B 

TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

l<7 SAID#: 

\m 

Date: iM 

Remediation Contractor: _Coastal Environmental Group_ Year: 20( «V 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

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 

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

Confirmation data 

a/ Photographs V m^ 9 ^ V^/V-ny ^ ^ iU ' tr^C.P(VP(Xlii^ 

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 

Utility clearances 

Property information from Douglas County Assessor's Office 

AM l^ 

Signature Date 

30054457 

Superfund 
Property Access Checklist 

Propcrrj ID: \\1{ ^ O WORKSTAJlTtD ON: _/ /_ 

Property D WORK COMPELTED ON: / / Addre>!,: ^^ ^ V4 ^^•2» \ 

O^vnc ^ i ^ NNiOOdLS Renter 

Address: ' Phone: 

P*.v: 

Celt/Pager: 

Phone 40^-(c(8\ \ Additionul Inlnrmxliiin: 

F«x: 

CclLTager. , 

O NotifiCiition Leitcr Sent: / / B.v: 

0 ^ Access; Agreemem Signed: X'22/C a B> boACuAo 

{ ^ RestonitiOD Agreement Signed: TK /"i. ^ itf i By OCWWV D 

D Topsoil Sempling (if applicubic) ' / / I By: 

D Disposal Sampling (rf applicable) / / By: 

D Gnrdcn Sampling (if applicable) / / By: 1 

1 0 f Utility Clearance Called: ^ / 1 / 0 ^ Byq/s/od 

Q ' Video/Photos (Before) 0n:^/3l/fi^ By OdrtmliO 1 

1 D Video/Pholos (During) O B: 7 ' / By: 1 

D Video/Pholos (After) On: / / By: 

D Video/Pholos (30-Day) On: / / By: 

''•@Cj>ro|icrty Complelion Agreement Signed: i^/lfi/e ^ By: • 1 

• Final Report Issued: / / By: 

Air MonitorinK {»£ applicable) 

D Community D Crew By; 

RcAuJls: 

C ] Comrounit)' O Crc-vs- On: / / Bv: 

Results: 

I 1 Community Q Crcn On: / / Bv: 

Results: 

Omaha Lead Srte 
Property ID #

Property 

Address:

Initial Contact:

Second Contact:

Final Contact:

Final Action:

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

CONTACT FORM 

 \\1 Kn 

 ?^(\\( ^ K| ? A ?^V 

 Date: Time: Action: 

 Date; Time: Action: 

 Date: Time: Action: 

 Transmit to EPA D Other Action: D 
Douglas Coimty Account Infcouation Page 1 of2 (MJl^C 

Douglas County, Nebraska Property Record - R2013680000 

Print Report 

NEW Feature - Parcel Dimensions available (3) scale 0-50 ft west of 52nd St - ViOW OH Ma p Information is valid as of 2009-8-3 Treasurer's Tax Report 

New Feature •• ^ - • Auto Sales Search 

Owner 

WOODS JAY A 

3918 N 23 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 1368 0000 20 

Account Type: Residential 

Parcel Number: 2013680000 

Parcel Address: 

Legal Description: 

3918 N 23 ST 

OMAHA NE 68110-0000 

PLAINVIEW LOT 5 BLOCK 4 50 X 124 

Value Informatio n 

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

Improvement 

$54,500.00 

$54,500.00 

$54,500.00 

$54,500.00 

$6,500.00 

$5,900.00 

Total 

$61,500.00 

$61,500.00 

$61,500.00 

$61,500.00 

$13,500.00 

$12,900.00 

Sales Informatio n 

Sales Date: 1998-09-29 

Deed Type: 

Price: 

Grantor: 

D 

$15,500.00 

Book: 1277 Page: 433 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres 

0.14 

SF 

6200.0 

Units 

1.0 

Depth 

124.0 

Width 

50.0 

Vacant 

No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accoimtno=R20... 8/11/2009 
Douglas County Account Infoaaation ^m^K 

Buflding 1 

CLICKJO ENLARGE IMAGE 

Square Footage: 1598.0 

Perimeter 0.0 

Unit Type: 

Built As: 1 1/2 Story Fin 

HVAC: Central Air to Air 

Exterior: Frame Vinyl 

Interior: Drywall 

Roof Cover: Composition Shingle 

Roof Type: Gable 

Floorcover: Allowance 

Year Built Year 

Remodeled 

Percent 

Remodeled 

1910 0% 

Detail Type Detail Description 

Add On Fence Chain Link 

Appliance Allowance 

Basement Bsmnt Block 8 ft 

Basement Minimal Finish 

Fixture Base Fixtures 

Fixture Bath Full 

Garage Detached 

Porch Encl Screen 

Porch Slab Roof Ceil 

Page 2 of2 

3918 N 23 a 1 lilZ Stay Fin 

iat'HfCt'nt jtf Mlywmltmtm >X n 'Ilk tDir 

eae ^ n ^ ^ iBTi:tr 

loir 

uff 

EfX Scmtr. 

tassf f l 

CLICK TO ENLARGE IMAGE 

Percent Complete: ! 100.0% 

Quality: Fair 

Condition: Fair 

Condo Square Footage: 0.0 

Rooms: 8.0 

Units: 1.0 

Baths: 1.0 

Bedrooms: 4.0 

Stories: ; 1.5 

Foundation: I Block 

Sprinkler Square Footage: 0.0 

Adjusted Year Physical Age Built 

1910 99 

Units 

1.0 

1.0 

1008.0 

300.0 

1.0 

1.0 

220.0 

120.0 

36.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R20... 8/11/2009 
Page 1 of2 

Create Another Ticket Back to Irth Internet Send Email ] ][ 

• YOUR TICKET NUMBER IS 2371835. 

Original Call Date: 9/24/09 Time: 12:41 pm Op: ELIZABETH18790 

Work to Begin Date: 9/28/09 Time: 1:15 pm 

State: NE Coxinty: DOUGLAS Place: OMAHA 

Address: 3918 Street: N 23RD ST 

Twp: 15N Rng: 13E Sect-Qtr: 03-SW 

Twp: Rng: Sect-Qtr: 

Legal Given: C 


Type of Worit: lead remediation 


Location of Work: LOCATE ENTIRE PROPERTY 


Remarks: FAX ALL CLEARS TO: (877)662-4211 


: UNSURE OF CORNER LOT 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ELIZABETH Phone: (877)662-4210 


Work Being Done For: Coastal 


Depth of Excavation: 4f t Corner Lot: N Front: y Rear: Y 


Involves Tunneling or Horizontal Boring : N Explosives: N 


ALTS72 CXCATV MAGELLAN MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number UtiUty Type 

ALT872 WINDSTREAM COMMUNICATION NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

MAGELLAN

Day: 9185747098 

 MAGELLAN MIDSTREAM PARTNERS LP DEBORAH Alt: 

Emerg: 9185747098 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY

Day: 4025047823 

 Alt: 

Emerg: 4025047970 

http://www.dhon.org/irthinteraet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/24/2009 
Page 2 of2 

OMAHACOF CITY OF OMAHA-TRAFFIC.SEWER RON 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

OPPDGPR5 OMAHA PUBLIC POWER DISTRICT NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/24/2009 
As-Built Drawing d L 

COASTA L Omaha Lead Superfund Site 

1126 

Omah a Exterior Paint Lea d Site North Arrow Owner Name: 

Site SIcetch 

• Good Address : 3918 N 23 ST_ • Poor Phone: H; w. [~1 Not paint (S) 

Sampl Lead Sample Samples Collected e Number LAB 

Concentration Collected Firm: Sverdrup 

RYASCPXA-1126 YA 90.4 ppm g 

n Date: _

RYBSCPXA-1126 YB 125.8 D Time: _

 ppm g 

RYCSCPXA-1126 YC ppm n

 D Samples Analyzed RYDSCPXA-1126 YD 554.8 El ppm g ] 

RDZSCPXA-1126 DZ 

334.6 ppm g • XRF Unii Book; 

RGZSCPXA-1126 GZ 1256 ppm g j D Date: _ 11/22/1999 

RPZSCPXA-1126 PZ 

ppm Time: _ 08:28 D a 

Staff: Number of Samples = 5 

Legend: YA = Yard (NE), YB = Yard (SE), YC = Yard (SW), YD = Yard (NW), DZ = Drip Zone, GZ -• Garden. PZ = Play 

OLS#: 1126 

Date Excavated: 10/6/09 

Datfe USEPA Signed Off: 10/23/09 

Area Sodden: 846 sa ft 

Air Conditioner 

EA = 162PPM@1" 

•..• y -J- • ;-:•• :^.'.y! V .1 j ' ' y 'v: - .;• :•>••• y i-v- !^v.•;;••..^-LV:!':. : i-yy-j-1.'. . 

04*M I 0123 

Legen d 

Conors tie Dri p Zone Excavate d Quadrants Excavate d 

Area replace d wit h mih Area replace d wit h 

Area lef t bar e Sod '^^•^^ Rock/Mulch 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
1126 UMe Inr.ffl-P. ^/ ^ 

Omaha Exterior Paint North Arrow Owne Lead Site r Name: 

Site • Good Sketch Address: 3918 N 23 ST • Poor Phone W: : H: (D Q Not paint 

Sample Number 

RYASCPXA-1126

RYBSCPXA-1126

RYCSCPXA-1126

RYDSCPXA-1126

 YA 

 YB 

 YC 

 YD 

Lead 

Concentration 

90.4 ppm 

ppm 

ppm 

ppm 

125.8 

554.8 

Sample 

Collected 

• 

LAB 

•

•

• 

Firm:

Date: 

Time: 

Samples Collected 

 Sverdrup 

Samples Analyzed 

RDZSCPXA-1126 DZ 334.6 ppm 0 D XRF Unit: Book: 

RGZSCPXA-1126 GZ 125.6 ppm a Date 11/22/1999 

RPZSCPXA-1126 PZ ppm a n Time 08:28 

Number of Samples = ; 5 1 Staff: 

Legend: YA = Yard (NE), YB = Yard (SE), YC = Yard (SW), YD = Yard (NW), DZ = Drip Zone, GZ = Garden, PZ = Play 

\ - ^ 

Rev 4 046141 ni2.'! 
^

t. '8 Ayz 

1126 

Q 

Omah Exterior Paint North Arrow a Lead Site Owner Name: 

Sit • Good e Sketch Address: 3918 N 23 ST • Poor 

Phone: "^ W: Q Not paint 

Sampl Lead Sample Samples Collected e Number LAB Concentration Collected Firm; Sverdrup 

RYASCPXA-1126 YA 90.4 _ ppm D Date: 

RYBSCPXA-1126 YB 125.8 _ ppm 0 D Time: 

RYCSCPXA-1126 YC ppm a 

n Samples Analyzed RYDSCPXA-1126 YD 554.8 ppm 0 0 

RDZSCPXA-1126 DZ 334.6 _ ppm 0 a XRF Unit: Book: 

RGZSCPXA-1126 GZ 125.6 _ ppm 0 a Date: _ 11/22/1999 

RPZSCPXA-1126 PZ ppm D n Time: _ 08:28 

Staff: Number of Samples 1 

Legend YA = Yard (NE), YB = Yard (SE), YC = Yard (SW), YD = Yard (NW), DZ = Drip Zone, GZ = Garden, PZ = Play 

\s> 
% 1126 

Omah Exterior Paint North Arrow 

Owne a Lead Site r Name: 

Site • Good Sketcli Address: 3918 N 23 ST • Poor 

Phone: H: W: (S) Q Notpaint 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

Firm:. 

Samples Collected 

Sverdmp 

RYASCPXA-1126 YA 90.4 ppm Q D Date:. 

RyBSCPXA-1126 YB 125.8 DPm D Time:. 

RYCSCPXA-i126

RYDSCPXA-1126

 YC 

 YD 554.8

ppm 

 ppm 

a 

D Samples Analyzed 

RDZSCPXA-1126

RGZSCPXA-1126

 DZ 

 GZ 

334.6

125.6

 ppm 

 ppm 

m 

D 

XRFUn 

Date:. 

t Book: 

11/22/1999 

RPZSCPXA-1126 PZ ppm a Time:, 08:28 

a Staff: Number of Samples = 

Legend: YA = Yard (NE). YB = Yard (SE). YC = Yard (SW). YD = Yard (NW). DZ = Drip Zone. GZ = Garden. PZ = Play 

Rev4 046141.0123 
COASTA l iHVIItONHIHTAt 

6 K O t) r . IN C 

Consent for Access To Froperty 

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: 

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 

wori( 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 perfonned. 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 wori( 

and confimfi 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^-^^ V

 COASTAL 

^ i «»o"** « a o u r I » c 

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

piles, dog houses, etc; 

c 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; 

c 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. 

<i Allow videotaping and/or photographing of the property. 

AGREEMENT NOTT O 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 (402) 991-1199 

^ ,I grant access to my properties

 D I do not grant access to my properties 

Ic^^^Cf^-Zi. Signature n < Date Signature

 Date 

O

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

Page 2 of2 
COASTA L 

C n O U ^ • H € 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreemem 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). 

Property ID: [| 2 ^ 

Property Address: 0,'^JQ ^ 'ZS ^^ ' 

Owner: HQ=y. Uigfa>-&;' 

Phone: 

^ . ^^^^( 1 

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. 

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

The lemoval. storacje, disposal, and/or return ofthese'items is ttie Owner's responsibility. 

ttem: 

A^^K. ^-^( / fiiT)^ 

item: / 

Item: 

Kem: 

ttem: 

^// rinJ iJr &Kh,^ 

ttem: / 

ttem: 

Kem: 

Page 1., ^ 
COASTA L 

items to Be Removed By Contractor During Remediation and^Rejgjaced^ 

> ttem: 

^., L ^ Y ^ 

ttem: 

32^ K

mI . Kem: 

Item: 

Item Quantity 

Pre-existing property area, 

that will be excavated, that Tb 

is covered with grass. 

Number of trees > 2 inch 

tnink diameter ^ 

Number of trees <= 2 inch 

^ trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. ^ / ^ 

All.nth ;i sketch ol llif 

sprirkloi liiv'.uii 

Number of and size of 

each garden/ flower bed 

area. 5 

Aimth :i skL'icli ol' rcljiiivi' 

<izi's .nnd loc;iii('ii.> 

Agreed upon value of plant 

malerials not to be 

replaced bv contractor. 

N'OIr l!ii' \HIIIC \\ill nt 

iisi'i.' 10 It; m .'• |)lali! 

>oiii.;uT Id the priipcin 

u^^ ner: 

Easement Area, to be Yd 5 excavated 

Landscape Inventory 

Unit Condition/Type/Species 

Quadrants 

Each 

Each 

Each 

Each 

SquareFeet 

/ 

S 

Each ?~i^ ^^ ^ 

Page 2 . - > 
C O A S 1 A L 

I Addttlonal Comments / Instructions: 

2,- I hf^ Ho-ri6L 

L 

^ cLCheck the tx)x 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. 

^ I agree O I do aot agree 

Owner's Signatui Datee Gbntractor' ^ntractor'ss Sigimtnr Signatoree Date

Page 3 of ±_ 
# 

BVID# l\lJ f 

XRF PROPERTY SAMPLE SHEET 


Date lolilfff Address 2></^^. / J -L3 ^4 ^ 

Project Omaha lead FP Znd year option Sample time am/pm 

XRFID# ^V)8^f sample length 30 sec 

Shot# Reading Sample area Shot# Reading Sample area 

JM M. /ry? 2Q2 ^ 

UIOL m> ^/^ Dtepth /i^yy 2-2.^ ^ Depth 

mi^ H^ -^^^ ^ i^:f^ /^ ^ 

Average /^ ^ — / jp Average ^ — ? 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

RETEST AREAS 

Shot# Reading Sample area Shot# Reading Sample area 

Depth I3epth 

Average Average 

lab sample # Lab result Sample area XRF Avg. 

Signature ^(lOi^O^O A 

Print pAAoniVv^iK

o 

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

Coastal Environmental Group Inc. 

www.coastalhazmat.com COASTAL •*l- PHOt*-^ INVIIOIIHEIITAl 

C 1 0 U P. IH C 

EXECUTIVE SUMMARY: 

BVID #1126- (3918 N 23 ST) 

No Issues or Concerns I I Issues/Concerns 

Detail Explanation: 

-COASTAL TO ISSUE REIMBURSEMENT CHECK FOR $400.00 (COMPLETED 1/28/10) 
EPA 

EPA Property Close Out Form 

2 ^ Property ff: il2lfl. Property Address:* 

Date/Time: Owncr's Name:. ^ . 

Quads Excavated; Y ' ^ Contractor CrouD""Onnt"^Q\ Clr>VlYt)mfy\4Q \ 

Yes No Excavation General 

" ^ I. If necessaiy, were the correct quadiant(s) excavated and restored? 

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

C / ' 

Grading Sod and VegetatioB 

Yes No 

I. Does the grading around the perimeter ofthe house in excavated areas generally slope away 1 ^ ' 

from the house? _ ^ 17' 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 77" day time period) 

4. Are sodded areas generally firm and evenly graded? 

i / 

5. Are the joints between the sod strips generally tight? (Only evaluate if inspected at a 30 day t y ' 

time period) 

6. Was die properly graded such that water will not pool on the propert>'? 

17 7. Was danuge to landscaping or plant materials avoided? 

Gates, FcDcta aad RetaJBing Walls 

I. Do gates open and close freely? (Ifapplicable) 

Ves

1/ 

 No 

I. Were all gates or fences taken down during restoralion activities reinstalled? (Ifapplicable) l y 

3. Was damage to gates or fences avoided? (Ifapplicable) l y 

4. Was damage to retaining walls avoided? (Ifapplicable) ^ 

FouDdation, Siding and Gutters 

Ves No 

1. Was damage to the siding or trim avoided? 

l y 

2. Was damage lo the foundation avoided? L / 

t y 3.

 Was damage to windows avoided? 

L / 4. Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? A 

Sidewalks and Driveways (Copcrctc) 

Yes No 

1. Was damage to driveway surfaces avoided? y 

2. Was damage to walkway surfaces avoided? 

L / 
Owners comments: 

Inspection notes: 

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

EPA Representative Dd m hoLJ ^ . Date: /0/jZj/(77 
% 

Property Completion Agreement 

rins agreement documenls the completion of remedial acliviiies perlbimed on my properly My signalure 

will designate that I am satisfied with the restoralion of my propeily, and thai no items are in qucslioiw. 

now, or al any lime in the future, except ihose ilems listed below, if any 

Property fP: WJJJ ? 

Property AddrcM; ^-7 ^ ^g M 2-.:^ ^ 

Phone: ^^-J^ ^ UO^.|nb\ \ 

Restoration Items rn Qu^tron: 

Item 

mil l uujfc 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

tP n I Agree I'cstoralion i% compltied, except as noted 

[_| I rlo not a|>rec resiomtion it eompleled 

Date CMtrarlor' s Signature Dale 
% 

Property Damage Settlement 

Property ID 1126 

Property Address 3918 N 23 St 

Owner Woods Jay 

Phone (402)408.6611 

I have received from the contractor, Coastal Environmental Group Inc. (Coastal), the sum of $200.00 to 

compensate for plants and river rock that were removed during the removal of lead impacted soil from 

the property. 

Compensation type Check 1878 

Value of Check $200.00 

Check to the order of Woods Jay 

Description of Damage 

While excavating 3918 N 23 St (BVID 1126) Coastal damaged some plants beyond salvage. Property 

owner received a check for the amount of $ 200.00 dollars for the replacement ofthe plants. 

My signature below acknowledges the replacement of my plants; further, I acknowledge that this 

work was completed satisfectory and wtthin my and release Coastal Environmental Group, Inc. from 

further obligations or liabiltty related to this property. 

^^•J?^!K>#i^^l'^?"^W^ Tn 

1878 COASTAL ENVIRONMENTAL GROUP INC. 27-6/1040003 

6247372904 2411 MARTHA STREET 

OMAHA, NE 68105 iNio 

DATE 

PAY OMI iVolljMJMds ORD£R 

mi TiAX)Kx^n^(t oMlfst) nn i I ARS Q SOvlatl* on 

mMstoODSanliMA. 

FOR wii.mh^^'^^'^ ^ -i<f^A£jA^ r.5^^* ^ 

illOUOOOOSfli: E.Ei.7 3 7E=10t.ii' OiaTB 

Owner^sSigMture Date ' Contractor's Signature ' ' Date 

Page 1 of 1