TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 2^79^ ^ Date: lllllo7 

Address: ^2(^Z F^pr.Si- Remediation Contractor: _Coastal Environmental Group_ Year: 2007 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

D 

D 

s/ 

Video of property (DVD) 

Executive Summary 

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 

Photographs ' ' 

As-built sketch ... 

D 

D 

D 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Descriptionof areas not meeting ROD cleanup criteria ^ 

Utility clearances 

Property information from Douglas County Assessor's Office 

D 

D 

D 

40317907 

Ilillli 

Superfund 

ItliJo? ' Date 
Property Access Checklist 

f 

Property ID: ^^Q^^ ^ n WORK STARTED ON: / /_ 

 ON: /_ 

Property .Address: ^^ ^ 7^// ^ ^ n WORK COMPELTED /

Renter: 

Phone: 

Fax: 

u IHEU'K/O T Cell/Paaer: 

Phone: jj^'^ ) ^g^CJ , ^^C^ : Additional Information: 

Fax: 

Cell/Pager: 

• Notification Letter Sent: Bv: 

S ' Access Agreeme nt Sif!ned:^/^/Q 2 B.V-- t^VA^^IvXiartf^ 

S ' Restoration Agreement Signed: ^/^/a > By: ^C^^,MLr.u;tr 

O Topsoil Sampling (if applicable) / / By: 

CU Disposal Sampling (if applicable) Bv: 

I I Garden Sampling (if applicable) Bv: 

I I Utility Clearance Called: :^//4/ ^ B.v:fe- jl^b^n^ l '^// b l a ^

D Video/Photos (Before) On: By: PI 10/0 7 fjyy^-c-y^^etrl Vi-(kd 

n Video/Photos (During) On: Bv: 

n Video/Photos (After) On: Bv: 

n Video/Photos (3«-Day) On: Bv: 

I I Property Completion Agreement Signed: / / Bv: 

n Final Report Issued: Bv: 

Air Monitoring (as applicable » 

CU Community CU Crew On: / / By: 1 

Results: 

CD Community CJ Crew On: / / B.v : . II 

Results: j 

n Community CU Crew On: / / By: 

Results: 

Omaha Lead Site 
Total CJ^pFant Square Footage to be Excavated = 411 

Property Classification: 800 Total Drip Zone Linear Footage to be Excavated = 66 

Exmx 

Uv1|^<p(^(U4 

y ' y ) . .•<••:••••> : 

A , * • • ••)'• " Tfmfi^ S',:> 

7 r- /!*> li .1 ••# 1 y l 

06^M(^]1 ' Pacific street 

Legend NorthArrow Omaha Lead Site 

N Omaha, Nebraska |?^y^] Concrete 

yy \ Excavated Area Property Number 

OLS-20932 ^^ g Existing Structure Scale 

• •— • Fence Property Address 1 Inch = 20 feet or 1 grid = 5 x 5 ft 4362 PACIFIC ST ^^y^ Permanent Landscaping 

,.A^' ' ^1.3, ^ 

— — — Quadrant Boundary Post Excavation Concentrations (ppm) 

Street Boundary .\0,vv HGL F1 . B2 Play Area 

% V^]y * i — Hyiirol>r)L<iqK In, F2 DZ Easement 

(Q ) Tree/Shrub Bl Garden Other 

Description of post excavation areas: F1, front yard left-hand quadrant: F2, front yard hgtit-hand quadrant; Bl, badtyard left-hand quadrant: B2, backyard right-hand quadrant; 

DZ. drip zone (1-3 foot area of soii around the foundation of the house). 
20932 

Owner Name: DANIEL E JENSEN 

Address: 4362 PACIFIC ST 

Phone: .H3?1 J'i'TlSiyv: 

Sample Number 

RYASCPXA-20932

RYBSCPXA-20932

RYCSCPXA-20932

RYDSCPXA-20932

RDZSCPXA-20932

RGZSCPXA 20032

f^PZ3CPXA-20932

ENTZ 

Aff.G i^gyi 1 6

 Fl 

 F2 

 Bl 

 82 

 DZ 

 GZ­

 PZ 

^ 

-vJ 

Lead 

Concentration 

?s ^ 1 ppm 

g<. c< l A ppnn 

Vp O cXoQvn 

ppm 

ppm 

Omah a Lea d Site 

Site Sketc h 

Number of Samples =^^ 5 I ; [ y 

C J /^ (Ll^bt^ 

Pi) 

saOc 

1 

•^U? ^ P/ Ac, ; . • 

II 

Sample LAB Collected 

n 

D 

D 

n 

D -B -Q­ -B­ -eExteriQt-Pfnnt North AJTOW 

• "^o d 

• Poor 

• Not paint V

Samples Collected 

Firm: ?- ^ - r^ T -Pfy^. O 

Date: ^S- 1 1 • ^ 

Time: ^•^ o A./ ^ 

Samples Analyzed 

XRF Unit: %, \ \ Book: m. Date:^-:g^.O U 

Time: A »s.vi / 

Staff: 

e 

5' 

[D.^^^^ . 

\ 

-it 

^J I 

"2^/ 

Wi^\><. 

r­ 3^3 

WMl ^ 

P^c;S^:t i r 

Omaha Lead Site 46130 
CONTACT FORM 

Property ID # io']yt 

Propeity 

Address: 

\')y lu y 

Initial Contact: Date: J Time: \S^0 Action: 

Second Contact: Date: Time: Action: 

Final Contact: Date: Time: Action: 

Final Action: 

Transmit to EPA D Other Action: D 

Comment: 

Owner 

Comment (s): 

\^v ^^ h^t 

Site 

Coordinator 

Comment (s): 

(7:00) m

I900_ 

P.^^ ^ 

yi)l- L-:>o^'73(.^ p S/IO ^t . 

^ C P hy^ 

0§<l/ "^1 
>lfcO SI-4, .- * .s*'' 

COASTA L ENVIRONMENTA L 

CROUP . IN C 

Consent For Access To Property 

' . . • • ' ^ ' . 

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: 

7 ^ °ft( •^S^ r 

Owner's Name Daytime Phone jwner s Name: -v. —» ^ q'b2-3?q-l33^ 

Address of Property 

covered by this 

Agreement: rvncaag^ n e \o?io^ 

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 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 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 
V*^'^'^/	 COASTA COASTAL! 

ENVIRONMENTA L 

G R 0 U r . INC . 

• Remove obstructions including boats, trailers, vehicles, playscape items, wood 

piles, dog houses, etc; 

• Remove flower bulbs or plants that the Grantor or the Grantor's tenant may wish 

to save; 

• Water and maintain replacement vegetation, including fertilizer application, as 

necessary subsequent to an initial watering period by EPA; 

• Abide by health and safety guidance provided by EPA; 

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

property to perform the work. 

• Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the work activities, or 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 (877) 234-6270. 

/ S I grant access to my properties D I do not grant access to my properties 

Vainr, ^^^^ ^ g-6-o"^ 

Signature Date Signature ^ Date 

X I would like to be present during any sampling that is required. 

Page 2 of 2 
v^ ^ *.* > 

COASTA L ENVIRONMENTA L y CROUP . IN C 

Consen t For Acces s To Property 

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: Daytime Phone: 

Qa n '^ "i^r. Ts,, .\eOaaa ^^-3^M-i^:3 M 3 

Address of Property 

covered by this 

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 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 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^'TP *

 COASTAL - ^ / -«C r ENVIRONMENTA L 

CROUP , 

• Remove obstructions including boats, trailers, vehicles, playscape items, wood 

piles, dog houses, etc; 

• Remove flower bulbs or plants that the Grantor or the Grantor's tenant may wish 

to save; 

• Water and maintain replacement vegetation, including fertilizer application, as 

necessary subsequent to an initial watering period by EPA; 

• Abide by health and safety guidance provided by EPA; 

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

property to perform the work. 

• Allow videotaping and/or photographing of the property. 

AGREEMENT NOT To INTERFERE 

The Grantor agrees not to interfere or tamper with any of the work activities, or 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 (877) 234-6270. 

grant access to my properties D i do not grant access to my properties 

Signature Date Signature Date 

O I would like to be present during any sampling that is required. 

Page 2 of 2 
COASTA L 

C A O U P . IN C 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of the propert>' 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 propertv' owner and the United States Environmental 

Protection Agency (EP.A). 

Property ID: 

Property Address: _ U('^ie _^ ^ \PcxQ. -(-• e 

yy^\ ^ 

Phone: ^ O X-^1 ^ 1 o ^ d o - ^.9 i.z 

On the attached diagram(s) indicate area(s) to e.xcavated and depth of excavation, location of all known 

utilities, subsurface features, surface structures and landscaping features, access location(s) to be used by 

contractor, and the direction of North. Indicate distances, depths, material types, etc. Indicate digital photos 

by referencing the photo-log number with an arrow indicating direction of view. 

Items To Be Removed By Owner Before Start Of Remediation: 

(Use additional sheets as necessary) 

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

Item: 

Item: 

^-\\^ gv\j\\i:n,. Vm , Luc>c ^ ^^'^^ ~~^\ 

Item: ; 

Item: 

Item: 

Item: ^- ^ 

Item: ^ 

Item: y ^ 

Page 1 of. k 
COASTA L ENVIKONMEMTA L 

c n o u p . IN C 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: 

Ihi ^iMfh. ^ W<\\\iff 

Item: 

Item: 

'V\vio\)i — y > 

4 y 

Item: 

/ 

Item: 

y 

Item: y/ 

Item: 

Item: 

/ 

Item: / 

Item: / 

Item: / 

Item: 

7

/ 

Item: 7 

7 

/ Item: 

/ 

Item: 

Page 2 of. 
COASTA L iNViKONnCNTA L 

O R O U F . I f* C 

Items To Be Removed By Contractor During Remediation And Replaced 

(Use additional sheets as necessary) 

Item: 

Item: 

4i?ii 

^Ovf 

Item: 

Item: 

\IWI^ ^ TW MuLOiA ^66? ^HiW- fui^ft/ ^--

Item:

/ 

/ 

Item: 

Item: 

/ 

/ 

Item: 

/ ' 

Item: 

// 

Item: 

y 

Item: 

Item: 

Item:

y 

/ 

y 

y 

Item: y ' 

Item: 

Page3of_W_ 
— « * 

COASTA L CNVINONHCNrA L 

CROU P IN C 

Landscape Inventory 

(Use additional sheets as necessary) 

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 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch o^ the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed 

area. 

Aitach a sketch of relative 

sizes and locations. 

Quantity 

4l1 

y 

y 

(1(7 

y \o 

Unit 

Square feet 

Each 

Each 

Each 

Each 

Square Feet 

Condition/Type/Species 

KAV^i 

!, 

(/li^<7 ^ 

Page 4 of. 
- - <» 

COASTA L ENVIMONMCNTA L 

Item 

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. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a sketch of were 

each plant will be placed 

b> the contractor. 

Agreed upon area of 

property to be replaced 

with grass sod. 

Include a sketch of the 

area(s) to be replaced with 

grass sod. 

Area of City or County 

property to be landscaped 

per their requirements. 

Include a sketch of the 

area (s) 

Easement Area, to be 

excavated 

Quantity Unit Conditlon/Type/Species 

W^ $ 

\KviOir 

y Each 

Hii SF 

SF 

^^fM^r 

i 

1 

SF 

^ 1 Wyfy 

Page 5 of U 
COASTA L ENVIKONMENTA L 

G « O U P IN C 

Additional Comments / Instructions: 

}^ fv 

y 

, y 

. y 

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

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

interior of house, including foundation cracks or fissures. 

n I do not agree 

€^'SQA ?r\\/n 

Owner's Signahire Date Contractor's Signature Date 

Page 6 of. 
PROPERTY CLEARANCE WORKSHEET 

Date Property ID ;;MmUrymc^ 

Property *• rimah a I e:>:ir{ 

Address 

Project Omaha Lead -- Fixed Price 4^0 ? ^ y y 

l^easurement XRF ID 0107-51 Count/Time 

Field SInots 

Shot # Reading Sample Area Shot # Reading Sample Area 

3Pyr ^\r) W^ Sfc * ^ 

Sample Area j y l?'(q ^ 

I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Bag) Sieved) •? 

2 ^ • y 

3 !^5< 

4 

1 2f 

XRF Corrected Value - > 

5 (use calibration chart or add 

20% to value) c^9 

Sample Area HAy^ Pass/Fai l ? 

I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Bag) Sieved) ? 

2 

3 f^ ^ 4 , 101 4 

XRF Correcte' TM^ dValue —> 

5 (use calibration chart or add 

20% to value) 

lAi 

Sample Area Pass/Fai l ? -/ 4-ty I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 K (Bag) Sieved) ? ^ 

2 ( / ^ ^ J 

3 I/*) 7 

4 

On ( ^ fY 1 / 

XRF Corrected Value —> 

5 m (use calibration chart or add 

20% to value) <^0 

Sample Area Pass/Fai l ? \^7^-ic Composite Composite Analytical Aliquot Composite Readings Lab Analytical Average (Dried & Spilt Sent (Bag) Number Results (Bag) Sieved) 7 

\32 XRF Corrected value --> 

i^' (use calibration chart or add 

2 0 % to value) 

kk 

Sample Area Pass/Fai l ? 

I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical Reading Average (Dried & Spilt Sent (Bag) Number Results 1 (Baq) Sieved) 7 

2 

3 

4 

XRF Corrected Value —> 

5 (use calibration chart or add 

20% to value) 

tISI AOOIIIOHAL SHlfl i I I 

XR H[[DFI) F Technicians Signiture (^ ^ixJXXJ t \ \iC^ W Jl^^.yK..,^' ^ ^ 

\ 
• ^ i—>' / [%^iW^'0l ^ ^ ^i^atM zzy V" \?^:=-1^ ' 

^ 9 ^ ^ Total ^H l ant Squar u e Footage to be Excavated = Property Classification: 800 TotalWi pp Zon Zonee Lii Linear Footage to t)e Excavated = 

Desaiption of post excavation areas Fl, front yard left-hand qtiadrant; F2, front yard nghl-hswid quadrant: Bl, badtyard teft-nand quadrant, 82, backyard nam-nano ouaarr 

OZ. drip zone (1-3 toot area of soil around the foundatton of the house; 
Page 1 of 

tsimmons@lkgs.he.net 

From: "Lehman Carlton" <ctl(gctlehman.net> 

To: "tsimnnons@lkgs.he.net" <tsimmons(gcoastalhazmat.com> 

Sent: Thursday, August 09, 2007 6:27 AM 

Subject: Fwd: Access Agreements 

Begin forwarded message: 

From: France-lsetts.Pauletta(gepamail.epa.gov 

Date: August 8, 2007 4:18:46 PM CDT 

To: ctl@ctlehman.^net, r.brown@erllc.com, mmateus@enviroservicesqroup.com 

Subject: Access Agreements 

Three property owners have contacted me today. They had questions about 

the process and what areas of their property were contaminated. I think 

I answered all of their immediate questions. I told them that someone 

from Coastal would be contacting them to develop a restoration 

agreement. 

Each property owner indicated that they would be sending in a signed 

access agreement. This is a heads-up to be ready. 

NRozalind Pietrantoni 

#408 

^104S9th 402-709-8636 

\ Troy Taylor 

#^2261 

829 S 21st 402-213-8813 

Patty Jensen 

\#20932 Pacific 402-384-1334 

• y c y 

—Pauletta 

8/9/2007 
i,!ML\ Omaha Lead Site—Fixed Price EP-R7-07-05 

oj^^v' l Coastal Environmental Group Inc. 

\^'^T ^ www.coastalhazmat.com 

^•<i.niy COASTA L ENVIRONHENTAL 

C R 0 U r . IN C 

EXECUTIVE SUMMARY: 

20932^362 PACIFIC ST 

^ No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation: 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

Total Quadrant Square Footage to be Excavated = 411 

Properly Classification 800 Total Drip Zone Linear Footage to be Excavated = 66 

Pacific Street 

Legend OLS# NorthArrow Omaha Lead Site : 20932 Omaha. Nebraska y ^ Date Excavated: 9/7/07 

Property Numlaer feaie U^P A Signed Off: 9/27/07 OLS-20932 Scale 

-•—• F«nce 

Property Address 1 Inch = 20 reel or 1 gM - 5 x 5 It 4362 PACIFIC ST Pofmanent Landscaping 

o,<^*«l,. Post Excavation Concentrations (ppm) 

F1 B2 Play Area — — — Quadrant Boundary 

^^^^ ^ Stre«t Boundary J^/V HC5L 

F2 DZ Easement 

(Q) Tr««iShrub 81 I3arden (Dther 

DescnptMT ctf pool eMcaw jBon aivas P1. front yard left riand quadrant F^. Iront yard right hand auadfani 31 bac^vard left hand quadrant. B2 bacttvard right r^ar\d quadrant 

OZ dnp ion * (1-3 fool ar M of aod around ttw foundation tfttiahouM) 

Legen d 

Area not Excavateti Vyyl Dripzone Excavateid K ^ Quadrants Excavated 

Contract! #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
sac EPA 

EPA Property Close Out Form 

Property #: ^c93"?'. Property Address: y^ 6 y /^^^rT//? ^ 

Date/Tinic: Owner's Name: yii^/7cy 'yi.'ity) . 1l/l/(r7 

Quads Excavated: 

Contractor Group ' 

Excavation General 

Yes No 

I. If necessary, were the correct quadrant(s) excavated and restored? 

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

Grading Sod and Vegetation 

Yes No 

I. Does the grading around the perimeter of the house in excavated areas generally slope away \ y ' 

from the house? 

L^-" 2.

 Has sod been laid in all areas that were excavated? 

3. 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 graded? 7^^ 

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

time period) 

6. Was the property graded such that water will not pool on the propert\? y^ 

7. Was damage to landscaping or plant materials avoided?^! /,/y'^y ' L y 

^ Gates, Fences and Retaining Walls 

Yes No 

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

t/' 

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

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

zy 

4. Was damage to retaining walls avoided? (If applicable) 

y ' 

Foundation, Siding and Gutters 

Yes No 

I. Was damage to the siding or trim avoided? 7>r' 

2. Was damage to the foundation avoided? 

y y ^ 

Was damage to windows avoided? 

4, Was damage to windows or door screens avoided? 

y 

Was damage to downspouts or downspout extensions avoided? 

Sidewalks and Driveways (Concrete) 

Yes y<o 

1. Was damage to driveway surfaces avoided? 

y " 

/ 

2. Was damage to walkway surfaces avoided? 

y y 
. 0>*'jners comments: 

Inspection notes: 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA Representative Date:?fc6^ 
Property Completion Agreement 

This agreement documents the completion of remedial activities performed on my property. My 

signature will designate that I am satisfied with the restoration of my property, and that no items are in 

questions, now, or at any time in the future, except those items listed below, if any. 

Property ID: "7 (2^ 7 ^ 7 

Property Address: //2^^ y y^y:j/>y^'<; r 

Owner: f2 . ly. lyiyri^ t7yyyspAy Phone: ^^/ ; (^^^- ^ 

Restoration Items in Question: 

Item: i 

Item: 'A\yy~^ ^ o (^ 

Item: 

Item: 

Item: 

item: 

Additional Comments: 

I \jy(/s m restoration is completed, except as noted 

I I do not agree restoration is completed 

Owner' vners Signatur Signaturee Date CoContractor' n s Signature 

I
Property Damage Settlement 

Property ED 20932 

Property Address 4362 PACIFIC ST 

Owner Dan & Patty Jensen 

Phone 402-384-1334 

I have received from the contractor. Coastal Environmental Group Inc. (Coastal), a sum of $ 300.00 as 

compensation for mulch and plant removed from property at 4362 Pacific St which was removed during the 

removal of lead-impacted soil from the property. 

Money Order R100070926808 

Value of Check $300.00 

Made Out To Dan & Patty Jensen 

Description of Miscellaneous Propertv Damage 

Coastal accessed the property at 4362 Pacific ST to complete lead restoration during excavation the property 

mulch and plants were removed during this possess. Coastal has agreed to pay the homeowner $300.00 as a 

buyout for the homeowner to replace and/or repair at their leisure. 

My signature below is acknowledgement of the receipt of the sum listed above, which I further 

acknowledge to be ^i r compensation for the miscellaneous property damage described above and 

release Coastal Environmental Group Inc from further obligations or liability related to this property 

damage. 

wner's SignatiA-e Date Contractor's Signature Date 

Page 1 of 1 
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