## r

TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAI D # : 

# I0IS 3 Date : /JlMl^O O 7 Address : Remediatio nContractor : Coasta l Environmenta l Group

_Year : 2007 SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S i

/ Video of propert y (DVD ) |)^^i , ifl > 

## M Executiv eSummar y S r

EPA-provide dpropert y sketc h E

lSigne dAcces s Agreemen t fo r subjec t propert y D Signe dAcces s Agreement(s ) fo r adjacen t propert y S TRestoratio nAgreemen t D Settlemen t document s (i.e. , fo r damag eo r t o replac eplants , etc. ) 0 ^ Confirmatio ndat a 0 Photograph s SO-CMit i Dgi6<^<> ^ S i As-buil t sketc h
• mSatisfactor y restoratio nsigne db y Propert y Owne r HPropert y close-out check lis t signedby EP A // / 7 1 2J)0~ J D Descriptio nof area s not meeting RO D cleanu p criteri a D Utilit y clearance s ^ Propert y informationfromDougla s Count y Assessor' s Office 

# urtsyerj j flg^ds5 okoAdiA
- ^ tQi^oJl ' jirf(\ n D 

## Signatur e Dat e 4031286 0 

# IHiiili i Superfun d

# ''B ^

Fina l Repor t Propert y Chec k Lis t (Pleas e plac e wit heac hfile) Jlar dCop y Informatio n

l \Propert y Chec k Lis t 2\^it e Workin g Drawin g Ma p \ . EP A original s Ma p 4\ ^ Dougla s Count y Assessor' s Ma p 5x , Propert y Contac t Shee t Agreemen t >vAcccs s Agreemen t "2x8.estoratio nAgreemen t Miscellaneou s Document s iv f ina l Ma p fro mth e Fiel d '^Chang e Order s r^|f t ">^R FDat a ^4^n y email s o r P O correspondence s v-v ^ Propert y Completio n K

, Executiv e Summar y ^A S BUIL T ^-Propert y Completio nAgreemen t X An y buyou t inf o o r reimbursemen t inf o ^/ ^ ^ Chec k o r mone y orde r copie s f^ (' ^ • ^EP A Propert y Clos e Ou t Fon n TxAttache dBegi nVide o 

### Electroni c Documentatio n xDrawing s

r\EP A origina l "^ . Workin g Drawin g N ^ A S Built.vs o X A S Built.jp g Photo s Begi nPhoto s \2 ' During/Excavatio nPhoto s

^ So dPhoto s X ; 30-Da y So dPhoto s Scanne dDocument s Fina l Document s ^ Executiv e Summar y Video s X ^ Begi nVide o '2^ ; M y Movi e

# 9

Propert yAcces s Checklis t Property ID : j Q ) ^ ? ) n WORK STARTE D ON : / / Property Address : n WORK COMPELTED ON : / / 

# i ^ ? > 2 p Ssd Owner : / /^ J ^ ^ ^ j-± ] ^ f,^ . Renter : 1 Address : Phone : Fax : Cell/Pager : Phone : Additiona l Information : Fax : Cell/Pager : ^ ? \Q ' 7 4 2 8 1 1 Notificatio nLette r Sent : / / By : 1 ^ Acces s Agreemen t Signed : 9 / / / /

OJ By : M Restoratio nAgreemen t Signed : ' ^ /JA/OJ By : O Topsoi l Samplin g (i f applicable ) 1 1 By : 1 1 Disposa l Samplin g (i f applicable ) 1 1 By : 1 1 Garde nSamplin g (i f applicable ) 1 1 , By : J ^ Utilit y Clearanc e Called : '' 1 //" ^ /d: ^ 

## ^y-?iU^PiL^^ % 

# \Wl M

1 ^ Video/Photo s (Before ) On:£\_l_U_ I C' V By : D Video/Photo s (During ) On : / / By : D Video/Photo s (After ) On : / / By : D Video/Photo s (30-Day ) On : / / By :
• Propert y Completio nAgreemen t Signed : / / By : nFina l Repor t Issued : / / By : Ai r Monitorin g (a s applicabl e 1 1 Communit y \Z \Cre w On : / / By : 1 Results : 1 1 Communit y C H Cre w On : / / By : Results : J O Communit y C H Cre w On : / / By : Results :
Omah a Lea d Sit e

# 1015 3 j Exterio rPaint Nort h Arrow Omah a Lea d Sit e Owne rName : VINCEN TMUNI Z SR * • Goo d Sit e Sketc h Address : 461 5 S22 ST • Poo r Phone : H W. 

# ^1

1 g^o t paint Sampl e Numbe r Lea d Concentratio n Sam.pl e Collecte d LA B Firm ; Sample s Collecte d Ti^ ^

AV^fM- Q RYASCPXA-1015 3 F1 

## L22 ­ pp m 

## D Date : O ^ [ nfO^ . RYBSCPXA-1015 3 RYCSCPXA-1015 3 RYDSCPXA-1015 3 F2 B1 B2 

# \X? ^ 

# m± f^Ot e pp m pp m pp m 

# cr D D D Time ; < ; 2- 1 . Sample s Analyze d •ROZSGPX A1016 3 92 - pp m 

## D D XR F Unit ; (o'^ H Book ; I5 D •RGZSCPXA-10t5 3 RPZ3CPXA-1015 3 62 - P2 ­ pp m pp m 

# n n D D Dat e Tim e 

## H- ift-Q ^ .£M . Numbe r ofSample s = ; ^ Staf f M^W Legend ; F1 = Fron t Left ,F2 Fron t Right . B1 = Bac k Left , B2 = Bac k Righ t DZ = Dri p Zone , GZ • Garden , PZ = Pla y Al l quadrant s are as viewe d fro m th e street , facin g property

Re

v 046141.012 3^

# 1015 3 - r [ Exterio rPain t Nort h Arro w 

### Omah a Lea d Sit e Owne rName:yiNCEN TMUNI Z SR • Goo d 

### Sit e Sketc h Address : 461 5 S 22 ST Phone : H: W: Q^o t pain t Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Collecte d RYASCPXA-1015 3 F1 

## 122 . pp m 

## D Dat e O' ^ I it(oG . RYBSCPXA-1015 3 F2 

## 12.? > pp m 

## D Tim e RYCSCPXA-1015 3 RYDSCPXA-1015 3 81 B2 

### J.&5_ -fiCLk . pp m pp m 

## D D Sample s Analyze d RDZSCPX A1016 3 BZ ­ pp m 

## D D XR F Unit ; (o^' i 

### Book ; i5 0 •RSZSCPXA-1010 3 -G ^ pp m 

## D D Date ; H • IP , • O U f^PZ3CPXA-1G15 3 -P2 ­ pp m 

## D D Time ; P M Staff ; MS W Numbe r of Sample s • Legend ; F1 = Fron t Left , F2 Fron t Right , B1 = Bac k Left , B2 = Bac k Righ t DZ = Dri p Zone , GZ = Garden , PZ = Play Al l quadrants ar e as viewe d fro m th e street , facin g propert y 

# ENT E EE B APR I 

## 201) 6 

## fez 

# 80 (^ :^(o{ 5 <z > ^z^•fc •

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AoaV(A . I Rev- 4 

## S. . 2-^51 5 046141.012 3

### Dougla s County Pag e 1 o f 1 Dougla s County , Nebrask a Propert yRecor d - R041608000 0 Informatio n i s vali d a s o f 2007-7-1 9 Prin t Repor t Value s not finalize d unti l afte rBoard of Equalizatio n Vie wo n IVIa p Owne r MARTINE Z ALD O 292 2 S 2 6 S T OMAH AN E 68105-000 0 Propert yInformatio n Ke yNumber : 160 8 000 0 0 4 Accoun t Type : Residentia l Parce l Number : 041608000 0 Parce l Address : 461 5 S 2 2 ST OMAH AN E 68107-000 0 Lega l Description : SOUT H OMAH ACIT YLOT S LO T1 2 BLOC K12 2 N 1/ 2 2 5 X 13 0 Valu e Informatio n j Lan d Improvemen t 

### Total 1­ 200 7 $ 2,500.0 0 $0.0 0 $ 2,500.0 0 200 6 $ 2,500.0 0 $0.0 0 $ 2,500.0 0 200 5 $ 2,500.0 0 $0.0 0 $ 2,500.0 0 200 4 $2,500.0 0 $0.0 0 $ 2,500.0 0 200 3 $2,500.0 0 $0.0 0 $ 2,500.0 0 200 2 $0.0 0 $0.0 0 $0.0 0 Sale s Informatio n Dat e 

### 2007-01-2 3 2006-11-2 9 2000-09-0 8 

### Typ e WD M

W D Boo k 200 7 200 6 216 7 

### Pag e01161 9 13599 7

44 5 Pric e $10,000.0 0 $1.0 0 $800.0 0 Lan d Informatio n Acre s 0.0 7

i S F F F 3250. 0 25. 0 Unit s 0. 0 Dept h 130. 0 Widt h 25. 0 Vacan t Ye s Lan d Attribute s Atbibut e Attribut e Desc riptio n Improvement Informatio n



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R041. . . 8/2/200 7

## CONTAC T FOR M Propert y I D # 

# 1 0 1 5 ^ Propert y Address : 

# 4G/ 5 ^ -Z Z Initia l Contact : Date : Time : Action : Secon dContact : Date : Time : Action : Final Contact : Date : Time : Action : Final Action : Transmi t t o EP A• Othe r Action : D

Comment : Owne r Commen t (s) : Sit e Coordinato r Commen t (s) :Pi ^ i



### -1 QV»^ ^• t COASTA L fNVmOhH fNTA L C H C U fIN C 

### Consen t Fo rAcces s T o Propert y RIGH TO F ENTR YT O PREMISE S 

### Granto r(th e propert yowner ) consent s t o an d authorize s th e Unite d State s Environmenta l Protectio n Agenc y(EPA ) o rit s authorize d representatives , collectivel y th e Grantee , t o ente ran d perfor m certai n environmenta l respons e activitie s upo n th e followin g deschbe d premises : Owner' s Name : Daytim e Phone : <^ e M g"8" 0 - 7*V;^ ^

Addres s o f Propert y covere d b ythi s 

# %I 5 

# S . z z ^ 

# ^ ^ Agreement : PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EP Ai s requestin g acces s t o collect soi l sample s an d remov e soi l tha t contain s elevate d concentration s o flea d an d ma ypos e a healt h hazard . Th e area(s ) wil l b e excavate d t o remov e contaminate d soil . Th e remove d contaminate d soi l wil l b e replace d wit h clea n material s an d th e are a wil l b e restore d t o it s origina l condition . Thi s wor k i s bein g performe d unde rth e Omah a Lea d Superfun d Sit e remediatio n program . Arepresentativ e o f Coastal Environmenta l Group , contracte d b yUSEPA . wil l contac t th e Granto rin-perso n t o discus s th e wor k t o b e performed , th e Granto rwil l hav e a n opportunit yt o revie wan d approv e th e planne d soi l removal , an d restoratio n wor k befor e i t begins . Onc e th e wor k i s finished , th e Granto rwil l b e aske d t o revie wth e wor k an d confir m tha t i t i s complet e an d meet s wit h th e Grantor s approval . Upo n completion , th e Granto rwil l receiv e writte n documentatio n fro m EP Atha t th e propert yha s bee n remediated . ENVIRONMENTA L RESPONS E ACTION S 

### B ysignin g thi s Acces s Agreement , th e Granto ri s grantin g th e EPA , it s employees , contractor s an d subcontractor s th e righ t t o ente rth e property , a t al l reasonabl e time s an d wit h prio rnotice , fo rth e sol e purpos e o f performin g th e work . Thi s acces s shal l remai n i n effec t unti l th e wor k ha s bee n satisfactoril ycompleted . Th e Granto rals o agree s to :

Pag e 1 o f2/ 

# iu' t ^ m ''-r^^ / COASTA L

• " I PBOl* - C « C L fIN C 

### •Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; •Remov e flowe rbulb sorplant s tha t th e Granto r orth e Grantor' s tenan t ma ywis h to save ; •Wate ran d maintai n replacemen t vegetation , includin g fertilize rapplication , as necessarysubsequen t toan initia l waterin g perio d byEPA ; •Abid ebyhealt h an d safet yguidanc e provide dbyEPA ; • If th e propert y is rented , assis t EP A in obtainin g tenan t approva l fo racces s to th e propert yto perfor m th e work . • Allo wvideotapin g and/o rphotographin g ofth e property . AGREEMEN TNO T TO INTERFER E 

### Th e Granto ragree s not to interfer eortampe rwit h an y of th e wor k activities , orwit h an y of th e wor k done , orwit h th e equipmen t use d on hi s property , orto undertak e an y action s regardin g th e us e of sai d propert ywhic h woul d ten d to endange rth e healt h or welfar e of th e Grantee s orth e environment , or :o allo wother s to us e th e oropert y in suc h a manner . Shoul d yo u hav e an yquestion s abou t thi s program , pleas e contac t Coasta l Environmenta l Group , at (877 ) 234-6270 .



## iZf\ i I gran t acces s to mypropertie s L j I do no t gran t acces s to mypropertie s

Signatur ^ Dat Dat e e Signatur eDat e gnatur e e ^ ^

11 woul d lik e to be presen t durin g an ysamplin g tha t is required .

Paae 2 of 2 ICOASTA L 

### Restoratio n Agreemen t Th e purpos e o f thi s agreement i s t o provid e amutual agreemen t a s t o condition s o f th e property prior to remediatio nactivities . Thi s wil l als o serv e a s documentatio nfo r th e purpos e o f assurin g that restoratio n activitie s are complete dto th e satisfactio no f th e propert y owner andth e Unite dState s Environmental Protectio nAgenc y (EPA) .

Propert y 

# 1 'D : Idl5 5 Propert y Address : 

## f\U o Vi\(K(L\Y\L J \ Owner : 

## f6/5 - J - ;2. 2 ^- ^ Phone : 

### yd2 - 

# u Uo - 

# •lU t O

nth e attache ddiagram(s ) indicate area(s ) t o e.\cavate danddept ho f excavation , locationo f all known utilities , subsurfac e features , surfac e structure s andlandscapin g features , acces s location(s ) t o b e use db y contractor , an dthe directio no f North . Indicate distances , depths , materia l types , etc . hidicate digita l photo s b

y referencin g the photo-lo g number w it ha n arro w indicating directio no f view . 

### Item s T o B e Remove d B yOwne rBefor e Star t O f Remediation : (Us e additiona l sheet s a s necessary ) Th e removal , storage , disposal , and/o rretur n o f thes e item s i s th e Owner' s responsibility . Item : 

# Yym h Item : Item : Item : Item : 

### / Item : Item : Item : Pag e 1 of .COASTA L 

### Item s T o B e Remove d B yContracto rDurin g Remediatio n An d No t Replace d (Us e additiona l sheet s a s necessary ) Item : 

# n m Item : 

### ^ \ Item : \ Item : Item : i 

# 1 Item : / Item : / Item : / / Item : / Item : / Item : Item : 

# 1 Item : 

## 1 Item : Item :

Pag e 2 of .COASTA L ENVIKOrMMt N T AL 

### Item s T o B e Remove d B yContracto rDurin g Remediatio n An d Replace d (Us e additiona l sheet s a s necessary ) Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item :

Pag e 3 o fCOASTA L



## Ite m

Pre-existin g property area , that wil l b e excavated , tha t i s covere dwit horass .

Numbe r o f tree s > 2 inch trunk diamete r

Numbe r o f tree s < = 2 inch trunk diamete r

Numbe r o f Sprinkle r Zones , Contro l Valves . Timers , Heads , etc . Anac hasketc ho f th e sprinkle r la \out .
Numbe r o f andsiz e o f eac hgarden/ tlowe r bed area . .Atiacl i askeic ho f relaii\ e ^ize s andlocations . 

### Landscap e Inventor y (Us e additiona l sheet s a s necessary ) 

## Quantit y Uni t Condition/Type/Specie s

Squar e fee t

Eac h

Each

Each

Each Squar e Feet

Pag e 4 o fC O AS TA 

## Ite m Agree dupo nvalu e o f plan t material s no t t o b e replace db v contractor . Not e thi s valu e will b e use dto issu e aplan t \ouche r t o th e propert y owner . Agree dupo nlist of plant material s that will b e replace db y contractor . B e ver y specifi c anddetailed . includ e asketc hof wer e eac hplant will be place d b\
- th e contractor . Agree duponare ao f property ' to b e replace d wit hgras s sod . Includ e asketc hof the area(s ) t o he replitce dwit h gras s sod . .Are aofCit> ' or Count y propert y to b e landscape d per thei r requireinents . Includ e c i -kei.'li ol ' ih t are a(s )

Easemen t .Area, t o be excavate d 

## Quantit y

/

/ 

## Uni t

$

Eac h

S F

S F

S F 

## Condition/Type/Specie s

Pag e 5 o fCOASTA L


### Additiona l Comment s / Instructions :

n Chec k th e boxi f Owne rdoe s no t wan t CE G t o documen t interio rfoundatio n wall s an d possibl e pre-existin g damage . B ycheckin g thi s boxCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro f house , includin g foundatio n cracks o rfissures .



## Q^ a agre e H H I d o no t agre e 

## ^J/j 9 ^^^.^^vL ^ ^/ / / O 7 

# ^//^ 7 Owner' s Signatur e Dat e ,/Contf^ctor' s Sigq^rfr e Dat e 

### ^ Pag e 6 of .—* 

### Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc . vwvw.coastalhazmat.co m COASTA L ENVIRONMENTA L G H O U r. INC . 

# EXECUTIV ESUMMARY : 10153—461 5 S 2 2 S T N o Issue s o r Concern s Issues/Concern s Detai l Explanatio n

# As-Buil t Drawin g COASTA L 

### ^ 

# mah aLea dSuperfun dSit e

1015 3 Exterio rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : VINCEN TMUNI Z S R • Goo d Sit e Sketc h Address : 451 5 S 2 2 S T 4 l « • Poo r Phone : H : W : Q^o t paint Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : fje ^ A^fn- O RYASCPXA-1015 3 F 1 , pp m 

### D Date ; 0< 4 i lUCQ, . 

# o x RYBSCPXA-1015 3 F 2 

### Llf u .pp m 

### D Time ; < : 2- 1 • RYCSCPXA-1015 3 B 1 1£L ^ pp m 

### D Sample s Analyze d RYDSCPXA-1015 3 B 2 fio^ pp m 

### D RD2SGPX A1016 3

. pp m 

### D D XR F Unit ; {o1' ^ Book ; f5 0 RG15CPXA-I0I5 3 S^
- . pp m 

### D Dat e H • /ft•O U 

# n ffP2SCPXA^1015a- . pp m Tim e 

### D 

### _£M . D Staff ; Numbe ro f Sample s = 

### MS W Legend - F 1 = Fron t Left , F 2 = Fron t Right , B 1 - Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P 2 = Pla y Al l quadrant s ar e a

s viewe d from th e street , facin g propert y

OLS# : 1015 3 Dat e Excavated : 10/1/0 7 Dat e USEP A Signe d Off : 11/6/0 7 

### Legen d Dripzon e Excavate d Quadrant s Excavate d Are ano t Excavate d 

### Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .Sif> L 

# EP A EP A Propert y Clos e Ou t For m Propert yft : j D j . ^ ^ Propert y Addre«3:yP'<^ > ' . , ^ " ^ Owner' s Name : Jt h[ UQ . J ^ O^Iutify^j... ^ ^ (^ ) Date/Time : Quad s Excavated : " BJ ^ Contracto r Grou p ^,-, ns^ ^ /! > <^tA^Ujy.-rnS ^ /^ ^ Excavatio nGenera l Ye s No 1 . If necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? i / 2 . If necessary , wer e th e correc t area s o f drip zone excavate dandrestored ? y Gradin K So dan dVegetatio n 1 . Doe s th e gradin g aroun dth e perimete r of th e hous e i nexcavate darea s generall y slop e awa y fromth e house ? Ye s 

### y N o 2 . 3 . Ha s so dbee nlai dinal l area s tha t were excavated ? Doe s th e sodappea r to b e generall y healthy an dgrowing ? (Onl y evaluat e if inspecte da t a3 0 da y time period ) t / t

/ 4 . 5 . Ar e soddedarea s generall y fir man devenl y graded ? Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e if inspecte da t a3 0 da y tim e period ) y 

## y 6 . Wa s the propert y grade dsuc htha t water will not poo l o nth e property ? 

## y 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? 

## y Gates , Fence s an dRetainin g Wall s Ye s N o 1 . D o gate s ope nandclos e freely? (If applicable ) 

# y 2 . Wer e all gate s or fence s take ndowndurin g restoratio nactivitie s reinstalled ? (I f applicable ) y 3 . Wa s damag e t o gate s or fence s avoided ? (If applicable ) u ^ 4 . Wa s damag e t o retainin g wall s avoided ? (I f applicable ) y Foundation , Sidiogan dGutter s Ye s N o 1 . Wa s damag e to th e sidin g or tri mavoided ? 

### y 2 . Wa s damag e to th e foundatio navoided ? / 3 . Wa s damag e to windows avoided ? 

## y 4 . Wa s damag e to windows o r doo r screen s avoided ? 

## y 5 . Wa s damag e to downspout s o r downspout extension s avoided ? i / Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e to driveway surface s avoided ? 

# y 2 . Wa s damag e t o walkway surface s avoided ? ^

## Owner s comments :

Inspectio nnotes :

Removal an drestoratio nactivate s complet e includin g the 30-da y so dwarranty : EPA Representativ e Po. ^ A ^ Date : ,,jclc 7

## Propert yCompletio n Agreemen t Thi s agreement document s th e completio no f remedial activitie s performe do nm y property . M y signature will designate tha t I a msatisfie dwit hth e restoratio no f m y property , andthat n o item s ar e i n questions , now , or a

t an y time i nth e future , excep t thos e item s liste dbelow , if any . Propert yID : 

# / O 

# /S' 3 Propert , Aadres.s : ^ / ^ ^ ^ ^^S/ ^ 

## Q""*^ " Al/i ^

ilj/^LW/V . - ^ Pho n 

# - r4Dr^ ) ^^ o - ^ . Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item : Additiona l Comments :

I I I iiRrei ' iTstoratio ni s (-omplctcd , excep t ii s note d I I I d o no t afjree lestoriitio ni s complete d 

### 7 ^-7- 7 

# Z?/; ^ ^ -• r 

### ^^-^ ^ 

### / / ' C 

## -^"' 7 Owner' s Signatur e "ST " Dat e Contractor' s Signatur e Dat ePROPERTYCLEARANC E WORKSHEE T

Dat e Propert yI D 

# »)//)/// ; 1 

# intb s Propert y Projec t Omah a Lea d - - Fixe d Pric e Addres s 

# 4/^/S^cpp^ ^ Measuremen t XR F I D 0107-5 1 Count/Tim e Fiel d Shot s Sho t # Readin g Sampl e Are a Shot * Readin g Sampl e Are a 

# sn : ^ 4
- V 

### d~( a

Sampl e Are a 

### ^A' U 

### J Aliquo t 1 I n Sit u Readin g Composit e Reading s (Bag ) Composit e Averag e

(Bag ) Composit e (Drie d & Sieved ) Analytica l Spil t Sen t La b Numbe r Analytica l Result s 2 3 4 

# h i i n A

( XR F Correcte d Valu e ­ > 

# ? 0 i 5 (us e calibratio n char t o rad d 20 % t o value ) 

# Q(^ Sampl e Are a Aliquo t 1 2 3 4 5 I n Sit u Readin g

- 5 * • 

### ^ y . 

## Co r 

## M

y ^C i 

## R' l q- U Composit e Reading s (Bag )



## L i V XR F Correcte d Valu e —> (us e calibratio n char t o rad d 20 % t o value ) Composit e Averag e

(Bag ) 

# ^ A S 3 Composit e (Drie d & Sieved ) Pass/Fai l ? Analytica l Spil t Sen t ? La b Numbe r Analytica l Result s

Sampl e Are a Pass/Fai l ? Aliquo t 1 I n Sit u Readin g Composit e Reading s (Bag ) Composit e Averag e

(Bag ) Composit e (Drie d & Sieved ) Analytica l Spil t Sen t ? La b Numbe r Analytica l Result s 2 3 4 XR F Correcte d Valu e —> 5 (us e calibratio n char t o rad d 20 % t o value ) Sampl e Are a Pass/Fai l ? I n Sit u Composit e Composit e Analytica l Aliquo t Composit e Reading s La b Analytica l Readin g Averag e (Drie d & Spil t Sen t (Bag ) Numbe r Result s 1 (Bag ) Sieved ) 7 2 3 

### 1 4 XR F Correcte d Valu e -- > 5 (us e calibratio n char t o rad d 20 % t o value ) Sampl e Are a Pass/Fai l ? I n Sit u Composit e Composit e Analytica l Aliquo t Composit e Reading s La b Analytica l Readin g Averag e (Drie d & Spil t Sen t (Bag ) Numbe r Result s 1 (Bag ) Sieved ) 7 2 3 4 XR F Correcte d Valu e - > 5 (us e calibratio n char t o rad d 20 % t o value ) u . lis t ADOinoNA i sum s 1 1 NfFDfl ) XR F Technician' s SIgnitur i 

# Xzf^^t ^

### ~f/i d/ry/yy T ^^>^i^h^( J A^ > A 2 =
Owne rName : VINCEN TMUNI Z S R Address:4615S22S T

Phone : H : Sampl e Numbe r RYASCPXA-1015 3 RYBSCPXA-1015 3 RYCSCPXA-1015 3 RYDSCPXA-1015 3 • f)OZSGPXA-4Q16 a • RGZSCPXA-IQIG 3 f^PZ3CPXA-1015 3 W : Leac i Concentratio n F 1 

## L22 ­ F 2 B 1 

# Aa _ B 2 

### fiOO' 9Z S* - P2 - 

### Omah a Lea d Sit e Sit e Sketc h Sampl e Collecte d LA B pp m 

## D pp m 

## D pp m 

# n pp m 

# n pp m 

## D 

# n pp m 

## D D pp m 

## D D Numbe ro f Sample s = ; i ^ Exterio rPain t • Goo d " • Poo r g^o l pain t 

## 10153 1 Nort h Arro w 

### 1 Sample s Collecte d Firm : Date : Time : Sample s Analyze d XR F Unit : iol' ] Book : fS O

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## H - /ft-Q ^ Time : 

## _£M . Staff : 

## NS W

= Pla y Legend : F 1 = Fron t Left , F 2 = Fron t Righ t B 1 = Bac k Left , 8 2 = Bac k Righ t D Z = Dri p Zone , G Z ^ Garden , P Z Al l quadrant s are a s viewe d fro m th e street , facin g propert y

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