TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#:_iWi _ Date: ik u 

Address: 'h^'^'7 V^WfenfyK ^ f 

Remediation Contractor: Coastal Environmentai Group 

SOIL REMEDIATION 

PROPERTY nL E FOLDER DOCUMENTS 

ef 

y 

y 

Video of property (DVD) 

Executive Summary 

EPA-provided property sketch 

Signed Access Agreement for subject property 

Signed Access Agreement(s) for adjacent property 

y Restoration Agreement 

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

-B - Confirmation data 

Photographs 

As-buih sketch 

Satisfactory restoration signed by Property Owner 

I 

Property close-out check list signed by EPA 

Description ofareas not meeting ROD cleanup criteria 

Utility clearances 

CJ 

Property infonnation from Douglas County Assessor's Office 

D 

D 

y^ 

Year; 200i 

' ^ 

30217991 mil 

Superfund 

Signature 
Property Access Checklist 

Property ID: ^^^^C ] 

Property Address: 3^1 ^ D^^ey^y^^ + 

n

D

 WORK STARTED 

 WORKCOMPELTED 

ON: 

ON: 

/

/

 / 

/ 

o^vncr Lu(^An Ch/^ive^T 

Address: ^52 3 Vavtnpor'\­ s t 

Renter 

PiMHie: 

Fax: 

Phonc: 33 ^ -31^ ^ 

Fax: 

Cell/Pagen 

Celi/Pagen 

AddHional Information: 

D NotHlcation Letter 

IZI Access Agreement 

GiZ Restoration Agreement 

D Topsoil Sampling (if applicabte) 

D Disposal Sampiing (if applicable) 

O Garden Sampling (if applicable) 

P^tilit y Clearance 

Q ^ Video/Photos (Before) 

O Video/Pbotos (Dnring) 

O Video/Pliotos (After) 

D Video/Photos (30-Day) 

f Property Completion Agreemoit 

Final Report 

Sent: / / Bv: 

Signed; l l /J^ l 17^ By: dii 

SX^tin IL i k- i IB. By- fJC±d\l\r) 

/ / By: 

By: 

By; 

Called; J7_ / ^/^ f 

On:l}_/_k_/Q ^y-A/VDY 9 

On: By; 

On: / / By: 

On: / / By: 

Signed; 14-M^/() ^ 

Issued: / / 

O Commnnity

Results: 

 DCrcw On: / / By: 1 

D Commnnity

ResoHs: 

 QCre w On: / / By: 

D Community

Results: 

 QCrcw On: / / By: 

Omaha Lead Site 
Douglas County Accoimt Infordgjipn Page 1 of2 rdMio 

Douglas County, Nebraska Property Record - R1305050000 

Print Report 

NEW Feature - Parcel Dimensions available (3) scale 0-50 ft west of 52nd St - Vie w OH Ma p Information is valid as of 2009-10-15 Treasurer's Tax Report 

New Feature ->' •^ -^ Auto Saies Search 

Owner 

CHAVEZ LUCIO 

3523 DAVENPORT ST 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number: 0505 0000 13 

Account Type: Residential 

Parcel Number: 1305050000 

Parcel Address: 3523 DAVENPORT ST 

OMAHA NE 68131-0000 

Legal Description: HAWTHORNE ADD LOT 6 BLOCK 7 48 X 111 

Value Informatio n 

Land Improvement Total 

2009 

2008 

2007 

2006 

2005 

2004 

$5,800.00 

$5,800.00 

$5,800.00 

$5,800.00 

$5,800.00 

$5,800.00 

$90,500.00 

$90,500.00 

$77,200.00 

$77,200.00 

$77,200.00 

$77,200.00 

$96,300.00 

$96,300.00 

$83,000.00 

$83,000.00 

$83,000.00 

$83,000.00 

1 

Sales Informatio n 

Sales Date: 1995-05-31 

Deed Type: D SooAr: 2005 Page: 408 

Price: $60,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.12 5227.0 1.0 0.0 0.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accoimtinfo.jsp?accountno=Rl... 10/21/2009 
Douglas County Account Inforn|||ip rn|||io n Page 2 of2 

Building 1 

2 STORY 

3523 Davenport St Basement Tinsti 4fltXl SfF» 

J i T 

r

Li

 First Floor 

 914.0 sq ft. Second Floor 

; ^ „ 79B0iq ft 

si»fli[n>»;Ar, 

CLICK TO ENLARGE IMAGE 

Square Footage: 1712.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: End Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 8.0 

Exterior: Frame Stucco Units: 2.0 

interior: 1 Drywall Baths: 3.0 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Stories: 2.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1918 0 0% 1918 90 

Defa/7 Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 798.0 

Basement Fair Finish 600.0 

Fixture Additional Fixtures 2.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 3.0 

Porch Slab Roof Ceil 176.0 

Porch Wood Deck 182.0 

Porch Wood Deck 30.0 

Storage Wood 208.0 

User Attic Full Finish 319.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rl... 10/21/2009 
Page 1 of2 

# 

"> 

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

YOUR TICKET NUMBER IS 2403303. 

Original Call Date: 11/09/09 Time: 2:27 pm Op: ELIZABETH18790 


Work to Begin Date: 11/12/09 Time: 3:00 pm 


State: NE County: DOUGLAS Place: OMAHA 


Address: 3523 Street: DAVENPORT ST 


Twp: 15N Rng: 13E Sect-Qtr: 21-NW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: lead remediation 


Location of Work: INCLUDE ALL EASEMENTS 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 Environmental Group 

Depth of Excavation: 4 fee t Comer Lot: N Front: Y Rear: 

Involves Tunneling or Horizonta l Boring : N Explosives: N 

CXCATV LEVEL3 MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 

Service Area Contact Plione Number UtiUty Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVEL3 LEVEL3 COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RICH/TRAFFIC

Day: 4024447197 

 Alt: 4024445161 

Emerg: 4024445160 

http://wvm.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/9/2009 
t Page 2 of2 

0PPDGPR5 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... 11/9/2009 
23379 

Omaha Lead Site Exterior Paint North Arrow 

Site Sketch • Good 

0^oo r 

SamDiing Address: 3523 DAVENPORT ST • Not paint 

Sample Lead Sample 

Samples Collected Number LAB Concentration Collected Firm: ?£. l^t CsoU-£^) 

RYASCPXA-23379 F1 __2lj_ppm e Date: S-f'S^ 

RYBSCPXA-23379 F2 _J^2J£__PPm n D Time: /.'2VP/*i 

RYCSCPXA-23379 81 .S0 3 ppm ET n Samples Analyzed RYDSCPXA-23379 B2 8 ^ ppm 

RDZSCPXA-23379 DZ 3B a ppm D

D XRF Unit: GISH O Book: 207 •RQZOOP)(A-20379 62­ — ppm u Date: 3 -20-0 6 D " " ppm 

Time: P M Lab RYASCPLA-23379 n Staff: MA W Result 354 ppm Number of Samples = | ^ \ \ \ \ 

Legend: F1 = Front Left, F2 = Front Rigtit, 81 = 8ack Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

^ .NTERE . 

D 

MAY f 6 2008 

^ 1 ^ 

• .SHED i BZ >*-j ^ 

DRwe 

mJ\0. y 

•^ 

/ 9 POAtl US-; l 

•3^23- 05 

DWEMPOKT © to 

•••ST. CO 

Rcv200!I.N Created: 2t>-Fcb-08 044701.U 1.23 
23379 

y^ IIM '1 % 

Omah Exterior Paint a Lead Site 

Sit • Good e SIcetch 

0^oo r 

Sampling Address: 3S23 DAVENPORT ST Q Nol painl 

Lead Sample Samples Collected Sample Number LAB Concentration Collected Firm: P£ . Z.c C,iu>3-g/r) 

RYASCPXA-23379 F1 277 ppm M Date: S-'-S' 

_RYBSCPXA-23379 F2 ppm n Time: \'.2<iP^^ 

RrCSCPXA-23379 Bl 

ppm D 0' Samples Analyzed RYDSCPXA-23379 B2 ppm 

RDZSCPXA-23379 DZ ppm 

a a ^ D 

3BS D XRF Unit: GSH O Book: 2Q 7 

••ROZGCrXA-gJJTO G2- ppm D n Dale J -20-D6 

ppm D n Time RYASCPLA-23379 .Lab ±t± 

Staff -Result 354 ppm Number of Samples - [ ^ [ | ) naw 

Legend: F1 = Front Left. F2 = Front Right. B1 = Back Left. 82 = Back Right DZ = Drip Zone, GZ = Garden. PZ = Play 

All quadrants arfl as viewed from the street, facing property 
23379 

ly liiyi '1 

Exterio Nortti Arrow r Paint 

Site SIcetch 

Omaha Lead Site • Good 

[g^oor 

Sampling Address: 3523 DAVENPORT ST • Not paint 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

Firm: 

Samples Collected 

RYASCPXA-23379 F1 277 ppm B Date: S-'-S' 

RYBSCPXA-23379 F2 ppm B D Time: r.^'iP,^ 

RYCSCFT<A-23379

RYDSCPXA-23379

 B1 

 82 02 ^ 

ppm 

ppm 

E' 

B' 

D 

D Samples Analyzed 

RDZSCPXA-23379 DZ 3B a ppm B^ D XRF Unit: CoSHO Bool<: 207 

•fiOZOCrXA-23379 82 - ppm D D Date: 3 -20-0 6 

Lab RYASCPLA-23379 ppm D D Time: Pn 

'Result 354 ppm Number of Samples ­ | ^ | \ \ | Staff: nsw 

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

All quadrants are as viewed from the street, facing property 

R<v 20OS.N Crcalcd: 2(>-Fel>-0S 
COASTA l 

^1 ("BO"' c It o u r IH C 

Consent for Access To Propertj^ 

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: /^^"^—h^ 

_>_____^-^=^______ „ 

Owner's Name Daytime Phone:/., ^ ^ , , 

Wg^l/g. CUcKV-g-Z 

Address of Property 

covered by this 3 5 2^3 V^Me-i^^ocV sV 

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 perfomned, 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 
..f^^ 

COASTA L 

tHVtKONHIKTAL 

"1 pno^*" C t O U r I H C 

X'^^y:^ 

« 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; 

c 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. 

«i 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 (402) 991-1199 

0 1 I grant access to my properties 

D i do not grant access to my properties 

Signature ^^ate ' Signature 

Date 

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

Page 2 of 2 
c ..> », s I f<< V I * O M M 

The purpose of this agreement is to provide a mutual agreement as to conditions ofthe 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: Q,* ^ '^"7 ^ 

Property Address:-Z^g j£j ^ \;p(X\J^ys.OQ ^\_ ^ . 

Owner: ^\/jy^ . cAij.Ajs. Ph...: <^'^^ y 3/cfi-' ^V^ - -^Ui 

On the attached diagram(s) indicate area(s) to excavate, surface structures and landscaping features and 

access location(s) to be used by the contractors. Indicate distances, depths, material types, etc. 

Photographically and Videographically document the existing conditions ofthe property and the basement if 

necessary. 

Items to be Removed by the Ovtrner before Start; of Remediation: 

'\ t\z :cn;ovc.i. gtorace, disoc?s£.l, enci/oc retctn o.' these items JF tn^ Uwr^ei s respcnsitiiliiy. 

item: f\ , 1 , ' \ ~ ~ """"^ f 

• ^ ^ ^ 

Item: 

Kem: 

Item: 

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

fl^^ SlKxQvW V\0v1^A-T 

Page 1 of. 
C .1 A S T M L 

Item: \

n Item: 

Item: 

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. 

A.uach r. sketch ol llie 

>fr',iklc i l;:\f.Li; 

Number of and size of 

each garden/ flower bed 

area. 

Aiiacli u skclcli ol rfl.itivf 

bi7.os and loc;iii(Mis. 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

••'civ- r.i' , -:li(. ' ••.ili h : 

JS''C '.c '^si'C r y.an ' 

>oiHvev 111 t'l'- |-,iT)v.M;'! 

u<\ ntr . 

Easement Area, to be 

excavated 

\ 

Landscape inventory 

Quantity Unit Condition/Type/Species 

^ \ Quadrants 

s Each 

Each 

Each 

Each 

Square Feet 

: i ^ Each 

Page 2 of. 
C <" A> s T /• L 

I Additional Comments / Instructions: 

1 - 5 <^<^^ ^^^^ ^^*^ ^W\V\oK 

j^Check the box if Owner does not want CEG to document interior foundation vvalls 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. 

0 I agree • I do not agree 

pMy.rL yyirrrsA'^ W-pycff yyW^rei ^ //k/ey 

Owner's Signature ^Dat e Contractor's Signature Date 

Page 3 of 
BVID# 21^1"^ 

XRF PROPERTY SAMPLE SHEET 


Date /(-/-Z-'OC \ Address 

Project Omaha Lead ARRA Sample time am/pm 

XRF ID# sample length 30 sec •^'iozfzShot# Reading Sample area Shot# Reading Sample area 

42.2­ fS^tiM (=JfNA S^(> 2M^:t:Z^ ^ \ 

^2.3 MS^I 3 Depth ^2_n 2.c:f, ^' 25 Depth 

^Z ^ ^S^') S 1" 3^2* •25^ t 2 ^ f," 

Average Hi-13 Average ZSM ^2,q 

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 Depth 

Average Average 

Signature &^MiQnA 

py^n^]f(>^.CAnM 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 325 

Mode SOIL 

Time 2010-02-22 16:23 

Duration 90.30 

Sequence Final 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm Error 

~yj Pb 13.376" 

Supervised By : ^A/Mg A 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 51.108 

Supervised By: 

Certificate of Verification 

322 

SOIL 

2010-02-22 16:22 

30.11 

Final 

23379 

3523 Davenport St. 

EM 

1 

O. BARAJAS 

1 

1 

± Error 

± 13.675 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 323 

Mode SOIL 

Time 2010-02-22 16:22 

Duration 30.11 

Sequence Final 

Flags 

BVID 23379 

ADDRESS 3523 Davenport St. 

QUADRANT EM 

DEPHT 1 

XRF TECH O. BARAJAS 

MISC 1 

NOTE 1 

ppm ± Error 

Pb 47.791 ± 13.319 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 45.066 

Supervised By: 

Certificate of Verification 

324 

SOIL 

2010-02-22 16:23 

30.08 

Final 

23379 

3523 Davenport St. 

EM 

1 

O. BARAJAS 

1 

1 

± Error 

± 13.135 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 329 

Mode SOIL 

Time 2010-02-22 16:28 

Duration 90.79 

Sequence Final 

Flags 

AVERAGE nftvg-Df-325g2§II7 

ADDRESS 3523"Davenport St. 

QUADRANT Bl 

DEPHT 6 

XRF TECH O. BARAJAS 

MISC 1 

NOTE 1 

ppm 

Pb "253:723" 

supervised By: ^^f^mW d 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 247.927 

Supervised By: 

Certificate of Verification 

326 

SOIL 

2010-02-22 16:26 

30.31 

Final 

23379 

3523 Davenport St. 

Bl 

6 

O. BARAJAS 

1 

1 

± Error 

± 25.033 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 327 

Mode SOIL 

Time 2010-02-22 16:27 

Duration 30.19 

Sequence Final 

Flags 

BVID 23379 

ADDRESS 3523 Davenport St. 

QUADRANT Bl 

DEPHT 6 

XRF TECH O. BARAJAS 

MISC 1 

NOTE 1 

ppm ± Error 

Pb 255.876 25.484 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 328 

Mode SOIL 

Time 2010-02-22 16:28 

Duration 30.29 

Sequence Final 

Flags 

BVID 23379 

ADDRESS 3523 Davenport St. 

QUADRANT Bl 

DEPHT 6 

XRF TECH O. BARAJAS 

MISC 1 

NOTE 1 

ppm Error 

Pb 257.367 ± 25.279 

Supervised By: 
in m 

iyA^'\ Omaha Lead Site—Fixed Price EP-R7-07-05 

§^^^^ ° Coastal Environmental Group Inc. 

Sr^^j^ www.coa8talhazmat.com 

'*tPBO^'^ COASTA L EHVIIOMIIIIITAl 

C lO U p. IN C 

EXECUTIVE SUMMARY: 

BVID #23379-(3523 DAVENPORT ST) 

No Issues or Concerns Q Issues/Concerns 

Detail Explanation: ^ _ 
^

i PA 

EPA Property Close Out Form 

Property # 

Datc/Tiroe: 

Quads Excavated Contractor Group f^cyv^fe g

Excavatioo Geaeral 

1. If necessaiy, were the correct quadrantCs) excavated and restored? 

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

GradiiiE Sod and Vegetatioii 

1. Does the grading around the perimeter ofthe house in cxcavaied areas generally slope away 

&x)m the house? 

2. Has sod been laid in ail 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 rum and evenly graded? 

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 property? 

7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and Relafailii£ Walls 

I I. Do gates open and clo.se fl-eely? (Ifappiicable) 

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

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

4. Was damage to retaining walls avoided? (Ifappiicable) 

FouDdatioD, SidioKand Gutters 

1. Was dainage to the siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

4 Was damage to windows or door screens avoided? 

5. Was damage lo downspouts or downspoul extensions avoided? 

Sidewalks and Driveways (Concrete) 

1. Was damage to driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

 gVffVCjp 

Yes No 

y 

/ 

Yes No 

• 

/ 

y 

J 

y 

J 

y 

Ves Nc 

y 

J 

J 

Yes No 

J 

J 

y 

y 

y 

Yes No 
d^ Ort'Dcrs comments: 

Inspection notes: 

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

EPA Representalive '^'^ ^ , Da(e:__|^||^'^_ 
Property Completion Agreement 

ihis agreemenl documents Ihe complclion of remedial acliviiies peri'oimed on my properly My signalure 

will designale ihal I am satisfied with the restoralion of my propeity, and ihal no ilems are in questions, 

now, or al any lime in ihe fuiure, except those ilems listed below, if any 

Property ID: 2 ??? n Q 

Property Address: ^^ ^ ^ TyAVe.t^mrV ­

^""%b)Qr:)CVi(r\VPZ 

^""'"(MOQ ?m-i\^Fi~ 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

[v j I a|>rcc I cstamlion K completed, rxccpi as noleri 

[_J I do nol »{'rtc restoration is completcri 

t^AyL tkcih^ W-n-^f M /ju0 ^ i(li^lf)^ 

Owner's Signarmr Date ^-^t^ti aclorli 's Signatur Sienaturee Dale 
•^t 

@ 

Property Owner Satisfaciiort Survey* uni / 0 3 9n{jQ 

Omaha Lead Superfund Sit 

Hprnediation Contractor: Coastal Environmental Group oUrtnrUlv U UlVlolUi M 

Property Identifier Number: /L?>y7<^ ^__ ^ 

Property Aridri>«: 35 ^ P/>.\f^£1 pTf^ - ^ ^ 

Property Owner's Name: 1 \Tr.ir \ OSf^rvWe y 

(above information to be filled out by remediation contractor prior to delivery of form 10 Property Owner) 

Instructions to Property Owner; 

This form is provided to you as a means of trying to capture your level of satisfaction with the 

work of the above-identified remediation contractor, as applicable to the sojl cleanup action at your 

property. The U.S. Environmental Protection Agency (EPA) is very Interested In your opinion regarding 

the work performed by its contractors. This form is intended to provide an easy means for you to 

express your opinion about the work performed on your property. 

Please indicate your level of satisfaction with the contractor's work by selecting a numerical 

rating (ranging from 1 to 10) using the following rating scale, then please sign and date the form and 

return It to the USEPA in the attached self-addressed & stamped envelope, (additional comments may 

also be provided in the space below, at the option of the property owner | 

9-10 "excellent" 

7-8 "very good" 

5-6 "acceptable" 

3-4 "poor" 

1-2 "ver/poor" 

Property Owner's Satisfaction Rating Reearding Contractor's Work 

© 5 

9 4 

8 3 

7 2 

6 1 

Additional Comments from Property Owner (optional: continue to back of page if needed) 

Propeny Owner's Stgnature:Oty^,A.<X i .J^C/J\AQ.J ^ Date: \{ - \ 1 - D ^