TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 5^.'^(3I Date: 3/j5/ii 

Address: ^^\i. p tocV^g . ^ 

Remediation Contractor: Coastal Environmentai Group_ Year: _2010ARRA_ 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

tif Executive Summary 

1/ EPA-provided property sketch 

Signed Access Agreement" for subject property 

Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

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

Confirmation data 

1/ Photographs \t f (k^Vd^^TlOM \ tiiO^P\\\S ^ \ ^^^ 

1/ As-built sketch 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Description of areas not meeting ROD cleanup criteria 

A Utility clearances 

Property information from Douglas County Assessor's Office 

w 

^DatT 
vv 

Property Access Checklist 

PropertylD: ^^2,2^ \ 

Property Address: p^ •* / A 

C4^i(ifY ^ 

D

D

 WORK STARTED 

 WORKCOMPELTED 

ON:

ON:

 /

 /

 / 

/ 

Owner: 

Address 

I ^ £)y>ut/^t^^ Renter: 

Phone: 

Fax: 

PhoneT

Fax: 

 C|qtf. Tj^q ^ 

Cell/Pager: 

Additional Information: 

Cell/Pager: 

D Notification Letter 

^ Access Agreement 

l/Q. Restoration Agreement 

D Topsoil Sampling (if applicable) 

D Disposal Sampling (if appUcable) 

D Garden Sampling (if applicable) 

Q UtiUty Clearance 

^ Video/Pbotos (Before) 

n Video/Pbotos (During) 

D Video/Pbotos (After) 

D Video/Pbotos (30-Day) 

n Property Completion Agreement 

n Final Report 

Sent: / / 

Signed:/^/^//( O 

Signed:/^//^/ ^ 

/ / 

/ / 

/ / 

CaUed: w / i /x„ 

On : V / Ob / u» 

On: / / 

On: / / 

On: / / 

Si&ned: / / 

Issued: / / 

By: 

By: vc V 

By= ,. ^ 

By: 

By: 

By: 

^y-xvA/xo

By: >ovo>c 

By: 

By: 

By: 

By: 

By: 

 vt-v ^ 

Air Monitoring (as appUcable) 

D Community DCrew 

Results: 

On: / / By: 1 

Q Community

Results: 

 QCrew On: / / By: 1 

D Conmiunity QCrew On: / / By: 

Results: 

Omaha Lead Site 
Douglas Cotmty Account Ii^tti^PDn Page 1 of2 

Douglas County, Nebraska Property Record - R1917720000 

Information is valid as of 2010-8-30 

New Feature

Owner 

CITY OF OMAHA 

C/0 PLANNING DEPARTMENT 

1819 FARNAM ST #1111 

OMAHA NE 68183-0000 

Property Informatio n 

Key Number: 1772 0000 19 

Account Type: Ex Government 

Parcel Number: 1917720000 

Parcel Address: 3316 CORBY ST 

OMAHA NE 68111-OOOO 

Legal Description: OMAHA VIEW LOT 21 BLOCK 12 50 X 120 

Value Informatio n 

2010 

2009 

2008 

2007 

2006 

2005 

Land 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Show All Transactions 

Improvement 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Land Informatio n 

Acres 

0.13 

SF 

6000.0 

Units 

0.0 

Deptfi 

120.0 

Print Reoort 

View Interactive GIS Mao 

Treasurer's Tax Reoort 

 -»-^- » Subdivision Sales Search 

Total 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Width 

50.0 

Vacant 

Yes 

http://douglasne.mapping-oiiline.coiii/DouglasCoNe/static/accoimtinfo.jsp?accountno=R191... 9/3/2010 
OLS#: 29321 As-Built Drawing ^ Date Excavated: 10/8/10 

Date USEPA Sioned Off: 11/23/10 COASTA L mh aha Lead Superfund ^ e Area Sodden: 4025 sq ft 

29321 

Omaha Exterior Paint Owne Lead Site r Name: Cmr OF OMAHA 

Site • Good Sketch Address: 3316 CORBY ST • Poor Phone: » 402-441-5150 

Q^Not paint 

Sample Numt)er Lead 

Concentration 

Sample 

Collected LAB 

Firm.

Samples Collected 

 lyfe-S (^^(^y^0 

RYASCPXA-29321

RYBSCPXA-29321

 Fl 

 F2 

l/°3 

ZS3 

ppm 

ppm EJ 

n 

D 

Date: 

Time; 

f/6{./ofc>" 

gf . ^^ - a-t ^ 

RYCSCPXA-29321

RYDSCPXA-29321

-«e2sepxA-2932i

 Bl 

 B2 

 ez 

2 ^ 

J,H± 

ppm 

ppm 

ppm 

Q 

B' 

D 

n 

D 

D 

Samples Analyzed 

XRF Unit lOCTJ Book: /^ 9 

RGZSCPXA 20321 GZ ppm D D Date: 9 ­ /Z-0( ^ 

RPZSCPXA. 20331 P2 ppm D D Time: Ao-^ 

Staff: ^^u / Number of Samples = 

Legend: Fl = Front LefL F2 = Front Rigtit, B1 = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

A l quadrants are as viewed from the street, facing property 

ENTERED 

SEPiO 8 m i 

82=171 PPM@6" 

EA=153PPIWI@1" 

046141 0123 

Legend 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with Area replaced with 

Sod Rock/Mulch Area lef t bare 

Contrac t #: EP-R7-07-05 Coasta l Environmental Group Inc . 
29321 Iv. \\/ M .c^ :e-«i. 

Omaha Exterior Paint 

North Amw Owne Lead Site r Name: CITY OF OMAHA 

Address: 3316 CORBY ST Site Slcetch • Good 1 • Poor Phone: H: 402-441-5150 V)^ 

(3^ Not paint 

Sample Number Lead Sample 

Samples Collected LAB Concentration Collected Firm: ^^ ^ ^^(n^ Q 

RYASCPXA-29321 Fl 1 (o ^ ppm D 

Date: l/cbCfof a 

RYBSCPXA-29321 F2 ZS 3 ppm 

D Time: ^' • ^H- • QtA/ l 

RYCSCPXA-29321 B1 ZlS" i ppm Q D 

Samples Analyzed RYDSCPXA-29321 B2 ^"•^ M ppm 

D 

ppm n D XRF Unit: 100 1 Book: \(o9 

RCZSGPXA 20321 GZ ppm D D Date: 9 - 11-OG> 

RPZCCPXA 20321 P i ppm 

D D Time: Ao ^ 

Staff: (^<,W Number of Samples • 

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

All quadrants are as viewed from the street^lacing property f* • • ' • r • • •' —. . t * ' ' .. O*"*^ ^ Jk. ' • 

046HI.0123 
« 29321 

Omah Exterior Paint North Am^w Owne a Lead Site r Name: CITY OF OMAHA 

Sit • Good e Slcetch Address: 3316 CORBY ST • Poor 

Phone: ": 402-441-5150 W: 

[3 ^ Not paint 

Sampl Lead Sample Samples Collected e Number LAB Concentration Collected Firm: 

RYASCPXA-29321 Fl llo3 ppm n Date: -r/GC/ofc. 

RYBSCPXA-29321 F2 2S3 

ppm 

n Time: <H\ a^ - a trt/1 • 

RYCSCPXA-29321 Bl 

ZSI 

ppm B n 

Samples Analyzed RYDSCPXA-29321 B2 J.W1. 

ppm D 

ppm 

U D XRF Unit /on y Book: /69 

RGZSCPXA 20321 GZ ppm D D Date: 9 • tl-OL , 

nnZCGPXA 20321 - PZ ppm D 

n Time: kry^ 

Staff: /v?w Numt)er of Samples = ' ^ 

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

All quadrants are as viewed from the street,, facing property 

Rev4 
29321 

Omah Exterior Paint NorthArrow 

Owne a Lead Sito r Name: CITY OF OMAHA 

Site • Good Sketch Address: 3316 CORBY ST • Poor Phone: H: 402-441-5150 W: 

Q^Not paint 

Sample Lead Sample 

Samples Collected Number LAB Concentration Collected Finn: >Hfe'S tNV^rt^O 

RYASCPXA-29321 F1 liflLi ppm D Date: -r/6C/ofej 

RYBSCPXA-29321 F2 2S3 ppm CJ D Time: <^'. a^ " C{ VW • 

RYCSCPXA-29321 81 I S \ ppm Q D Samples Analyzed RYDSCPXA-29321 82 iel l ppm 0' D 

RDZOCPXA-29321 BZ ppm D D XRF Unit: /Cn7 Book: /69 

RGZSCPXA 20321 GZ ppm D D Date: 9 - /2 - O ^ 

npZCCPXA'20321 P2 ppm D D 

Time: A n ^ 

Numbe Staff: r^^w r of Samples = ^ 

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

All quadrants are as viewed from the street, facing property 

--r 

ENTERED 

SEP 0 8 'im b'^'i '^^1 

^ \ "hX 

.hif. 

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l(a3 X.S^r 

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0461410123 
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Clou t

CoiiJ=eii\ fof A(:c;o-i\^ "IO I'lopeiiy 

RIGHT OF ENTRY TO PREIV/JISES 

Granlot (the property' owner) consents to and aulhorizes the United States 

Environmental Protection Agency (PPA) ot its suthorized representatives, collectively 

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

following described premises: 

Owner's l\!ame: Daytime Phorie: 

Cn^i crOi I//)/) I-i A 

Address of Property 

covered by this 

Agreement: 331^ Ccf^'^"^^'' 

PURPOSE OF RESPONSE ACTIVITIES 

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

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 performed, 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 AcTioivis 

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

contractors and subcontractors the right to enter the properly, al all reasonable times 

and with prior notice, tor 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 C A S 1 A I 

l^Yl^o»^K^^•1tI • 

' Remove obstructions incluciing boats, Iraileis, vehicles, plgyscafie \\^.\-\\^., wooo 

piles, doo houses, etc; 

< F^emove flov/ei bulbs oi plants thai ihe Grantoi or the Grantni's tenent may wish 

to save; 

Waler and maintain teplacernent vegetation, including ferliiizer applicption, as 

necessary' subsequent to an initial V\'3tering period by EPA; 

< Abide toy health and safety guidance piovided by EPA; 

( If the property' is rented, assist EPA in obtaining tenant appioval foi access lo 

the property to perform the work. 

I Allow videotaping and/or photographing of the properly. 

AGREEMENT HO I TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the work activities, oi with any 

of the work done, or with the equipment used on his properly, 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, al (402) 991-1199 

,0 1 grant access to my properties D I do not grant access to my properties 

„_.^.^ .......^ ...z^ir^v-/^..._ 

•'signature Dale Signature Date 

Q I wouid like, to be pfesent dUFitig any sampliric Uiat is leqi'ired, 

Paae 2 of 2 
C O A.s T i»,L CNVINONHCNTA L 

CROUP , IN C 

Restoration Agreement 

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

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

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

Protection Agency (EPA). '7JG'X. 7 \ 

Property ID: ffi^y^^^^JeOj/. / ^{-^^00 0 " ^?^ ^ / 

Property Address: ^ Hh^b Cc^B\ ^T. Owner: On''< Of- OA/iAHf\ 

Phone: ^w nnf) 

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. 

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

item: 

Item: 

Item 

Page 1 of y 
C O A S T A, L (NVIHONMENTA L 

CROUP , IN C 

Items to Be Removed By Contractor During Remediation and Replaced 

Item 

Landscape Inventory 

Quantity Unit Condition/Type/Species 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Nuniber of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

'tir-^ 

r-/-

Quadrants 

Each 

Each 

Nuinber of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketcii of the 

sprinkler layout. 

0 Each 

Number of and size of 

each garden/ flower bed 

area. 

.Altacii a skelch of relati\f 

sizes ancl locations. 

Each 

Square Feet 

Agreed upon value of plant 

materials not to be 

replaced by contractor. 

Note thi.s \iiluf uill hc 

used lo issue a plant 

^(»llclle|• Id tlic propcil) 

0\MU'l'. 

Easement Area, to be 

excavated 

Page 2 of y 
1 

# 

C O A S T A» U • MVinONMfNTAt . 

CROUP . IN 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. 

C] Please check this box if you understand the information outlined above. 

^Oea^ oJ' ^ ^ ^Wu^^^"^^^-^ 

n Check the box if Owner does not want CEG lo documeni interior foundation walls and possible 

pre-existing damage. By checking this box CEG is nol responsible for any damage done to the 

inlerior of house, including foundaiion cracks or fissures. 

afj n 1 do not agree agree 

fO-'l-IC <-^^~i ^ l£. wner's Signature Date Contractor's Signature Date 

Page 3 o. ^ 
BVID# Zi.3Z-| 

XRF PROPERTY SAMPLE SHEET 


Date . 1 ­ IZ. ­ ZO U Address 3S>1^ Cex-ey 

Project Omaha Lead ARRA Sample time ' am/pm 

XRF ID# ^'=^OZZ. sample length 30 sec 

Shot# Reading Sample area Shot# Reading Sample area 

la n i t is &z 

{Glr 153 t lb Depth Depth 

(60 TJ^O i t 3 ^ " 

Average /? / "^ / ^ \ / Average 

Shot# 

J^O 

/•^( 

(^ZAverage 

Reading 

43 i 18 

l^^' - l ^ 

IGi ± /°l 

/55 

Sample area 

BA 

Depth 

1" 

/g ^ 

Shot# 

Average 

Reading Samplearea 

Depth 

Shot# Reading Sample area Shot# Reading Samplearea 

Depth Depth 

Average Average 

Shot# Reading 

RETEST AREAS 

Sample area Shot# Reading Sample area 

Depth Depth 

Average 

[MMM. OMikitogs 

Average 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Certificate of Verification 

169 

SOIL 

2011-01-12 18:50 

90.99 

Final 

Avg of 166-168 

3316 CORBY ST 

B2 

6" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

± Error 

± 19.748 

'm^J^ 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 141.008 

Supervised By: 

Certificate of Verification 

166 

SOIL 

2011-01-12 18:49 

30.21 

Final 

29321 

3316 CORBY ST 

B2 

6" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

i: Error 

± 18.935 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA .01821 

XL3t-39022 

Reading No 

Mode 

Tinrie 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 133.148 

Supervised By: 

Certificate of Verification 

167 

SOIL 

2011-01-12 18:49 

30.52 

Final 

29321 

3316 CORBY ST 

B2 

6" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

± Error 

± 16.650 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 240.484 

Supervised By: 

Certificate of Verification 

168 

SOIL 

2011-01-12 18:50 

30.26 

Final 

29321 

3316 CORBY ST 

B2 

6" 

C.PADILU 

CONFIRMATIION 

CLEAR 

± Error 

23.659 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Pb 

Supervised By: 

Certificate of Verification 

173 

SOIL 

2011-01- 12 18:53 

90.97 

Final 

Avg of 170-172 

3316 CORBY ST 

EA 

1" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

± Error 

± 18.903 

M M 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 143.340 

Supervised By: 

Certificate of Verification 

170 

SOIL 

2011-01-12 18:51 

30.21 

Final 

29321 

3316 CORBY ST 

EA 

1" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

± Error 

± 18.995 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 157.076 

Supervised By: 

Certificate of Verification 

171 

SOIL 

2011-01-12 18:52 

30.57 

Final 

29321 

3316 CORBY ST 

EA 

1" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

± Error 

18.009 
Thermo 

S C I E N T I F I C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 161.223 

Supervised By: 

Certificate of Verification 

172 

SOIL 

2011-01-12 18:53 

30.19 

Final 

29321 

3316 CORBY ST 

EA 

1" 

C.PADILLA 

CONFIRMATIION 

CLEAR 

Error 

19.704 
•Sr ^^ _ ^ 

Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

www.coastalhazmat.com •'I PROl * 

COASTA L 

[NVKONNiNTAl 

GROUP . IN C 

EXECUTIVE SUMMARY: 

BVID #29321-(3316 CORBY ST) 

No Issues or Concerns Issues/Concerns 

Detail Explanation: 

-DAN GARVEY WALKED THE PROPERTY ON 12/2/2010 
4

s ^ 

EPA Property Close Out Form 

Property ff: _ 2-'^5?-} Property Address: 

Date/Ttme; Owner's Name:. /4. 

Quads Excavated: Contractor Group 

Excavation General 

1. If necessary, werc the correct quadnint(s) excavated and restored? 

2. If necessary, were the correct areas of drip zone excavated and restored? 

Grading Sod and VcKctatJon 

1. Does the grading around the perimeier ofthe house in excavaled areas generally slope away 

from tbe house? 

2. Has sod been laid m ali areas that were excavated? 

J. Does the sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 

day time period) ^ 

4. Are sodded areas generally firm and evenly giaded? 

5. Are die joints between the sod strips generally tight? (Only evaluate if inspected at t 30 day 

time period) . _ 

6. Was the properly graded such that water will not pool on the property' 

7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and ReUtaing Walls 

1. Do gates open and clo.se freely? (If applicable) 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicabk) 

3. Was damage to gates or fences avoided? (tf applicable) 

A. Was damage 10 retaining walls avoided? (Ifapplicable) 

Foundation, Siding and Gntlers 

I. Was damage to the sidmg or trim avoided? 

2. Was damage to fhe foundation avoided? 

3. Was damage to windows avoided? 

 Was damage to windows or door screens avoided? 

5. Was damage lo downspouts or downspoui extensions avoided? 

Sidewalks and Driveways (Coocrtte) 

I. Was damage lo driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

Yes No 

Yes No 

/ 

_ / 

/ 

/ 

/ 

T 

J 

Yes Nu 

/ 

/ 

/ 

/ 

Yes No 

/ 

/ 

/ 

1/ 

Ves No 

y 

y 
OM'oers comments: 

I 

[inspection no<es: 

Removal and resloration activates complele including the 30-day sod warranry: 

EPA Representative ^'^ ^ Date: tt\t\^o 
Properly Completion Agreement 

litis ayictmeni fliitumeni} ilie tomplclion ol icincdial aciivints pcloimed m my pmpcfiy My .<igiiaiuie 

wili dCMfinalr ihai i am suiiftfied wiih ihe trsunaiinn of my piopeily and ll)f>i no iicins are m questions 

WW. or at any lune m ilic fulurr i xccpi iliost iicms lisied bdow, if any 

Property Addrc»^ ^.^l i -C^OfS ^ Js A 

Owner: l_CvV>(^ '__o£_. _Q.na.^lc,-rH-^~' 

P"""' S-ii^Z .w^^-^^L., W,L-/B... 

Restoration Ilems in Queslion: 

Item: 

llem: 

Item: 

II i.jt . 

ItemItem: 

Item: 

. I 

Additional Comments: 

fW 

I J I rio not iiicrt >otot'Rlinn it toniplcirrt 

^yy^ '^'3-/^-/6 QrQ^^mm /l-^3-/D 

Ownf I 'j SignimiiT Da If Cfinliacio i 's Si(n»liii( Dalr