# • i i 

# • •

TRANSMITTA Lo f OMAH ALEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAID# : 1451 1 Date : 7//5A/A q Address : .__2D2 2 

## 5 ^." ^ H " Remediatio nContractor : Coasta l Environmenta l Grou p Year ; 200* ^ SOI LREMEDIATIO N PROPERT YHL EFOLDE RDOCUMENT S . / 

### Vide o ofpropert y (DVD ) • ^ Executiv eSummar y V EPA-provide dpropert y sketc h ^2

f Signe dAcces s Agreemen t fo r subjec t propert y f ^ Signe dAcces s Agreement(s ) fo r adjacen t propert y y

TRestoratio nAgreemen t mt ^ Settlement document s (i.e. , fo r damag e or t

o replac e plants , etc. ) s f

Confirmationdata i / ' Photograph s ^U-t^^Cfi(i/{kW2l ^ -^ fe<^WAtl^ ^ ')<7 l^jyv , ^ As-buil t sketc h V ^ Satisfactor y restoratio nsigne db y Propert y Owne r T

y Propert y close-ou t chec k lis t signe db y EP A t^ LDescriptio nofarea s not meeting RO D cleanup criteri a f / Utilit y clearance s s TPropert y infonnatio nfro mDougla s Count y Assessor' s Offic e [ I 

## n n 

# &W0UU
- Signatur e" 3005450 9 

# T ^ Dat e Superfun di'Ett


## Propert yAcces s Checklis t Property ID : |H'5\" 7 D WORK STARTED ON : Property Addiess : "^Tf] H ^ "^" ^ ^L D WOR K

COIVIPELTE D ON : 1 Owner : f^^^ ^ fia\\f\^ r 1 Address : 3cjnl ^

Phone : 5^1-^02 5 Fax : 1 Ccll/Pascr :

O Notificatio nLette r SJAcces s Agreemen t 1 "S S Restoratio nAgreemen t

C

D Top.soil Samplin g (if a|)plicablc ) Q Disposa l Samplin g (i f applicable ) E

H Garde nSamplin g (if applicable ) M Utilit y Clearanc e 1 5 7 Video/Photo s (Before )

nVideo/Photo s (During ) nVideo/Photo s (After ) D Video/Photo. s (30-Day ) nPropert y Completio nAgrcemen i nFilia l Repor t Renter : | Phone : Fax : Cell/Pager : Additiona l Information :

Sent : / / Bv : 

### Signed : |J2_/X'- ^ 

# B.v : t. e Signed : j2_/X/ ± 

# B.:6. C

/ / By : / / By : / / By : 

## Called : i£_/Jl/ ^ 

# By : e c On:ic_/_[D / C \ 

# ^y-l\lltk/^n(xr \ On : / / Bv : On : / / By : On : / / By . Signed : / / Bv : Issued : / / By . Ai rMonitorin g (a s ai)plicabl e

CH Communit yQ Cre w ) Results : On : / / 

## B> : J
CH Communit y Results : [ H Cio v On : / / By :
CD Communit > Results : C H Crc^ v On : / / B> :

Omah a Lea d Sit e

## Property I D U Property Address : Initial Contact : Secon dContact : Final Contact : Final Action :

Comment : Owne r Commen t (s) : Site Coordinato r Commen t (s) : CONTAC T FORM 

# 43i\ l ^v^-i l 5 ?. a5 ^ Date : Time : Action :

Date : Time : Action : Date : Time : Action : Transmi t to EF AD Other Action : D



# hp^*<< :

## R^j^n t Reques t for Actio nFor m(fll^ ) 

# MK ^

Projec t Name : Projec t No
. Omah a Lea d - Fixe d Pric e 

## EP-R7-07-0 5 Projec t Location : Propert yI D Omaha , N E 1431 7 Hom e Owner' s Tamm yBahne r Name : Propert yAddress : 307 2 S 3 3 S t Phon e Number : Dat e & Tim e Reques t 402.291.400 0 6/30/200 9 Received : Documente d by : ELIZABET H CACERE S| Issue :

Tamm ycalle d becaus e th e powe ra t he rresidenc e i s out . P O think s a powe rlin e mayhav e bee n damage d durin g remediation
. PI C provide d P O wit h Contracto rphon e numbe ran d tol d P O tha t informatio n woul d b e forwarded
. Coasta l contracte d a license d electricia n t o replac e a n undergroun d condui t tha t extende d firo m th e garag e t o

th e house
. Th e condui t wasn' t identifie d b ylin e locat e an d w e damage d i t whil e excavatio n th e property . Th e electrician s responde d t o th e cal l th e sam e da y6/30/200 9 an d schedule s repair s wit h th e homeowner s fo r Thursda yan d complete d th e repair s o n Frida yth e thinj
. Thi s cal l ha s bee n completed
.
Propose d Actio n • Issu e no t previousl y • Follow-u p Require d X N o Furthe rActio n I s a s Follows : Identified ; Investigatio n Necessary

• Additiona l comments :

### Dougla s Covmt y Accoi >U|^i^Kni { 

### atio n Pag e 1 of 2 • # Dougla s County , Nebrask a Propert yRecor d - R194292000 0 Prin t Repor t NE WFeatur e - Parce l Dimension s availabl e @ scal e 0-5 0 ft wes t o f52n d S t - Vlevt fO H Ma p Informatio n i s vali d a s o f2009-5-1 2 Treasurer' s Ta xRepor t Ne wFeatur e -•••" • Aut o Sale s Searc h Owne r BAHNE R BRIA N T ETA L 307 2 8 3 3 S T OMAH AN E 68105-000 0 Propert yInformatio n Ke yNumtier : 429 2 OOO O 1 9 Accoun t Type : Residentia l Parce l Numlter : 194292000 0 Parce l Address : Lega l Description : 307 2 S 3 3 S T OMAH AN E 68105-000 0 PARKVAL E LO T6 BLOC K8 4 1 X 13 0 Valu e Informatio n 

### 2009 200 8 200 7 

### 200 6 200 5 200 4 Lan d $5,900.0 0 $5,900.0 0 $5,900.0 0 $5,900.0 0 $5,900.0 0 $5,900.0 0 Improvemen t $80,300.0 0 $80,300.0 0 $80,300.0 0 $67,800.0 0 $67,800.0 0 $67,800.0 0 Tota l $86,200.0 0 $86,200.0 0 $86,200.0 0 $73,700.0 0 $73,700.0 0 $73,700.0 0 Sale s Informatio n Sale s Date : Dee d Type : Price : Grantor : 

### 1997-05-1 4 $69,950.0 0 Book : 206 5 Page : 37 3

Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s 0.1 2 S F 5330. 0 Unit s 

### 1. 0 Dept h 

### 130. 0 Widt h 

### 41. 0 Vacan t N o Improvement Informatio n 

### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R194. . . 6/6/200 9

### Dougla s County Acc o i^l^n^n i 

### atio n 

### Pag e 2 of 2

Buildin g 1

Rr* t Floo r "l»eon a Floor" ' 633. 0 sq . f l 464. 0 sqf t «i r I M \ 1 6 P

11/ 2 STOR YFINISHE D

CLIC KT O ENLARG E IMAG E Squar e Footage : 1097. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Averag e

Buil t As : 1 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 5. 0 Exterior : Fram e Stucc o Units : 1. 0 Interior : Drywal l Baths : 1. 0 Roo fCover : Compositio n Shingl e Bedrooms : 2. 0

Roo fType : Gabl e Stories : 1. 5 Floorcover : Allowanc e Foundation : Blocl < Sprinkle rSquar e Footage : 0. 0 Yea r Percen t Adjuste d Yea r Yea rBuil t Physica l Ag e Remodele d Remodele d Buil t 191 8 0 % 191 8 9 0 Detai l Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 f t 624. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Garag e Detache d 228. 0 Porc h Enc l Soli d Wal l 160. 0 Use r 1/ 2 Stucc o & 1/ 2 Shingl e 1. 0 Use r Atti cFul l Finis h 464. 0 Use r She d - N V 1. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R194. . . 6/6/200 9

# 0 Pag e 1 of 1

" > Creat e Anothe rTicke t Bac k t o Irt h Inteme t , Send , Emai l



### • YOU RTICKE T NUMBE RI S 2293379 . Origina l Cal l Date : 6/12/0 9 Time : 3:0 8 pm Op : ELIZABETH1879 0 Wor k t o Begi n Date : G/lG/0 9 Time : 3:4 5 pm State : N E County : DOUGLA S Place : OMAH A Address : 307 2 Street : S 33RD S T Twp : 15 NRng : 13 E Sect-Qtr : 33-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : lead remediatio n Locatio n o f Work : LOCAT E AL L EASEMENTS . LOCAT E ENTIR E PROPERTY Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LOT . Compan y: COASTA L ENVIRONMENTAL SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Being Don e For : Coasta l Dept h o f Excavation : 4f t Corne r Lot : N Front : Y Rear : Involve s Tunneling o r Horizonta l Boring : N Explosives : N CXCAT V MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F Servic e Are a Contac t Phon e Number Utilit y Typ e Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , INC HEID I Alt : 402934046 9 Emerg : 402932975 7 

### Day : 402504782 3 MUD02 METROPOLITA NUTILITIES DISTRICT SAND Y Alt : 

### Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE RRO N 

### Alt : 402444516 1 Emerg : 4024445160 Day : 406728934 3 0PPDGPR 6 OMAH APUBLI C POWE RDISTRICT N A 

### Alt : 4062071494 Emerg : 888728934 3 Day : 406728934 3 QLNNEIFQWES T LOCA LNETWOR K

N A 

### Alt : 4062071494 Emerg : 888728934 3
http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 6/12/200 9http://www.dhoaaatirthintemet/DHONNoticeCreation/MessageText. . LM& t
Creat e Anothe rTicke t Bac k t o lit h Inteme t Sen d Emai l



## • YOURTICKE T NUMBE RI S  2300156 . Origina l Cal l Date : 6/22/0 9 Time : 12:4 4 p m Op : ELIZABETH18 7 9 0 Wor k t o Begi n Date : 6/24/0 9 Time : 1:1 5 p m State : N E County : DOUGLA S Place : OMAH A Address : 307 2 Street : S 33R D S T Twp : 15 NRng : 13 E Sect-Qtr : 33-NW Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : Lea mRemediatio n Locatio n o f Work : INCLUD E AL L EASEMENT . LOCAT E ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LOT . Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Bein g Don e For : Coasta l Dept h o f Excavation : 4f t Corne r Lot : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F 

## Servic e Are a Contac t Phon e Number Utilit y lyp e CXCAT V CO X COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 

## MUD0 2 METROPOLITA NUTILITIES DISTRIC T Day : 402504782 3 SAND Y Alt : Emerg : 402504797 0 

## OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRO N Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 

## 0PPDGPR 6 OMAH APUBLI C POWE RDISTRIC T N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 Day : 406728934 3 

## QLNN E1 FQWES T LOCA LNETWOR K 

## N A Alt : 406207149 4

lo f 2 6/22/200 9 12:4 4 P M

### htq)://www.dhoaQ«ju1hintemet/DHONNoticeCreation/MessageText.. . 

## Emerg : 888728934 3

2 of 2 6/22/2009 12:4 4 P MOLS# : 1431 7 Dat e Excavated:6/30/0 9 

# As-Buil t Drawin g Dat e USEP ASigne d Off : 7/28/0 9 C OASTA L Are a Sodden : 72 1 s q f t 

# Omah aLea dSuperfun dSit e INVIRONHKNTA L O f l O U F
. IN C 

## 1431 7 Omah a Lea d Sit e Exterio rPairr t Owne rName : BRIA N TBAHNE R Sit e Sketc h • Goo d • Poo r 0 No t pairr t

Omah aLeadSit e 4613 0 Legen d Concret e Dri p Zon e Excavate d Quadrant s Excavate d Are a replace d wit h Are areplace dwit h Are alef t bar e Sod Rock/Mulc h Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .

## 1431 7

Omah aLea dSit e 

## >^CV^6F ^ 4613( 1

# 1431 7 Omah a Lea d Sit e Exterio rPain t Nort hArro w rOwne rName : BRIA N TBAHNE R 

### Sit e Sketc h • Goo d • Poo r 0 No t pain t

Omali aLea dSit e 4613 0 

# '^^oj mOwiw rNam* : BRIA N TBAHNE R AddfMs : 3072S33S T

Phon* : H : Sampl e Numt>e r RYASCPXA-1431 7 F l RYBSCPXA-1431 7 F 2 RYCSCPXA-1431 7 B 1 RYDSCPXA-1431 7 B 2 RDZSCPXA-1431 7 D Z fiOZ00PKA-1-M17 0 2 RP2SCPXA-1431 7 P Z Omah a Lea d Sit e Sit e Sketc h w Lea d Concentratio n Sampl e Collecte d LA B 

### D /^ ^ pp m 

### D / Vj P pp m 

### D 'rv 7 po m 

### D 73 / .pp m 

### D pp m 

### D l^ltyoo m 

### D 

## 1431 7 Exteito rPain t Nort h Arrow • Goo d n Poo r g J No t pain t Sample s Collecte d Firm : PJ»t > ^ DA \ t ^ tV N Date : QT - \S-O M Time : 'S' . VO Sample s Analyze d XR F Unit : BJ'^ ^ Book : j^f Date : ^./V-^?y - Time : f^T ^ Numbe ro fSample s = I j ^ Staff : 

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# 7^a / 

# 3
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COASTA L INVIHeNflfNTA l 

### ^««. ^ ••O WP , tN C ^ 

## Consen t Fo rAcces s T o Propert y RIGH TO F ENTR YTO 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 follovi/in g describe d premises : Daytim e Phone : 

## l>ol t 6 •b-^"' ' ^- t Addres s o fPropert y covere d b ythi s Agreement : 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 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 remove contaminate d soil
. Th e remove d contaminate d soi l vi/il 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 ofCoasta l Environmenta l Group , contracte d byUSEPA , wil l contact 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 v^r k befor e i t begins
. Once 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 that 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 Athat th e property ha s bee n remediated
. ENVIRONMENTA L RESPONS E ACTION S 

### Bysignin 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 rrrotice , fo rth e sol e purpos e o fperformin g th e work
. Thi s acces s shal l remai n I n effect unti l th e work ha s bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :

l o f2• •

COASTA L iMvitonnniiA i s I 0 u r . I * i c



### •Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; • Remov 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 ; • Abid e b yhealt h an d safet yguidanc e provide d b yEPA ; • I fth 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
. • Allo wvideotapin g and/o rphotographin g o fth e property . AGREEMEN TNO TT o INTERFER E 

### Th e Granto ragree s no t t o interfer e o rtampe rwit h an yo fth 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 fsai d propert yv^lc h woul d ten d t o endange rth e healt h o r welfar e o fth 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 (712 ) 352-018 8



## p/g i gran t acces s t o mypropertie s D I d o no t gran t acces s t o m ypropertie s 

# C-'i'O^ l Signature Date Signature Dat e
QI woul d lik e t o b e presen t durin g an ysamplin g tha t i s required
.

### • • 

# N

COASTA L 

## Restoratio n Agreemen t The purpos e o f thi s agreement i s t o provid e amutual agreemen t a s to condition s ofth e property prio r to remediatio nactivities . Thi s wil i als o serv e a s documentatio nfor th e purpos e o f assurin g tha t restoratio n activitie s are complete dt o th e satisfactio no f the propert> ' owne r andthe Unite dState s Environmental Protectio nAgenc y (EPA) .

Property ID : 

# WT T Propert y Address : "^tyi-^ y '^h^ ^ 

# ^ 1 Owner ; hU ^ f7(W^ ^ Phone : O

nth e attache ddiagram(s ) indicate area(s ) to excavate danddept ho f excavation , locatio no f all known utilities , subsur^ e features , surfac e structure s andlandscapin g features , acces s location(s ) to b e usedb y contractor , andth e directio no f North . Indicate distances , depths , materia l types , etc . Indicate digital photo s b

y referencin g the photo-lo g number wit ha narro w indicatin g directio no f view . 

## Item s T o B e Remove d B yOwne rBefor e Start O fRemediation : (Us e additiona l sheet s a s necessary) Th e removal , storage , disposal , and/o rretu m o f thes e item s I s th e Owmer' s responsibility
. Item : 

### Item : ( J '

-— . Item : 

# ^^ 3 Item : . ^ ^ ' Item : . , ' Item : - Item : /- ' Item : Page t 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 as necessary)

" Item : 

# l\h a"iihmA(1/ ^ boL/y^ J

Item : Item : Item : Item : Item : Item : Item : Kem : Item : Item : item : Item : Item : Item :

Pag e 2 of
.

### # • C p AS T AL CMVlMOMMIMTA l cn o u rIN C 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 : 

# <o\ l ' fa>n^ Item :



# . W&? - fm f

# m l>- ^ Item : Item : Item : Item : Item : Item : Item : Item : item : Item : Item : Item : Item :

Pag e 3 of
.

### 1 ^ COASTA L t N vlHONMtM fA L GROUP
. IH C



## Ite m

Pre-existin g propert y area , that wil l b e excavated , that i s covere dwit hgrass .

Numbe r o f tree s > 2 inc h trunk 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 . Attac hasketc ho f th e sprinkle r layout .
Numbe r o f an dsiz e o f eac hgarden/ flowe r be d area . Attac hasketc ho f relativ e size s an dlocations . 

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

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

Square fee t



### • , Eac h 

### \

Eac h 

### \

Each 

# if f

Each Square Feet 

### \

Pag e 4 of
.COASTA L • MVIJIONr«AMTA L OHOU P *N e 

## Ite m N Agree dupo nvalu e o f Diant material s no t t o b e renlace db v contractor . Not e thi s valu e will b e use dt o issu e aplan t vouche r t o th e propert y owner . 

### \ 

## Quantit y Urii t

$ 

## Condition/Type/Specie s

Agree dupo nlis t o f pla ^ material s tha t wil l be ^ replace db y connector . B e very specifi c an ddetailed . Eac h Includ e asiietc ho f wer e eac hplan t will b e place d b y th e contractor . 

### \
Agree dupo nare ao f property to b e replace d wit hgras s sod . Includ e asketc ho f th e arca(s ) t o b e replace dwit h gras s sod . 

### S F

Are ao f City o r County proper ^ t o b e landscape d pe r diei r requirements . 

### \ S F Includ e area(s ) a sketc ho f th e 

### /

Easemen t Area , t o b e excavate d 

### S F 

# RjxAxyv^ ^CMf e

Pag e 5 of
.

### • • ; OAST AL
. MVlkOMMCHTAi , « • tfF
. IM C 

### Additiona l Comment s / Instnictfons :

D Chec k th e bo xi fOwne rdoe s no t wan t CE G t o documen t interio rfoundatio n wall s an d possibl e pre-existin g damag a B ycheckin g thi s bo xCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro fhouse , indudin g foundatio n crack s o rfissures
.

EOragr O I d o no t agre e age e 1 Owner' s S%;natur e Dat e doi^ctor* 8 Signatar e Dat e PageSo f

## BviD # iM5 n XR F PROPERT Y SAMPL E 

## SHEET Dat e Addres s 

## Ln ' m- m 

# '6b na^? > ^ V Projec t Omah a lea d F P 2n d yea ropilc n 

### Sampl e tim e 

### am/gi g 

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### 3 0 se c

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

### mn.2f» t i*s.^ p f»>\.r^tw.Mt » 

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# SsM . iaiL*iu±J5Jd2 ^ t/>3U > °H.8 1 t IT.-'S l 

# Ii L InSl . m n^ ± j ^ .fi ^ Dept h 

### t»q.q5j:ii.i< » Dept h 

### j£Ji2 L 

## \^Z\ ±1^.1 % 

# "T z J a 

# S : ^q g i Il.l? , Averag e \'h\l>.l< ^ t \5.'! ^ Averag e qii,.l U J H .L
. Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a 

# M ^ Jfi3k - I^.T±l*i.S- ^ tXT.^?.llM.1.' ? 

# J2 L u>q" i IIL33
­ lll.qitl?t,'A 7 

# mt,*\\\nf ^ Dept h 

# j£ z Dept h Averag e 12 1 ^ 4 ±I H •2^ ^ 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 Sho t # Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h Dept h Averag e Averag e la b sampl e # La b resul t Sampl e are a XR F Avg
. 

### Signatur e tpCAJ^no A Prin t rJi7c.hP-H o CjQlPe^ f 5

>

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o f Verificatio n XL3t-3208 9 Readin g N o 68 4 Mod e SOI L Tim e 2009-06-3 0 14:1 3 Duratio n 121.7 4 Sequenc e Fina l Flag s AVERAG E 

### ^^oL650=683- 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E easemen t INSPECTO R nicola s DEPT H 1 SAMPL E TYP E CLEARANC E NOT E
pp m ± Erro r Pb ± 0573561 7 Supervise d By : Cf^jJ^orULfy ­

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1 

## Certificat e o f Verificatio n XL3t-3208 9 Readin g N o 68 0 Mod e SOI L Tim e 2009-06-3 0 14:1 0 Duratio n 30.4 8 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E easemen t INSPECTO R nicola s DEPT H 1 SAMPL E TYP E CLEARANC E NOT E

pp m Erro r P

b 140.25 0 ± 15.30 1 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe r Scientifi c 90 0 Middlese x Turnpik e Billerlca , M A0182 1 

## Certificat e of Verificatio n XL3t-3208 9 Readin g No 68 1 Mode SOIL Tim e 2009-06-3 0 14:1 0 Duratio n 30.2 1 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E easemen t INSPECTO R nicola s DEPT H 1 SAMPL E TYP E CLEARANC E NOT E
pp m Erro r P b 134.45 9 ± 15.36 7 Supervise dBy :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1

XL3t-3208 9 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D # ADDRES S QUAD/ZON E INSPECTO R DEPT H SAMPL E TYP E NOT E
pp m P b 142.09 0 Supervise d By : 

## Certificat e o f Verificatio n

68 2 SOIL 2009-06-3 0 14:1 2 30.5 5 Fina l 1431 7 307 2 s 3 3 s t easemen t nicola s 1 CLEARANC E

± Erro r ± 15.57 5

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3208 9 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D # ADDRES S QUAD/ZON E INSPECTO R DEPT H SAMPL E TYP E NOT E
pp m P b 130.21 0 Supervise d By : 

## Certificat e o fVerificatio n

68 3 SOI L 2009-06-3 0 14:1 3 30.5 0 Fina l 1431 7 307 2 s 3 3 s t easemen t nicola s 1 CLEARANC E

± Erro r ± 15.18 0

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3208 9 Readin g N o 68 9 Mod e SOIL Tim e 2009-06-3 0 15:3 0 Duratio n 120.7 4 Sequenc e Fina l Flag s AVERAG E Av g o f685-68 8 

# G ADDRES S 3D7Z~s33-s t QUAD/ZON E B 2 INSPECTO R nicola s DEPT H 6 SAMPL E TYP E CLEARANC E NOT E

± Erro r pp m P b [96.25 ^ ± Supervise d By : CfiQAJ^n/lO ^

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3208 9 Readin g N o 68 5 Mod e SOI L Tim e 2009-06-3 0 15:2 8 Duratio n 30.2 0 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E B 2 INSPECTO R nicola s DEPT H 6 SAMPL E TYP E CLEARANC E NOT E
Erro r pp m P b ± 14.45 5 131.05 2 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

XL3t-3208 9 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D # ADDRES S QUAD/ZON E INSPECTO R DEPT H SAMPL E TYP E NOT E
pp m P b 94.81 9 Supervise d By : 

## Certificat e o fVerificatio n

68 6 SOI L 2009-06-3 0 15:2 9 30.1 9 Fina l 1431 7 307 2 s 3 3 s t B 2 nicola s 6 CLEARANC E

± Erro r ± 12.51 4

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o f Verificatio n XL3t-3208 9 Readin g N o 68 7 Mod e SOIL Tim e 2009-06-3 0 15:2 9 Duratio n 30.1 8 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E B 2 INSPECTO R nicola s DEPT H 6 SAMPL E TYP E CLEARANC E NOT E

pp m±Erro r P b 69.95 4 ±11.18 6 Supervise d By :

# Therm o SCIENTIFI C Therm o Fisher Scientifi c 90 0 Middlese x Turnpik e Billerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3208 9 Readin g N o 68 8 Mod e SOI L Tim e 2009-06-3 0 15:3 0 Duratio n 30.1 7 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E B 2 INSPECTO R nicola s DEPT H 6 SAMPL E TYP E CLEARANC E NOT E


### pp m±Erro r P

b 89.19 5 ±12.227 Supervise dBy :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o f Verificatio n XL3t-3208 9 Readin g N o 69 9 Mod e SOI L Tim e 2009-06-3 0 15:5 1 Duratio n 121.0 0 Sequenc e Fina l Flag s AVERAG E rAvgof695=69S ? ADDRES S ^trr2rs~33-sf ^ QUAD/ZON E D Z INSPECTO R nicola s DEPT H 1 3 SAMPL E TYP E RETES T NOT E
pp m Erro r P b rl273 ^ rpr26§ / Supervise d By : VflOft>OJ7ff ^

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3208 9 Readin g N o 69 5 Mod e SOI L Tim e 2009-06-3 0 15:4 9 Duratio n 30.1 9 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E D Z INSPECTO R nicola s DEPT H 1 3 SAMPL E TYP E RETES T NOT E

± Erro r pp m P b ± 14.82 5 138.69 8 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1 

## Certificat e o fVerificatio n XL3t-3208 9 Readin g N o 69 6 Mod e SOIL Tim e 2009-06-3 0 15:5 0 Duratio n 30.2 0 Sequenc e Fina l Flag s BVI D # 1431 7 ADDRES S 307 2 s 3 3 s t QUAD/ZON E D Z INSPECTO R nicola s DEPT H 1 3 SAMPL E TYP E RETES T NOT E
Erro r pp m P b ± 14.24 6 122.32 6 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

XL3t-3208 9 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D # ADDRES S QUAD/ZON E INSPECTO R DEPT H SAMPLE TYP E NOTE
pp m Pb 111.92 4 Supervise d By : 

## Certificat e o fVerificatio n

69 7 SOIL 2009-06-3 0 15:5 0 30.1 1 Fina l 1431 7 307 2 s 3 3 s t DZ nicola s 1 3 RETES T

± Erro r ± 13.41 7

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1

XL3t-3208 9 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D # ADDRES S QUAD/ZON E INSPECTO R DEPT H SAMPL E TYP E NOT E
pp m P b 136.41 0 Supervise d By : 

## Certificat e o fVerificatio n

69 8 SOIL 2009-06-3 0 15:5 1 30.5 0 Fina l 1431 7 307 2 s 3 3 s t D Z nicola s 1 3 RETES T

± Erro r ± 14.58 7

## / Jfk ^

\ Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta i Grou p Inc
. ^^^^ ^

www.coa8talhazmat.co m \p„e ^

COASTA L IHViaONNINTA l G IO U P , IN C 

# EXECUTIV ESUMMARY : BVID #14317-(307 2 S 3 3 ST ) No Issue s o r Concern s [ ^ Issues/Concern s Detail Explanation : -SO D IS BROW NDU ETO PROPERT Y OWNER S DOG(EVALUAT E3 0 DA Y SO D PHOTOS )4 

# EP A EP APropert y Clos e Ou t For m Propert y# Propert yAddress; - ^fll/ - - ^ . ''^^^'' ' Datc/Tlm c Owner' s Name : Ajfl P••V^lQ-t^^ y• Quad s Excavate d avated : Sl ^ ^X^'L ; Contracto rGrou p CjOoftbL l GtAttTMrltA y Ye s No Excavatio nGenera l i^ " 1.

If necessaiy , wer e th e correc t quadrant(s ) excavate dan drestored ? : ^ 2.

If necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? Ye sNo Gradin g So d an d Vegetatio n 1.Doe s th e gradin g aroun dth e perimete r ofth e hous e inexcavate darea s generall y slop e awa y 

# V" fromtb e bouse ? 2.Ha s so dbee nlai d inal l area s tha t wer e excavated ? 3.

Doe s Ut e so dappea r to be generall y healdi healdi y an an

d d Bftov»ing?XOnl y yevaWlat e e i f inspecte d at a a 3

3 eva^t inspected^at^ 0 ^^^ing?^0nl ^ da y tim e period ) ^ 

## P ^ ^ TJ ^

h(^C - /^^ ^ hyji KJt/i L 4.Ar e sodde darea s generall y nr man devenl y graded ? ly^ ' 5.

Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat eif inspecte d at a30 day tim e period ) 6.Wa s th e propert y grade dsuc htha i wate r wil l no l poo lonth e property ? 

## i ^ 7.Wa s damag e to landscapin g or plan t material s avoided ? Gates , Fence s an dRctoinin g Wal b Yt s No 1. Do gate s ope nan dclos e freely? (I f applicable ) 

## L ^ ^ Wer e al l gate s or fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (Ifapplicable ) 1 ^ ' 3.Wa s damag e to gate s or fence s avoided ? (Ifapplicable ) 

## U- ' 4.Wa s damag e to retainin g wall s avoided ? (Ifapplicable ) Foundation , Sidin g an dGutter s Yes No I.Wa s damag e to th e sidin g or tri mavoided ? 

## 1 / ^ 2.Wa s damag e to th e foundatio navoided ? 

# y 3.Wa s damag e lo window s avoided ? 

## TT- ' Wa s damag e to window s or doo r screen s avoided ? 

# -y ^ 5.

Wa s damag e to dowrnspout s or downspou l extension s avoided ? 

# 1? ^ Sidewalk s an d Driveway s (Concrete ) Yes No 1.Wa s damag e lo drivewa y surface s avoided ? 

# lyc 2. Wa s damag e lo walkwa y surface s avoided ?

# m%

Propert yConf>pletlo n Agreemen t Thi s agrcemen i documenl s Ih e compiclio n o l remedia l acliviiie s perlbime d o n m yproperl yM ysignalui e wil l designat e iha i J a m salisfie d wit h th e restoratio n o fm yproperly , an d Iha l n o item s ar e i n question.^ , now . o ra l an ylim e i n ih e futui-e , excep t ihos e item s liste d below , ifan y

Propert yID : ) L j ^ ) ' j Propert yAddress : •a/N'T O ^ !? ^

< + 

## Q""^ " ^lAtt . "bfthner . Phone : ^ 4 | , ^^y; ^ Restoratio n Item s i n Question :

Item : Ilem : Item : t' w » 'wr mmtmmv t j 1 Item : Item : Item : Additiona l Comments :

l\fI ngrc crestoratio n i < complcitd , rxccp l a s noltr l [_ J I fl o no l ajjre cresiomtio n i s eomplele d

Owno'.«Sicnatnr rDat e CJint i aclor' s Signatur e Dal e

## Wate rBil l Settlemen t

Property E ) 1431 7 Property Addres s 307 2 S . 33" " Stree t Tenan t Mr . BrianBahne r Plion e 402-341-808 5

I hav e receive dfix)mth e contractor , Coasta l Environmental Grou p Inc . (Coastal) , th e su mo f $ 70.5 6 for wate r usag e require dt o maintai nth e sod . Chec k Number 178 9 Valu e o f Chec k $70.5 6 Mad e Ou t T o Bria nBahne r Descriptio n o fSettlemen t T o reimburs e tenan t fo restimate d wate rcharge s o n thei rMU D monthl yinvoices
. M ysignatur e belo wi s acknowledgemen t o fth e receip t o fth e su m liste d above , whic h I furthe r acknowledg e t o b e fai rcompensatio n an d ful l paymen t fo rth e above , an d releas e Coasta l Environmenta l Grou p Inc
. fro m furthe robligation s o rliability
. 

# n

/ • / 

# 2 ­ 

# lyl M ^ 

# n U Owner' s Signatur e Date "cd r infractor' s Signature Date

Pag e 1 o f1

# h'il nOil t m' i 3i o •<.!.' ) 

# \ w#11- ) 

# n Account s 129003-117379 8 BRIA N BAHNE R Service addreaa : 307 2 8 33R D 8 T Cal l 81 1 befor e yo u di g i n you ryard , buil d a fence , etc . Cal l a t leas t hw o workin g day s i n advance
. Utilitie s wil l mar k gas , water , electric , cabl e an d phon e lines
. N o charg e fo rthi s service
.

35 0 1



# J , - fcillili.,, Se p O d No vDa e Ja n Fe b MarAp rMa yJu n Ju l Au g You rGa a Ua a ftet 1 2 Montti * • Pas t 134 * MonU M Thi s Mont h Las t Yea r Billin g units : 8 7 Us e pe rday : 0. 3 0. 2 Averag e cos t pe rday : $0.6 5 $0.8 1 Numbero fday s i n tsillin g cycle : 3 0 3 1 4 0 1 I 

# Jltll-- - 

# i L
Se p Oc t No vDe cJa n Fe b MarAp rMa yJu n Ju l Au g You rWate rUa e

• PM t 1 2 Month s B Past 134 4 Montti s Thi s Mont h Las t Yea r Billin g units : 2 5 2 6 Us e pe rday : 0. 8 0. 9 Averag e cos t pe rday : $1.2 0 $1.3 0 Numbe ro fday s i n billin g cycle : 3 3 3 0

Pleas e retu m thi s portio n o fth e bil l wit h payment . • Pleaaed o no t atapl e paymen t t o bill
. 

# X e-mail : ou8tomer_9eivloe(^mudomaha.oo m websita : www.mudomaha.oo m METROPOLITA N UTILITIE S DISTRIC T 1723HameyS t • Omaha , N E 68102 - 402.554.666 6 885

0 001 0 M U RP 07 08082009 YNNNN Y0 1 00282 1 BRIA N BAHNE R 307 2 8 33R D S T OMAH AN E 68105-366 4 

### >l>|l" lI'illll|l> lI"ll<l'll>ll»"|ll|' lIl l

Givetoth e Hea t Ai d Fund
. Seewww.mudomaha.com
. Monthl ydonatio n ~ Add : Q $ 2 D $ 3 D $ 5 Othe r$
_ 172 3 Harne yS t • Omaha , N E 6810 2 •402.554.666 6 e-mail : customer_service@mudomaha.co m • website : www.mudomatia.co m Billin g date Au g 7,200 9 Previou a balance Paymen t reoeive d -Than k yo u Curren t ohargea Ne wbalance 

## • Tota l du e Au g 25,200 9 Yourbudge t paymen t o f$138.0 0 i t du e Au g 25,200 9 Budge t varianoes :

Currently-$67.4 4 Tota l ° -$51.5 0 Detail s o fourren t oharges : 

## METROPOLITA N UTILITIE S DISTRIC T



### ImGieai . Think Blue . $138.0 0

138.0 0 O R 138.0 0 138.0 0 

## $138.0 0
QA S RESIDENTIA L RAT E A : Ju l 1 t o Ju l 3 1

Mete rNumbe r26855 8 Curren t rea d (aohiao : 732 6 - Previou s rea d (estimate) : 731 8 » 8 CC F Ga s Use : 8 CC F x1.02 4 (hea t value ) = 8.19 2 therm s

3 0 day a 8.19 2 therm a at 0.528 6 > $4.3 3 Senric e Charg e 12.0 0 Ga s Cos t . • $16.3 3 Ga s Infrastmotur e Replacemen t 3.0 0



## WATE R RESIDENTIA L RAT E W-1 : Ju l 1 t o Au g 3

Mete rNumbe r3505231 5 Size : 5/ 8 -inc h Cunen t rea d (esuimte) : 172 8 - Previou s rea d (estimate) : 1703 • •2 5 CC F Wate rUse : 25.00 0 CC F o r18,70 0 gallon s 9.00 0 CC F a t 0.961 4 « $8.6 5 16.000 CC F at 1.345 1 ­ 21.5 2 Servic e Charg e 4.8 6 Wate rCos t • Wate rInfrastructur e Replacemen t Cit yo fOmah a Sewe r Sale s Ta x > Curren t Charge s $35.0 3 2.0 0 9.5 9 4.6 1 $70.5 6



## 000129003117379800000013800 0 Du e o n o rbefor e Au g 25 : $138.0 0 You rbudge t paymen t o f$138.0 0 i s du e Au g 25
. Amoun t Paid : METROPOLITA N UTILITIE S DISTRIC T P O BO X 360 0 OMAH AN E 68103-060 0 

## |„|.,„j,i|i..„i..,i,|iiiii|.||.,|i||i||,i...|l'liil"ii'n'l ' Account : 129003-117379 8'•f^^ r««»e«^' i ' (402)556-360 0 ^ ^ 431 5 Cumin g Street , Omaha , N E6813t^M 8 Afte rBus
. Hour s Sunda y& Holiday s Call : ; 7t h & Sewar d ^ 36t h & k 87t h & Mapl e Bellevu e Millar d Springfiel d Chaic o Valle yElkhor n Co
. Bluff s ^"A^H'IDO I 556-360 4 556-360 6 556-360 3 556-360 7 • ­ 556-3605 ' 253-277 0 §56-360 1 359-592 3 556-360 2 (712)322-7044" ' 557-489 1 Ticke t # Plan t •Dit e V Tlrh e Tmc K Drive r Dispatche r 3369725 6 07/145/09 ' •iO:0 6 3344 ^ ^ ,*.L.^CKMA N.JEFF
Customer : •4533 3 -COST A V : • o CONSTSUCTION f RrojQc t 0'
. .Orde r# 2011' A P07Jo b # Deliver y address/instruction s a ' • >

i f 307 2 SOUT H 33R D ^V E f*

1 7 0 ,'6 0
COASTA L ENVIRONMENTA L QROU P INC
. 

### 175 3 241 1 MARTH ASTREE T 27-6/104000 3 OMAHA
. N E 6810 S 624737290 4 

# ^//H/ ^ DAT E PA

Y TO TH E ORDE ROF _ 

# X>nmtn^ AX?i^? ­ 

# ^JZU^ Z
• tXO n V\OMr(^ A?^Afejr>H j S^Vrr^^\f) i imbhlgi>ainil.NA . mbmk a iwlihiUiiuiii i FOR 

# i2 S

1:101.0000sai : & EU73 7 Eqoi,n-^0175 3 MI.?^IHD M IJOAD ' CHARG EHR. & SEK W.AVh'L.Xiii. ' bUDioia l ,:? . .6 0

STAR T TIME : Ju l .1. 6 / 2jpb 9 10:30:0(-- > Ta x ,1 4 . S S Tota l *4i.x WARNING : D O NO TALLO WAN YSKI N O R BOD YPAR TT O COM E INT O CONTAC TWIT H WET , UNH(^ fNftgjf^^RET^
. ^-'^STTT' ^ SKIN : First , secon d o rthir d degre e burn s ca n resul t fro m we t unhardene d concret e and/o rdr ycemen t powde rcontactin g th e skin
. T o preven t contac t wit h th e skin , wea rhig h rubbe rboots , waterproo fgloves , waterproo fclothin g an d long-sleeve d shirts
. I fth e ski n come s int o contac t wit h wet , unhardene d concrete , promptl yremov e th e concret e wit h a drytowe l an d the n was h th e are a thoroughl ywit h soa p an d water . I fth e ski n come s int o ^^

contac t wit h concret e juice s throug h saturate d shoe s o rclothing , remov e immediatel yan d rins e affec^ d ski n area s a s directe d above
. I fan yski n ^ rednes s o rirritatio n persists , see k promp t medica l attention
. EYES : I fany^concret e materia l get s int o th e eyes , rinse immediatel ywit h v/a ^ fo r1 5 minute s an d see k medica l jattention
. o , i
. 0 0 I agre e t o Infor m other s wh»xna yt> e workin g wit h th e wet , unhardene d concret e o fit s hazards
. -..-.-. ' ^. , ^,: . n Al l order s ar e fo rstree t cur b delivery
. Th e weigl\t o fth e truc k coul d l^iis e damag e t o th e propert yi fdriv ^ beydfi d tti&cur b line
. I F I INSTRUC TTH E DRIVE R T O G O BEYON D TH E 6UR B LINE , fASSUM E AL L RESl>(»4SIBILIT YFO R AL L RESULTIN G OAM^E ^ AN D AGRE E T O INDEMNIF Y > AN D HOL D SELLE R AN D IT S AFFILIATE S AN D SUBSIDIARIE S HARMLES S FRO M AN YCLAI M FOR^UC H DAMAGES
.

Th e water/cemen t rati o affect s th e plasti can d hardene d propertie s o fconcrete . Selle rwil l no t accep t responsibilit yfo rconcret e i fwate ri s adde d a t th e jobsite
. "
. "."' " " , ' • < ' ' ' <" FAVO R D E VE R E L LAP P REVERSCPP^R AL AVERSI6 N E N ESPAftOL / feleage a6 e revers e s'jd e fo rSpanis h version. ) I hav e rea d an d understan d Qj e warning s abov e an d I als o understan d an d Prin t name : agre e t o th e Additiona l Term ? an d Condition s stated-g p th e revers e sid e o f thi s ticket : (Mus t b e signe d tefor e deliverytruc k wil l ttriload ) Signature : I acknowledg e receip t o fth e item s se t fort h abov e i n goo d conditio n an d Signature/initials : ,a

s describe d i n typ e an d quantit ya s se t fort h above: ' A M A M P M P M 

### 2.0 c 2.0 0 Ordere d quantit y Cumulativ e tota l Arrive d o n jo b site : Left jo b site : Wate radde d (gallons) :