GROUP, INC. 
/3/ / / li 28833 

Omah Extenor Paint North Arrow a Lead Site 

Sit • Good e Sketch • Poor 

Sampling Address: 2858 OHIO ST Q Klot paint 

Sample Number Lead Concentration XRF LAB Samples Collected 

RyASCPXA-28833 Fl D Firm ?€J: ^ M\Z//^IA 

811 PP^^ 

RyBSCPXA-28833 F2 2 / 2 ppm D Date l6-L'i-2.oj O 

RYCSCPXA-28833 B1 Time 9:/ 6 /9.M. -^"IH PP"^ B D 

RYDSCPXA-28833 B2 3^ ^ ppm B D Samples Analyzed 

RDZaCPXA'20033 BE ppm D D 

RQZOCPXA'20033 Gg- ppm D XRF Unit lOfiU c Book 2 ^ n 

f»;P£OOr)(A-20033 P? ppm D Date 10-20-I D 

Time /\A ) 

Number of Samples - [ /I - [ | Q | 

Staff: M5V/ 

Legend: Fl = Front Left, F2 = Front Right, 81 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla^ 

Al quadrants are as viewed fronn the street, facing property 

iOCT 1 5 2010; ..31H ..3HH 

: BZ 

T 

1^:5 ^ l>.llr'oSf­

/..m.y ZIZ 

FZ 

7 

/; '/ 

y ' : ( : • 

/ y '• •/: • 

• y . ' ^ 

Rtv 2008 CrMttd K-Stp-10 
lilll 28833 

Exterior Paint North Arrow Omaha Lead Site 

> • Good Site Sketch i • Poor 

Sampling Address: 2858 OHIO ST 0'Klot paint 

Sample Number Lead Concentration XRF LAB Samples Collected 

RYASCPXA-28833 Fl f^ l ppm Q D 

RYBSCPXA-2883 Date: //>-/.';-2 a/ 0 3 F2 2/ 2 ppm Q n 

RYCSCPXA-28833 Bl Time: f'/ S y^.A4. 

-^IM PP"i B D 

RYDSCPXA-28833 B2 

3HH ppm B D Samples Analyzed 

RDgaGPXA-20033 BE 

— ppm n D 

RQZOCPXA-2003 XRF Unit: ICfiU a Book: 2 ^ 3 GS­ ppm D D 

RPZOOP)CA-20033 PS ppm D D Date /O •2£>' 10 

Time AM 

Numt)er of Samples = | // . 

Staff: tnv^ 

Legend: Fl = Front Left, F2 = Front Right, Bl = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla^ 

Al quadranis ate as viewed from the street, facing propeity 

i.jsriim 

iocT 15201ft JD H .;... '3\H 

61 : •' BZ 

§ 

^v 

Z0.58" ^/Irh Sl ?­

•

Af : 

83jy. ZIZ 

z

A .'-ZZ . 

/ 7

7 r \ 50' 

.w^**«­

mn ?5r Rtv 2001 CreatCft I4-S<p-10 
COASTAI r t -<^ ' INVIItOHMIHIA ENVIKONHIHTAl l

C R 0 U r . I h C 

Consent for Access To Propeiiy 

RIGHT OF ENTRY TO PREMISES 

Grantor (the property owner) consents to and authorizes the United States 

Environmental Protection Agency (EPA) or its authorized representatives, collectively 

the Grantee, to enter and perform certain environmental response activities upon the 

following described premises: 

Owner's Name: OtYVoW Daytime Phone: HO>H>A.*A-<A'^Hfc 'y\ 

Address of Property 

covered by this ^e>s?7 o\^ o -c^ 

Agreement: 

PURPOSE OF RESPONSE ACTIVITIES 

The EPA is requesting access to collect soil samples and remove soil that contains 

elevated concentrations of lead and may pose a health hazard. The area(s) will be 

excavated to remove contaminated soil. The removed contaminated soil will be 

replaced with clean materials and the area will be restored to its original condition. This 

work is being performed under the Omaha Lead Superfund Site remediation program. 

A representative of Coastal Environmental Group, contracted by USEPA, will contact 

the Grantor in-person to discuss the work to be perfomned, the Grantor will have an 

opportunity to review and approve the planned soil removal, and restoration work 

before it begins. Once the work is finished, the Grantor will be asked to review the work 

and confirm that it is complete and meets with the Grantor's approval. Upon 

completion, the Grantor will receive written documentation from EPA that the property 

has been remediated. 

ENVIRONMENTAL RESPONSE ACTIONS 

By signing this Access Agreement, the Grantor is granting the EPA, its employees, 

contractors and subcontractors the right to enter the property, at all reasonable times 

and with prior notice, for the sole purpose of performing the work. This access shall 

remain in effect until the work has been satisfactorily completed. The Grantor also 

agrees to: 

Page 1 of 2 
c: C A 5 1 *. i I ^TI*0*>KI » Ta t 

I « D l» » I » C 

Remove obstructions incljciing bocls, tieileis, vehicles, picyscepe items, wood 

piles, dog houses, etc: 

Remove fiov»'ef bulbs oi plants that the Grantoi or the Gientoi's tenant may wish 

to save; 

Water and maintain leplacement vegetation, including ferlilizei application, as 

necessar)' subsequent to an initial watering period by EPA; 

Abide by health and safety guidance piovided by EPA; 

If the property is rented, assist EPA in obtaining tenant approval foi access to 

the property' to perform the work. 

Allow videotaping and/or photographing of the property. 

AGREEMENT NOT To IKHTERFERE 

The Grantor agrees not to interfere or tampei with any of the W'orl< activities, oi with any 

of the work done, or with the equipment used on his property, or to undertake any 

actions regarding the use of said property which would tend to endanger the health or 

welfare of the Grantees or the environment, or to allow others to use the property in 

such a manner. 

Should you have any questions about this program, please contact Coastal 

Environmental Group, at (402) 991-1199 

( ^ grant access to my properties D I do not grant access to my properties 

Date Signature Date 

Q I would like to be piesent during any sampling thet is requited. 

Page 2 of 2 
VS 

C O A S T A L • NVIRONMINTA L CROUP , INC . 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions ofthe property prior to 

remediation activities. This will also serve as dociunentation for the purpose of assuring that restoration 

activities are completed to the satisfaction of the property owner and the United States Envirorunental 

Protection Agency (EPA). 

Property ID: Sl9>)ft^ ^ 

PropertyAddress: r^^^ ^ (^; ^ ^ 

Owner: C iJjlA Q^ (^MmAW 

Phone; ^^^ \ ^ ^ . ^>^,j^ft 

On the attached diagram(s) indicate area(s) to excavate, surface structures and landscaping features and 

access location(s) to be used by the contractors. Indicate distances, depths, material types, etc. 

Photographically and Videographically document the existing conditions ofthe property and the basement if 

necessary. 

Items to be Removed by the Owner before Start of Remediation: 

The removal, storage, disposal, and/or return of these items is the Owner's responsibility. 

Item: 

kj(\U -oVnr^A, VP, W . '^•oj.jiA. . 

H^-. ^ ^ 

Kem: 

Item: 

Items to be Removed by the Contractor During Remediation and Not Replaced 

Item: 

^Mux -oV^J^t^ i^ U VA'^fA, Item: 

Kem: 

Kem: 

Paget of_S_ 
COASTA L • NVmONMKNTA L GROUP . INC . 

Items to Be Removed By Contractor During Remediation and Replaced 

Item: 

_2£kii

Item: 

Item: 

Item: 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

Nimiber of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch of the 

sprinkler layout. 

Nimiber of and size of 

each garden/ flower bed 

area. 

Attach a sketch of relative 

sizes and locations. 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Easement Area, to be 

excavated 

1 soL 

Quantity 

V\ 

y 

y 

Z 

/ 

z 

V b 

Landscape Inventory 

Unit 

Quadrants 

Each 

Each 

Each 

Each 

Square Feet 

$ 

Condition/Type/Species 

Each ^tx>^s ^ "^etM^-Vs 

Pago 2 of 3 
•w O A 5 T A L 

C M O U «• , IM C 

Additional Comments / Instructions: 

The city of Omaha ordinances may prohibit you from using dirt or gravel areas on your property 

as driveways or vehicle parking areas. The Environmental Protection Agency (EPA) may be 

removing and replacing soil underlying a gravel or dirt area on your property that you may be 

using as a driveway or vehicle parking area. If this is the case, you should understand that this 

removing and replacing of soil does not mean that any illegal driveway or parking area on your 

property is made legal. To the contrary, you may be cited by the city if you use a gravel or dirt area 

as a driveway or parking area, not withstanding any removal or replacement of soil by the EPA. 

If you have any question about legality of a certain driveway or parking area, you may contact 

the city of Omaha's Planning Department at (402) 444-5150. 

lease check this box if you understand the information outlined above. 

„ Check the box if Owner does not want CEG to document interior foundation walls and possible 

e-existing damage. By checking this box CEG is not responsible for any damage done to the 

interior of house, including foundation cracks or fissures. 

Q I do not agree 

PrJ^ -^O^ miLD 

Ignature Date tractor^ Signature Date 

Page 3 of. 
BVID# 2^3 3 

XRF PROPERTY SAMPLE SHEET 


Date 9-7o-ff Address 

Project Omaha Lead ARRA Sample time 

XRF 1D# i'?«da > sample length 

Shot # Reading Sample area Shol# 

" 7 0 ll^t /r 'F\ 7V 

7 f 1 ^ ± 7(/ Depth 75­

n ^ 1 3 t./</ \ b " 1G 

Average 7r t !(/ Average 

Shot# Reading Sample area Shot# 

Depth 

Average Average 

Shot# Reading Sample area Shot# 

Depth 

Average Average 

RETEST AREAS 

Shot# Reading Sample area Shot# 

Depth 

Average Average 

Signature, 

Print Z>>^'M PAA ^ 

asx^- oH/o Sr 

am/pm 

30 sec 

Reading Sample area 

^ O t 12 >^>f 

i>T l /( / Depth 

(oVit AV y 

U 3 t 13 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Depth 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 73 

Mode Soil 

Time 2011-08-20 15:19 

Duration 90.49 

Units ppm 

Sigma Value 2 

Sequence Final 

Flags 

AVERAGE Avg of 70-72 

ADDRESS 2858 Ohio st 

QUADRANT Fl 

DEPHT 6" 

XRF TECH KING 

MISC confirmation 

NOTE confirmation 

ppm ± Error 

Pb 75.705 ± 14.689 

Supervised By: -0-^ r^ 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 84.661 

Supervised By: 

Certificate of Verification 

70 

Soil 

2011-08-20 15:17 

30.18 

ppm 

2 

Final 

28833 

2858 Ohio st 

Fl 

6" 

KING 

confirmation 

confirmation 

± Error 

± 15.238 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 69.436 

Supervised By: 

Certificate of Verification 

71 

Soil 

2011-08-20 15:18 

30.11 

ppm 

2 

Final 

28833 

2858 Ohio st 

Fl 

6" 

KING 

confirmation 

confirmation 

± Error 

± 14.432 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 73.019 

Supervised By: 

Certificate of Verification 

72 

Soil 

2011-08-20 15:19 

30.20 

ppm 

2 

Final 

28833 

2858 Ohio st 

Fl 

6" 

KING 

confirmation 

confirmation 

± Error 

± 14.397 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 63.268 

Supervised By: 

Certificate of Verification 

77 

Soil 

2011-08-20 15:23 

90.46 

ppm 

2 

Final 

Avg of 74-76 

2858 Ohio st 

EA 

1" 

KING 

EX-SITUS 

confirmation 

± Error 

± 13.935 

^^y 
O 

Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 60.456 

Supervised By: 

Certificate of Verification 

74 

Soil 

2011-08-20 15:21 

30.17 

ppm 

2 

Final 

28833 

2858 Ohio st 

EA 

l " 

KING 

EX-SITUS 

confirmation 

± Error 

± 13.718 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 65.091 

Supervised By: 

Certificate of Verification 

75 

Soil 

2011-08-20 15:22 

30.16 

ppm 

2 

Final 

28833 

2858 Ohio st 

EA 

1" 

KING 

EX-SITUS 

confirmation 

± Error 

± 14.044 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Certificate of Verification 

76 

Soil 

2011-08-20 15:23 

30.13 

ppm 

2 

Final 

28833 

2858 Ohio st 

EA 

1" 

KING 

EX-SITUS 

confirmation 

ppm ± Error 

Pb 64.257 ± 14.042 

Supervised By: 
/1|^ \

3 ^^^ZI

\y^^^

 Omaha Lead Site—Fixed Price EP-R7-09-06 

 Coastal Environmental Group Inc.

 www.coastalhazmat.com 

 VI 

COASTA L INVIIONMINTAL 

G I O U P. IN C 

EXECUTIVE SUMMARY: 

BVID #28833- (2858 OHIO ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 
' ^ 

Property Completion Agreement 

This agreement documenis Ihe completion ol remedial acliviiies perloimed on my properly. My signaiuie 

will designate Ihal I am satisfied with the restoradon ofmy properly, and thai no items are in questions, 

now, or al any lime in the futuie, except those items listed below, if any 

PropertylD: '^If^^^ ^ 

PropertyAddress: g,^^ ^ ^v ^ -E^ 

Owner: Q^^ ^ ^ ^ O^Vxo . >M-rL ' "^\\ V \..JL»-^Vv 

Phone: ^ ^ ^_^^ ^ ^ V^^HO , 

Restoration Items in Question: 

Item: 

Item: 

Item: 

ia^—e»»TPg-*«^^Bi^g| •! » Hlf^'^PW^^^'WMB 

Item: 

Item: 

Item: 

Additional Comments: 

ry j I ayrcc rr.^toralion is compieled, except as noted 

[ I I do not Ajjrec resloration i.s conipletcd 

iZ'Z^LJ y 7tif; £ ^ /h ^ fy^y^ 

Owne r Date Contrarlor' s Signalurc Dale 
EPA Property Close Out Form 

Property H: .ZKMJl. Property Addresir. ~.2l£^—QM0 ^ 

Dete/Tlne: Owtier's Wttint:. /,... Cf tV <) f Q<feg=Sig= 

Qu»di ExcEvalfd: ContrGClor Group L<5t<5'!l?L_L 

Excavation Gcncrti 

Vts No 

1. If necessBiyi ^crc the correct qiiadrant(s) excaveted and restored? 

/ 

2. If necessary, were the correel areas of drip zone excavaied wid restored? 

/ 

Grading Sod and Vegctalion Yes No 

1 Does the grBding around the pcrimeier ofthe house in excavaied areas generally slope away F ^ 

from tbe house? \-.-/­

2. Has sod been laid in all areas that were excavaied? 

i Does the lod appear to be generally healthy and growing? (Only evaluate if inipertrd at fi ?0 7 

day time period) 

4. Air sodded areas generally firm and evenly graded? / 

S Are thcjoints t>etween the sod strips generally tight? (Only tvalualt if inspecied at i 30 day 

time period) y 

6. Was the propeny graded such thai waier will nol pool on ihc property'' 7 

I 7. Was damage to landscaping or plant maierialt avoided? / 

Gales. Fencea a»d Reuining Walls _ Ve j .N(i 

I ! Do gates open and close freely? (If applicable) 

2. Were all gates oi fences taken down during restoration aciivities reinstalled? (If applicabk) / 

}. Was damage to gates or fences avoided? (If applicable) y 

4. Was damage toretaining walls avoided? (If applicable) 7 

Foupdation, SidJBK and Gutters 

Ves .No -

1. Was damage to the siding or trim avoided? 

2. Was damage tn the foundation avoided? 

Was damage to windows avoided? 

"A 

4 Was damage to windows or door screens avoided? — /

 ' 

Was damage to downspouts oi downspoul extensions avoided? 

y 1

Sidewalks and Driveways (Concrett) Vcs No 

1. Was damage to driveway surfaces avoided? A 

2. Wa.s damage lo walkway surfaces avoided? "y 
OM-ners comreients: 

Inspection notes: 

Rernoval and resloration activates complete including the 30-daY sod warranry; 

HPA Representative ^ J H Dale: «»li*l" 
0 

P^opl'^l^ Ow niT .Vsisfssnicnt of Performance Konn 

\nic-iKiin Kecf'\er> and KeiiuesinK-ni ^l.•| i \HK\) 

Omalia Lead .Superfund ,Sill' 

• 2(109 201(1 

Renu'diaiion C ooOaclor: Coaslal Environmental Group • t;i'-R7-09-(J6 

Propcrl) Identifier .ViinihcT: 2,^6? ? 

Properfy Address: 2Sff l " U^\D~ ^X '_.,„ 

ProperM Otvner's N'a/rie; C.JJ24.^0A .GOTj&!?iA ... 

Instructions (o the Piopcrry Owner; 

This form sene."; in record the Propeny f.)wners assessment (if petfnnnance (Incentive I 

Qua)jt\ .Assiiranct" .Suneillance Plan) in\ol\in^ the listed remeriialKin conlracior. as applicable 

ic the Omaha Lead .Site. Thi.* form document? the iimelincsj ofpunch lisl re.<;(i)uiion. business 

ieJaiHin.s. compiaini lesciluiion and ihcuvejal) qualilv or\\(irk If need ht. ihe Pr()pen\ Owner 

!))i!> u\[\r/c \h]s fomi U' tec did problem.^ and or issues not speciricail\ tied let cn assianed 

jicltiie.'-s. foi example. Inisin(.-.'•.'• rtlaiuvi.*^ ih^i L't-ncjal!> oon"; inljou ihc L-uidehnes ^ei fonJ! in the 

f'eifoniiancc W'oik Siaicnieni. 

The I'uiperi.v 0\Miei uijl indicaie ins liei a'^se.'-.^inem ol pciJonnaiKc unli the niiiiiactor'­

wurk h\ c/iccking.ii jii/uieriral rating on the (able helo« usintf ilic nuiiicik.ii deflnilion.'' fioiii 

tlie lalint: .scale bclou. then .sign & date the fonji 

4-1(1 ••e.vc.ellent" 

7-8 "ver> ^ood" 

.''-6 "acccpiablf" 

^-'i "poor" 

\-2 'Aciy pool' 

I'roperh ()\Mit'i\s A.ssessnicul urPeri'orniance Reaardint; (he (. oiitrucior's Work 

^ : . I . I 

I'ropti t^ l)\\ nei Addiiioiiiil (^oiiiiiicni!. fi oiii loDlioiial: ooiiijiuH- an li:ick iiat^e il iittded) 

PiopiTl) f)»n(r SioI)atIIn-; 1)111.: i^'^/-^^^ ^