# B TRANSMITTALof OMAHA LEAD SIT E SOI LREMEDIATIO NFIL EFOLDE R l< 7 

### SAID# : Date : 

# \ m i M

Remediatio nContractor : _Coasta l Environmenta l Group _ Year : 20 ( 

# « V SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S Vide o o f property (DVD ) '/ 

### Executiv e Summar y EPA-provide dproperty sketc h Signe dAcces s Agreemen t for subjec t property Signe dAcces s Agreement(s ) for adjacent property Restoratio nAgreemen t D 

### Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) Confirmatio ndat a 

# a

/ Photograph s V m^ 9 ^ V^/V-ny ^ ^ iU ' tr^C.P(VP(Xlii ^ As-buil t sketc h Satisfactory restoratio nsigne db y Property Owne r Property close-ou t chec k lis t signe db y EPA Descriptio no f area s no t meetin g RO D cleanu p criteri a Utility clearance s Property informatio nfromDougla s County Assessor' s Offic e 

# A M l ^ Signatur e Dat e 3005445 7 Superfun d

## Propert yAcces s Checklis t Propcrr j ID : \\1{ ^ O WORKSTAJlTt D ON : _/ /_ D WOR K COMPELTE D ON : / / Propert yAddre>!, : ^^ ^

V 4 ^^•2» \ O^vnc i

^ ^ NNiOOdL S Rente r Address : ' Phone : P*.v : Celt/Pager : Phon e 40^-(c(8\ \ Additionu l Inlnrmxliiin : F«x : CclLTager . , O NotifiCiitio n Leitc r Sent : / / B.v : 0

^ Access ; Agreeme m Signed : X'22/C a 

### B > boACuA o {

^ RestonitiO D Agreemen t Signed : T K/"i. ^ itf i B yOCWWV D D Topsoi l Semplin g (i f applicubic ) ' / / I By : D Disposa l Samplin g (r f applicable ) / / By : D Gnrdc n Samplin g (i f applicable ) / / 

### By : 1 1 0f Utilit yClearanc e Called : ^ / 1 / 0 ^ 

## Byq/s/o d Q ' Video/Photo s (Before ) 

## 0n:^/3l/fi ^ B yOdrtmli O 1 1 D Video/Pholo s (During ) O B : 7 ' / 

### By : 1

D Video/Pholo s (After ) On : / / By : D Video/Pholo s (30-Day ) On : / / By : ''•@Cj>ro|icrt yComplelio n Agreemen t 

## Signed : i^/lfi/e ^ By : • 1
• Fina l Repor t Issued : / / By : Ai rMonitorin K{» £ applicable )

D Communit yD Cre w By ; RcAuJls : C ] Comrounit) ' O Crc-vs - On : / / Bv : Results : I 1 Communit yQ Crc n On : / / Bv : Results : Omah a Lea d Srt e

## Propert y I D # Propert y Address : Initial Contact : SecondContact : Fina l Contact : Fina l Action :

Comment : Owner Comment (s) : Site Coordinator Comment (s) : CONTACT FOR M \\ 1 K n ?^(\\( ^ K | ?A ?^ V Date : Time : Action :

Date ; Time : Action : Date : Time : Action : Transmi t to EP A D Other Action : D

### Dougla s Coimty Accoun t Infcouatio n Pag e 1 of 2 (MJl^ C Dougla s County , Nebrask a Propert yRecor d - R201368000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e (3 ) scal e 0-5 0 ft wes t o f 52n d S t - ViO W O H Ma p Informatio n i s vali d a s o f 2009-8- 3 Treasurer' s Ta xRepor t Ne wFeatur e • • ^ - • Aut o Sale s Searc h Owne r WOOD S JA YA 391 8 N 2 3 S T OMAH AN E 68110-000 0 Propert yInformatio n Ke yNumber : 136 8 000 0 2 0 Accoun t Type : Residentia l Parce l Number : 201368000 0 Parce l Address : Lega l Description : 391 8 N 2 3 S T OMAH AN E 68110-000 0 PLAINVIE W LO T5 BLOC K4 5 0 X 12 4 Valu e Informatio n 200 9 200 8 200 7 200 6 200 5 200 4 Lan d $7,000.0 0 $7,000.0 0 $7,000.0 0 $7,000.0 0 $7,000.0 0 $7,000.0 0 Improvemen t $54,500.0 0 $54,500.0 0 $54,500.0 0 $54,500.0 0 $6,500.0 0 $5,900.0 0 Tota l $61,500.0 0 $61,500.0 0 $61,500.0 0 $61,500.0 0 $13,500.0 0 $12,900.0 0 Sale s Informatio n Sale s Date : 1998-09-2 9 Dee d Type : Price : Grantor : D $15,500.0 0 Book : 127 7 Page : 43 3

Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s 0.1 4 S F 6200. 0 Unit s 1. 0 Dept h 124. 0 Widt h 50. 0 Vacan t N o Improvemen t Informatio n 

### http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accoimtno=R20. . . 8/11/200 9

### Dougla s County Accoun t Infoaaatio n 

## ^m^ K Bufldin g 1

CLICKJ O ENLARG E IMAG E Squar e Footage : 1598. 0 Perimete r 0. 0 Uni t Type :

Buil t As : 1 1/ 2 Stor yFi n HVAC : Centra l Ai rt o Ai r Exterior : Fram e Viny l Interior : Drywal l Roo f Cover : Compositio n Shingl e

Roo f Type : Gabl e Floorcover : Allowanc e Yea rBuil t Yea r Remodele d Percen t Remodele d 191 0 0 % Detai l Typ e Detai l Descriptio n Ad d O n Fenc e Chai n Lin k Applianc e Allowanc e Basemen t Bsmn t Bloc k 8 ft Basemen t Minima l Finis h Fixtur e Bas e Fixture s Fixtur e Bat h Ful l Garag e Detache d Porc h Enc l Scree n Porc h Sla b Roof Cei l 

### Pag e 2 of 2

391 8 N 2 3 a 1 lil Z Sta yFi n iat'HfCt'n t jt f Mlywmltmt m>X n 

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Ef X Scmtr . tass f f l
CLIC KT O ENLARG E IMAG E Percen t Complete : ! 100.0 % Quality : Fai r Condition : Fai r Cond o Squar e Footage : 0. 0 Rooms : 8. 0

Units : 1. 0 Baths : 1. 0 Bedrooms : 4. 0 Stories : ; 1. 5 Foundation : I Bloc k Sprinkle rSquar e Footage : 0. 0 Adjuste d Yea r Physica l Ag e Buil t 191 0 9 9 Unit s 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. . . 8/11/200 9

### Pag e 1 of 2

Creat e Anothe rTicke t Bac k t o Irt h Interne t Sen d Emai l ] 

# ] [

• YOU RTICKE T NUMBE RI S 2371835 . Origina l Cal l Date : 9/24/0 9 Time : 12:4 1 pm Op : ELIZABETH1879 0 Wor k t o Begi n Date : 9/28/0 9 Time : 1:1 5 p m State : N E Coxinty : DOUGLA S Place : OMAH A Address : 391 8 Street : N23R D S T Twp : 15 NRng : 13 E Sect-Qtr : 03-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Worit : lead remediatio n Locatio n o f Work : LOCAT E ENTIR E PROPERTY Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABETH Phone : (877)662-421 0 Wor k Being Don e For : Coasta l Dept h o f Excavation : 4 f t Corne r Lot : N Front : yRear : Y Involve s Tunneling o r Horizonta l Boring : N Explosives : N ALTS7 2 CXCAT V MAGELLA NMUDO l OMAHACO F 0PPDGPR 5 QLNNEI C 

### Servic e Area Contac t Phon e Numbe r UtiUt y Typ e ALT87 2 WINDSTREA M COMMUNICATIO N N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 CXCAT V CO X COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MAGELLA N Day : 918574709 8

MAGELLA NMIDSTREA M PARTNER S L PDEBORA H Alt : Emerg : 918574709 8 MUDO l METROPOLITA NUTILITIE S DISTRIC T SAND Y Day : 402504782 3

Alt : Emerg : 402504797 0
http://www.dhon.org/irthinteraet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/24/200 9

### Pag e 2 of 2

OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE RRO N 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0
OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T N A 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES T LOCALNETWOR K 

### N A 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/24/200 9

# As-Buil t Drawin g dL COASTA L 

# Omah aLea dSuperfun dSit e 112 6 Exterio rPain t Omah a Lea d Sit e Nort h Arrow Owne rName : Sit e SIcetc h • Goo d Address : 391 8 N 2 3 ST _ • Poor Phone : H ; w . 

# (S ) [~ 1 No t pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : Sverdru p RYASCPXA-112 6 Y A 

# n Date : _ 90. 4 pp m g RYBSCPXA-112 6 Y B 

### D Time : _ 125. 8 pp m g RYCSCPXA-112 6 Y C 

# n pp m D Sample s Analyze d RYDSCPXA-112 6 Y D 

### E l 554. 8 pp m g ] RDZSCPXA-112 6 D Z 334. 6 pp m g 

# • XR F Uni i Book ; RGZSCPXA-112 6 G Z 

### D 125 6 pp m g j Date : _ 11/22/199 9 RPZSCPXA-112 6 P Z Time : _ 08:2 8 pp m D 

# a Staff : Numbe ro f Sample s = 5 Legend : Y A= Yar d (NE) , Y B = Yar d (SE) , Y C = Yar d (SW) , Y D = Yar d (NW) , D Z = Dri p Zone , G Z -• Garden . P Z = Pla y OLS# : 112 6 Dat e Excavated : 10/6/0 9 Datf e USEP ASigne d Off : 10/23/0 9 Are a Sodden : 84 6 s a f t Ai rConditione r

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

# 112 6 

# UM e Inr.ffl-P . ^/ ^ Exterio rPaint Nort h Arro w 

### Omah a Lea d Sit e Owne rName : • Good 

### Sit e Sketc h Address : 391 8 N 2 3 S T • Poo r W : Phone : H : 

# ( D Q No t pain t Sampl e Numbe r RYASCPXA-112 6 RYBSCPXA-112 6 RYCSCPXA-112 6 RYDSCPXA-112 6 Y A Y B Y C Y D Lead Concentratio n

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# • LA B 

# • • • Firm : Date : Time : Sample s Collecte d Sverdru p Sample s Analyze d RDZSCPXA-112 6 D Z 334. 6 pp m 

# 0 D XR F Unit : Book : RGZSCPXA-112 6 G Z 125. 6 pp m 

# a Date 11/22/199 9 RPZSCPXA-112 6 P Z pp m 

# a n Tim e 08:2 8 Numbe rof Sample s = ; 5 1 Staff : Legend : Y A= Yard (NE) , Y B = Yard (SE) , YC = Yard (SW) , Y D = Yard (NW) , DZ = Dri p Zone , G Z = Garden , P Z = Pla y

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# ' 8 Ay z 112 6 

# Q

Exterio rPain t Nort h Arro w 

### Omah a Lea d Sit e Owne rName : • Goo d 

### Sit e Sketc h Address : 391 8 N 2 3 ST • Poo r

Phone : " ^ W : Q No t pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm ; Sverdru p RYASCPXA-112 6 YA 90. 4

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## D Date : RYBSCPXA-112 6 Y B 125. 8

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# a n Sample s Analyze d RYDSCPXA-112 6 Y D 554. 8 pp m 

# 0 0 RDZSCPXA-112 6 D Z 334. 6

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# a RGZSCPXA-112 6 G Z 125. 6

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# D 

# n Time : _ 08:2 8 Staff : Numbe ro f Sample s 1 Legen d Y A= Yar d (NE) , Y B = Yar d (SE) , Y C = Yar d (SW) , Y D = Yar d (NW) , D Z = Dri p Zone , G Z = Garden , P Z = Pla y 

# \s >

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# 112 6 Exterio r Pain t Nort h Arro w 

### Omah a Lea d Sit e Owne rName : 

### • Goo d Sit e Sketcl i Address : 391 8 N 2 3 S T 

### • Poo r Phone : H : W : 

# (S ) Q Notpain t Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm: . Sample s Collecte d Sverdm p RYASCPXA-112 6 YA 90. 4 pp m 

### Q 

# D Date: . RyBSCPXA-112 6 Y B 125. 8 DP m 

# D Time: . RYCSCPXA-i12 6 RYDSCPXA-112 6 Y C Y D 554. 8 pp m pp m 

# a D Sample s Analyze d RDZSCPXA-112 6 RGZSCPXA-112 6 D Z G Z 334. 6 125. 6 pp m pp m 

# m D XRFU n Date: . t Book : 11/22/199 9 RPZSCPXA-112 6 P Z pp m 

# a Time: , 08:2 8 

# a Staff : Numbe ro f Sample s = Legend : Y A= Yar d (NE) . Y B = Yar d (SE) . Y C = Yar d (SW) . Y D = Yar d (NW) . D Z = Dri p Zone . G Z = Garden . P Z = Pla y

Rev 4 046141.012 3COASTA l iHVIItONHIHTA t 6 KO t ) r. IN C 

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

### Granto r(th e propertyowner) 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 describe d premises :

Owner' s Nam e Daytim e Phone :

PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EPAi s requestin g acces s t o collect soi l sample s an d remove soi l tha t contain s elevate d concentration s o f lea d an d maypos 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 its origina l condition . Thi s wori ( i s bein g performe d unde rth e Omah a Lea d Superfun d Sit e remediatio n program . Arepresentativ e o f Coasta l Environmenta l Group , contracte d b yUSEPA , wil l contact th e Granto rin-perso n t o discus s th e wor k t o b e perfonned . th e Granto rwil l hav e a n opportunityt 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 wori ( an d confimf i 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 EPAtha t th e property ha 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 , contractors an d subcontractors 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 f2V^-^^ VCOASTA L ^ i «»o"* *« a o u rI » c 

### t Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; cRemov e flowe rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma ywis h t o save ; < Wate ran d maintai n replacemen t vegetation , includin g fertilize rapplication , a s necessar ysubsequen t t o a n initia l waterin g perio d b yEPA ; c

Abid e b yhealt h an d safet yguidanc e provide d b yEPA ; •I f th e propert yi s rented , assis t EP Ai n obtainin g tenan t approva l fo racces s t o th e propert yt o perfor m th e work . <

iAllo wvideotapin g and/o rphotographin g o f th e property . AGREEMEN TNOTT O INTERFER E 

### Th e Granto ragree s no t t o interfer e o rtampe rwit h an yo f th e wor k activities , o rwit h an y o fth e wor k done , o rwit h th e equipmen t use d o n hi s property , o rt o undertak e an y action s regardin g th e us e o f sai d propert ywhic h woul d ten d t o endange rth e healt h o r welfar e o f th e Grantee s o rth e environment , o rt o allo wother s t o us e th e propert yi n 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 , a t (402 ) 991-119 9 ^ , I gran t acces s t o mypropertie sD I d o no t gran t acces s t o mypropertie s 

# Ic^^^Cf^-Zi . Signatur e n < Dat e SignatureDate
O

I woul d lik e t o b e presen t durin g an ysamplin g tha t i s required .

Page 2 of 2COASTA L C n O U ^ • H € 

## Restoratio n Agreemen t Th e purpos e o f thi s agreemen t i s t o provid e amutua l agreeme ma s t o condition s o f th e propert y prio r t o remediatio nactivities . Thi s wil l als o serv e a s documentatio nfor th e purpos e o f assurin g tha t restoratio n activitie s ar e complete dt o th e satisfactio no f th e propert y owne r an dth e Unite dState s Environmenta l Protectio nAgenc y (EPA) .

Propert y ID : [ | 2 ^ Propert y Address : 0,'^J Q ^ 'Z S ^^ ' Owner : 

# H Q=y . Uigfa>-&; ' Phone : 

## ^ . ^^^^( 1 O nth e attache ddiagram(s ) indicat e area(s ) t o excavate , surfac e structure s an dlandscapin g feature s an d acces s location(s ) t o b e use db y th e contractors . Indicat e distances , depths , material types , etc . Photographicall y an dVideographicall y documen t th e existin g condition s ofth e propert y an dth e basemen t i f necessary . Itom s t o b e Remove d b yth e Owne rbefor e Star t o f Remediation : Th e lemoval . storacje , disposal , and/o rretur n ofthese'item s i s tti e Owner' s responsibility . ttem: 

# A^^K . ^-^( / fiiT) ^ item : / Item : Kem :

ttem: 

# ^/ / rin J iJ r &Kh, ^ ttem: / ttem: Kem :
Pag e 1., ^COASTA L 

### item s t o B e Remove d B yContracto rDurin g Remediatio n and^Rejgjaced ^ > ttem: 

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# ^ 

# Y ^ ttem: 

# 32 ^ K I 

# m . Kem : Item :



### Ite m Quantit y Pre-existin g propert y area , tha t wil l b e excavated , tha t 

# T b i s covere dwithgrass . Numbe r o f tree s > 2 inc h tnin k diamete r ^ Numbe r o f tree s < = 2 inc h ^ trun k diamete r Numbe r o f Sprinkle r Zones , Contro l Valves , Timers , Heads , etc . 

### ^ / ^ All.nt h; i sketc ho l lli f sprirklo i liiv'.ui i Numbe r o f an dsiz e o f eac hgarden / flowe r be d area . 

# 5 Aimth: i skL'icl i ol ' rcljiiivi ' <izi' s .nn dloc;iii('ii. > Agree dupo nvalu e o f plan t malerial s no t t o b e replace db v contractor . N'OI r l!ii ' \HIII C \\il l n t iisi'i. ' 1 0 It ; m.' • |)lali ! >oiii.;u T I dth e priipci n u^

^ ner : Easemen t Area , t o b e 

# Y d5 excavate d 

### Landscap e Inventor y Uni t Condition/Type/Specie s Quadrant s

Eac h Eac h

Eac h

Eac h SquareFee t

/ S

Eac h 

# ?~i ^ ^^ ^
Pag e 2 . - >C O AS 1 AL

I Addttlona l Comment s / Instructions : 

# 2,
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# L

^ c L Chec k th e tx) x if

Owne r doe s no t wan t CE G to documen t interior foundatio nwall s an dpossibl e /pre-existin g damage . By checkin g thi s bo x CE Gis no t responsibl e fo r an y damag e don e to th e interior of house , includin g foundatio ncrack s or fissures .

^ I agre e O I do ao t agre e

^ntractor' Sigimtnr Date Owner' s Signatu i Date e Gbntractor' s s Signator e e Pag e 3 of ±_#

BVID # l\lJ f 

### XR F PROPERTY SAMPL E SHEE T Dat e 

# lolilfff Addres s 2></^^ . / J -L 3 ^4 ^ 

### Projec t Omah a lea d F P Zn d yea roptio n Sampl e tim e am/p m XRFID # 

# ^V)8^ f sampl e lengt h 

### 3 0 se c

Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a 

# J M 

# M . /ry ? 

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### UIO L 

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# / ^ ^ Averag e /^ ^

—/ j p Averag e ^ —? Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h Dept h Averag e Averag e

Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h Dept h Averag e Averag e
RETES TAREA S Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h I3ept h Averag e Averag e la b sampl e # La b resul t Sampl e are a XR F Avg . 

### Signatur e ^(lOi^O^OA 

# Prin t

pAAoniVv^i K o Orrery

## Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc . www.coastalhazmat.co m COASTA L •*l
- PHOt*- ^ INVIIOIIHEIITA l C 1 0 U P . IH C 

# EXECUTIV ESUMMARY : BVID #1126
- (391 8 N2 3 ST ) No Issue s o r Concern s I I Issues/Concern s Detail Explanation : -COASTA LTO ISSU EREIMBURSEMEN T CHEC K FO R$400.00 (COMPLETE D 1/28/10 )

# EP A EP A Propert y Clos e Ou t For m 2 ^ Propert yff : 

## il2lfl . Propert y Address: * Date/Time : Owncr' s Name: . ^ . Quad s Excavated ; Y ' ^ Contracto rCrouD""Onnt"^Q \ Clr>VlYt)mfy\4 Q \ Ye s N o Excavatio nGenera l " ^ I . If necessaiy , were th e correc t quadiant(s ) excavate dan drestored ? 2 . If necessary , were th e correc t area s ofdri p zone excavate dandrestored ? C / ' Gradin g So dan dVegetatio B Ye s No I . Doe s th e gradin g aroun dth e perimeter ofth e hous e i nexcavate darea s generally slop e awa y 1 ^ ' fromth e house ? _ ^ 

# 17 ' 2 . Ha s so dbee nlai dinal l area s that were excavated ? 3 . Doe s th e sodappear to b e generall y healthy an dgrowing ? (Onl y evaluate if inspecte da t a3 0 

# 77 " da y time period ) 4 . Ar e soddedarea s generally fir man devenly graded ? 

### i / 5 . Ar e th e joint s betwee nth e so dstrip s generally tight ? (Only evaluate if inspecte da t a3 0 da y 

### t y ' tim e period) 6 . Wa s di e properly grade dsuchtha t wate r will not poo l o nth e propert>' ? 

# 1 7 7 . Wa s danug e t o landscapin g o r plan t material s avoided ? Gates , FcDct aaa dRetaJBin g Wall s I . D o gate s ope nan dclos e freely? (Ifapplicable ) Ves 

# 1 / N o I . Wer e all gate s or fence s takendow ndurin g restoralio nactivitie s reinstalled ? (Ifapplicable ) 

## ly 3 . Wa s damag e t o gate s o r fence s avoided ? (Ifapplicable ) 

### ly 4 . Wa s damag e t o retainin g wall s avoided ? (Ifapplicable ) ^ FouDdation , Sidin g an dGutter s 

### Ve s N o 1 . Wa s damage t o th e sidin g o r tri mavoided ? 

## ly 2 .Wa s damag e l o th e foundationavoided ? 

### L / t y 3 .Wa s damag e to window s avoided ? 

### L / 4 . Wa s damag e t o window s o r doo r screen s avoided ? 5 . Wa s damage t o downspout s or downspou t extension s avoided ? 

# A Sidewalk s an d Driveway s (Copcrctc ) Ye s N o 1 . Wa s damag e to driveway surface s avoided ? 

# y 2 . Wa s damag e t o walkwa y surface s avoided ? L /

## Owner s comments :

Inspectio nnotes :

Remova l an drestorationactivate s complete including the 30-da y so dwarranty : EP A Representativ e DdmhoLJ ^ . Date : /0/jZj/(7 7

### %



## Propert yCompletio n Agreemen t rin s agreemen t documenl s th e completio n o f remedia l acliviiie s perlbime d o n m yproperl yM ysignalure wil l designat e tha t I a m satisfie d wit h th e restoralio n o f m ypropeily , an d tha i n o item s ar e i n qucslioiw . now , o ra l an ylim e i n th e future , excep t ihos e ilem s liste d below , i fany Propert yfP : WJJJ ? Propert yAddrcM ; ^-7 ^ ^g M 2-.: ^ ^ Phone : ^^-J^ ^ UO^.|nb\ \ Restoratio n Item s r n Qu^tron :

Ite m mil l uujf c Item : Item : Item : Item : Additiona l Comments :

tP n I Agre e I'cstoralio n i % compltied , excep t a s note d [_ | I rl o no t a|>re cresiomtio n i t eomplele d

Dat e CMtrarlor' s Signatur e Dal e

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## Propert yDamag e Settlemen t

Property ID 1126 Property Addres s 391 8 N2 3 S t Owner Wood s Ja y Phon e (402)408.661 1 

### I have receivedfro mthe contractor , Coasta l Environmenta l Grou p Inc . (Coastal) , th e su mof $200.00 to compensat e fo r

plant s andriver rock tha t wer e removedduring th e remova l of lea dimpactedsoil from the property .

Compensatio ntyp e Check 187 8 Valu e o f Check $200.00 Check t o th e orde r o

f Wood s Ja y Descriptio n o f Damag e 

### While excavating 391 8 N 2 3 S t (BVI D 1126) Coasta l damagedsom e plant s beyondsalvage . Propert y owne r receivedachec k

fo r the amoun t of $ 200.00 dollar s fo r the replacemen t ofth e plants . M ysignatur e belo wacknowledge s th e replacemen t o f m yplants ; further , I acknowledg e tha t thi s wor k wa s complete d satisfector yan d wtthi n m yan d releas e Coasta l Environmenta l Group , Inc . fro m furthe robligation s o rliabiltt yrelate d t o thi s property . 

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# T n 187 8 COASTA L ENVIRONMENTA L GROU P INC . 27-6/104000 3 624737290 4 241 1 MARTH ASTREE T OMAHA , N E 6810 5 

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### ' Contractor' s Signatur e ' ' Dat e Pag e 1 o f 1