TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: 1^^15 

Date: 12-3I'D 8 

Address: I^I H P^n ^ "^ ^ 

Remediation Contractor; _Coastal Environmental Group_ 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

y 

Executive Summary 

EPA-provided property sketch 

Signed Access Agreement for subject property 

Signed Access Agreement(s) for adjacent property 

y 

Restoration Agreement 

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

Confirmation data 

Year: 2008 

(j^x> rsod IcLiAper-^ J Photographs pce - <L>f.cnj) ^5 A ^ Q )CCAJ /?il D)n 

As-built sketch 

y Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 40316282 

Description ofareas not meeting ROD cleanup criteria 

Superfund y Utility clearances 

y Property information from Douglas County Assessor's Office 

y C^rJr/uJr^>rrr\ 

D 

17. ^\-n ^ 

Signatur Ignature 

e Date 

^/es/6f 
» 

Property Access Checklist 

PioiKMty ID: |<^^\f;) 

Property Address: ^3^->) ^ ^ ^ ^ ^ j 

D

n

 WORK STARTED

 WORKCOMPELTED

 ON:

 ON:

 /

 /

 /_ 

 /_ 

Owner: "TT is^Aj K^lcr/^imic. ^ni% Renter: 

•Address: Phone: 

Fax: 

Ccll/Paaer: 

Phone: 

Fax: 

LCHDlVHll^lC^a Additioniil Information: 

Cell/P """•^^^1-3^^ 

n Notification Letter 

^Jr Access Agreement 

{/\ Restoration Agreement 

[U Topsoil Sampling (if a|)plicable) 

1 1 Dis|)osal Sampling (if applicable) 

CH Garden Sampling (if applicable) 

0 Utility Clearance 

[^ Video/Photos (Before) 

D Video/Photos (During) 

n Video/Photos (After) 

D Video/Photos (3(>-Day) 

n Pro|)erty Completion Agreement 

D Final Report 

Sent: / / 

Sisjned: ' ^ / 0\ / 0% 

Sijincd: ^ /O l /o R 

/ / 

/ / 

/ / 

Called: K / 2 /O ^ 

On:j; / ^/V \ 

On: / / 

On: / / 

On: / / 

Signed: / / 

Is.sued: / / 

By: 

Bv: 

By: 

By: 

By: 

By:

^y-'^/Uo^ 

By: m Ik 

6: O\L 

:/vAU ' 1

By : 

By: 

By:

By:

By: 

1 

 II 

1 

1 

1 

Air Monitoring (as applicable 

1 1 Coniniuiiity CH Crew 

) 

Results:

On: / / 1 

 j! 

n C(Mnmunit>

Results: 

 CD Crew On: / / Bv: 

CD Community

Results: 

 CD Crew On: / / By: 

Omaha Lead Site 
CONTACT FORM 

Property ID # mK 

Property 

Address: \3|A?ine St 

Initial Contact: Date: Time: Action: 

Second Contact: Date: Time: Action: 

Final Contact: Date: Time: Action: 

Final Action: Transmit to EPA D Other Action: D 

M? 2'1040 

Comment: 

Owner 

Comment (s): 

"710 Site 7pf~f> Coordinator 

Comment (s): 
.Douglas County Account Informatio rn^i i n Page 1 of 1

Dougla s County , Nebrask a Propert y Recor d - R151925000 0 

Print Report 

NEW Feature - Parcel Dimensions available ffi scale 0-50 fl west of 90th St - Vie W O n Ma p Information is valid as of 2008-6-19 Treasurer's Tax Report 

New Feature -•->- > Auto Sales Search 

Owne r 

ETHNIC SANDWICH SHOP INC 

1438 S 13 ST 

OMAHA NE 68108-0000 

Propert y Informatio n 

Key Number: 1925 0000 15 

Account Type: Residential 

Parcel Number: 1519250000 

Parcel Address: 1310 PINE ST 

OMAHA NE 68108-0000 

Legal Description: KOUNTZE 3RD ADD LOT 13 BLOCK 9 W 70 FT S 1/2 LT 12 & W 70 FT 

Valu e Informatio n 

Land Improvement Total j 

2008 

2007 

2006 

2005 

2004 

2003 

$4,500.00 

$4,500.00 

$4,500.00 

$4,500.00 

$4,500.00 

$4,500.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$27,000.00 

$4,500.00 

$4,500.00 

$4,500.00 

$4,500.00 

$4,500.00 

$31,500.00 

Sales Informatio n 

Sales Date: 2003-10-01 

Deed Type: WD Book: 2003 Page: 218555 

Price: $22,000.00 

Grantor: Karen Orsi 

Grantee: Alfred S Orsi etal 

Valid/lnvalid: Valid 

Exclusion Reason: 

Lan d Informatio n 

Acres SF Units Depth Width Vacant 

0.12 5250.0 1.0 75.0 70.0 No 

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1438 S 13th Street. Omaha. NE 68108 

(402)422-1040 

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BuslnessM Search for: Ethnic Sandwrich Shop in Omaha NE { ^^^|g^ ^ 

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n a t s you r ^UU G k*reaic &con 

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340 - 619 

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oticy. Legal Notice and Twms under which this service is provided to you. 

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Page 1 of2 

"> 

Lp, Create Another Ticket Back to Irth Internet Send Email 

YOUR TICKET NUMBER IS 2097361. 

Original Call Date: 8/02/08 Time: 12:40 pm Op: ELIZABETH18790 


Work to Begin Date: 8/06/08 Time: 7:15 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1310 Street: PINE ST 


Twp: 15N Rng: 13E Sect-Qtr: 27-NE 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: lead remidiation 


Location of Work: LOCATE ENTIRE PROPERTY ALL THE WAY TO THE STREET. 


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


Company : COASTAL ENVIRONMENTAL SERVICE 


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


Work Being Done For: coastal 


Depth of Excavation: 4ft Corner Lot: Y Front: Y Rear: 


Involves Tunneling or Horizontal Boring : N Explosives: N 


ATTNEBRl CXCATV LEVELS MCINEB MCLEODNE MUD02 OMAHACOF 


0PPDGPR6 QLNNEIF QWEST2 


Service Area Contact Phone Number 

UtiUty 

Type 

ATTNEBRl ATT/T 

Day: 

Alt: 

Emerg 

80024136249 

80024136249 

CXCATV COX COMMUNICATIONS,

INC

 UCTTM 

 "^"^^ 

Day: 

Alt: 

Emerg: 

4029340469 

4029340469 

4029329757 

LEVEL3 LEVEL3 COMMUNICATIONS, 

LLC NA 

Day: 

Alt: 

Emerg: 

8773668344 

8773668344 

MCINEB MCI NO CALL PER MEMO 

Day: 

Alt: 

8002893427 

Emerg: 8002893427 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 8/2/2008 
Page 2 of2 

MCLEODNE MCLEODUSA NO NEED TO CALL OUT 

EMERGENCY 

Day: 8002891901 

Alt: 

Emerg: 8002891901 

MUD02 METROPOLITAN UTILITIES 

DISTRICT EDWINA 

Day: 4025047823 

Alt: 

Emerg: 4025047946 

OMAHACOF CITY OF OMAHATRAFFICSEWER RON 

Day: 4024447197 

Ah: 4024445161 

Emerg: 4024445160 

OPPDGPR6 OMAHA PUBLIC POWER 

DISTRICT NA 

Day: 4067289343 

Ah: 8887289343 

Emerg: 4067289343 

QLNNEIF QWEST LOCAL NETWORK NA 

Day:

Alt: 

 4067289343 

Emerg: 8887289343 

QWEST2 QWEST LONG DISTANCE SARA 

Day: 8002834237 

Alt: 3039921926 

Emerg: 8002834237 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 8/2/2008 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

NaiTie: (

Address:

Phone:

 Ws . . . , 

 f^/ A A ^ Orf 

 '^'^'h"'^'^/ 1 

Omaha Lead Site 

Site Sketch 

Date:

Time;

 ~I)/^g/^ 3 

 ' / '• / n 

North Arrow 

Date Excavated 

Date USEPA S g 

Area Sodded 

Team /hly S PxiV i 

Sample Number 

RYA5<:-PXA ­ /5?I5 

R.VOS<^PxA ­ iq^i ^ 

Lab RYDSCPLA-19815. 

Result 885 ppm 

OLS#: f9815 

8/11/2008 

ncd Off:19/10n!009 

: Q sdi ft 

BVID # ('^ C ( O 

Lead Concentration 

Zl6otl l t 

luu-o 1 ai 

.-r 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

XRF Code '??^t 

y 

Confirmation Sample 

', Yes CD 

)lYes n 

Yes Q 

Yes • 

No ^ ^ 

No IS ^ 

^ : 

No ET ^ --\ 

No n c y 

No D ^ 

No CD 

No • 

;-"x: 

UJ —=::^:::zrZ. B2 = 480 PPM @ 13" 

Eiectric?!' 

Pole ! 

- y 

IP ^ 'X 

i 1^_ _L. 

F1 =210 PPM @ 13" ^y y F2 = 429@13" 

' ^ 

rpxiss: 

Legend 

Concret e Dri p Zone Excavate d Quadrants Excavate d 

Area replaced with 

Sod ' ' 

Are a replace d wit h 

Rock/Mulch Are a lef t bar e 

Contrac t #: EP-R7-07-05 Coasta l Environmental Group Inc . 
P^V ^ (s^nof^ 
Name: y^<^ \ - _j _ Omaha Lead Site Date: F>/^^/^ S North AiTOw 

Address: /^/ A 4 X 0>4, Site Sketch Time: ' F n 

Phone: ^^^--^"7/ / 

Team /H] ^ ?:LIV, BVID# (^ ^ ( C XRF Code ^^n 

Sample Number Lead Concentration Confirmation Sampli 

RYA5<^PXA - /57<S (Yes n < 2^ P.yft4cPXA - 197/5 ^ t f 0 t 3 f ppm No ^ 

ppm Ye.__s LJ• No S ^ g.YoS^PxA - l<?5?l'; Yes CH ^- ^ No 1 ^ - \ ppm •fe 

ppm o-^ No n O r 

ppm )iYes O No n- ^ 

ppm Yes n No D

Lab Yes • RYDSCPLA-19815. ppm No • 

Result 885 ppm 

=^= 

(5) ,-34: =F "gy 'Tr ^ ^m i^ 

\Y i%i 7o^i$5 

-^==~ % 

r' ^ ^ 2K?i ^ 

-d< 

K^^:^ 

^ ,\u 

IP 

\ te'2. ~~< 

-=* ^ 3>3^<) ti// o 

& . 

I ^4|^±t(^ 

in 

< 

^?i 

i 

• ^ 

^i VjN^ ^ kkS o ^ ^ ^ -^2S ^ " ^ ^- I ^k ^ ^ 4^=^ i4J i^na: 
COASTA L ENVmONHEHTA l 'ftiw^ ^ C I O U r . IN C 

Consent For Access To Property 

RIGHT OF ENTRY TO PREMISES 

Grantor (the property owner) consents to and authorizes the United States 

Environmental Protection Agency (EPA) or its authorized representatives, collectively 

the Grantee, to enter and perform certain environmental response activities upon the 

following described premises: r a\ P. 

Owner's Name: rOjC Daytime Phone: y-ZZ — ) 0 t-/-O 

Address of Property l3\ a F\ne. «S4­ covered by this 

Agreement: 

PURPOSE OF RESPONSE ACTIVITIES 

The EPA is requesting access to collect soil samples and remove soil that contains 

elevated concentrations of lead and may pose a health hazard. The area(s) will be 

excavated to remove contaminated soil. The removed contaminated soil will be 

replaced with clean materials and the area will be restored to its original condition. 

This work is being performed under the Omaha Lead Superfund Site remediation 

program. 

A representative of Coastal Environmental Group, contracted by USEPA, will contact 

the Grantor in-person to discuss the work to be performed, the Grantor will have an 

opportunity to review and approve the planned soil removal, and restoration work 

before it begins. Once the work is finished, the Grantor will be asked to review the 

work and confirm that it is complete and meets with the Grantor's approval. Upon 

completion, the Grantor will receive written documentation from EPA that the property 

has been remediated. 

ENVIRONMENTAL RESPONSE ACTIONS 

By signing this Access Agreement, the Grantor is granting the EPA, its employees, 

contractors and subcontractors the right to enter the property, at all reasonable times 

and with prior notice, for the sole purpose of performing the work. This access shall 

remain in effect until the work has been satisfactorily completed. The Grantor also 

agrees to: 

Page 1 of 2 
%^^^ ^

 COASTAL 

t PBOt* 6 • O U f . I h C 

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

piles, dog houses, etc; 

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

to save; 

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

necessary subsequent to an initial watering period by EPA; 

• Abide by health and safety guidance provided by EPA; 

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

the property to perform the work. 

• Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the work activities, or with any 

of the work done, or with the equipment used on his property, or to undertake any 

actions regarding the use of said property which would tend to endanger the health or 

welfare of the Grantees or the environment, or to allow others to use the property in 

such a manner. 

Should you have any questions about this program, please contact Coastal 

Environmental Group, at (712) 352-0188 

Q^grant access to my properties D I do not grant access to my properties 

Signature Date 

r~l I would like to be present during any sampling that is required. 
Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement 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 propert\' owner and the United States Environmental 

Protection Agency (EPA). 

I Property ID: f<^9)^ ^ 

Property Address: ^^^^ p;^ g <^ 

Owner • P^^iC SrxJircy>r^ JKo^ 

phonefq^ ^2yy i y-.^s^r B 

On the attached diagram(s) indicate area(s) to excavated and deptli of excavation, location of all known 

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

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

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

Items To Be Removed By Owner Before Start Of Remediation: 

(Use additional sheets as necessary) 

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

Item: 

KioKlc; 

Item: 

Item: 

item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of (^ 
i^^ 

k 

COASTA L r »- VI MOMimMTAl . 

G R O U r iM C 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: 

Item: 

Item: 

Itei 

Item: 

Item: 

Kem: 

Page 2 of Co 
• ^ 

COASTA L 

Items To Be Removed By Contractor During Remediation And Replaced 

(Use additional sheets as necessary) 

Item: 

SX) ^ 

Item: 

syi F'P^ f)f t^a 

Item: 

item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 of. 
C O A S T ft U 

Landscape Inventory 

(Use additional sheets as necessary) 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed 

area. 

Attach a sketch of relative 

sizes and locations. 

Quantity 

ft ra 

3 

o 

a 

U 

Unit 

Square feet 

Condition/Type/Species 

Each 

-. 

Each 

Each 

Each 

Square Feet 

Page 4 of. 
COASTA L 

I M VIMONrtt N T A t 

Item 

Agreed upon value of 

plant materials not to be 

renlaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a skeicii of were 

each plant will be placed 

by the contractor. 

Agreed upon area of 

property to be replaced 

with grass sod. 

Include a sketch of the 

area(s) to be replaced with 

grass sod. 

Area of City or County 

property to be landscaped 

per their requirements. 

Include a sketch of the 

aiea (s) 

Easement Area, to be 

excavated 

Quantity 

y 

Uriit 

$ 

Each 

Condition/Type/Species 

SF ' • 

kllfr SF 

-

0 SF 

Page 5 of. 
C O A S T A L e « • w r . IM C 

Additional Comments / Instructions: 

Q Check the tx}x if Owner does not want CEG to documerrt 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. 

• lihTBot agree 

Contractor's Statur e 

Page 6 of. 
To whom it may concern: 

1 understand and acknowledge that Coastal Environmental Group has advised me of the following: 

1. City ordinances do not prohibit backfill of a property using crushed rock; and 

2. Restrictions may prohibit this rock backfill if the intent is to use the backfilled area as a rock-only 

(no hard surfacing) parking lot or drive, or if the backfill is part of a plan to change the property's 

land use. 

I hereby accept that Coastal Environmental Group will backfill my property at 1310 Pine Street, Omaha, 

NE with rock and that 1 will not use the property as a rock-backfilled parking area nor will the land use be 

changed. 

Property Owner 

1310 Pine Street 
BVID# Afe 

XRF PROPERTY SAMPLE SHEET 


Date ^ 1 C'V Address bio hvie sr 

Project Omaha lead FP 2nd year option Sample time am/pm 

XRF ID# sample length 30 sec ^>^-^ ^ 

Shot# 

mi 

mi 

Mo_ 

Average

Shot# 

TW" 

^oo^ 

Average

Shot# 

Average 

Shot# 

Average 

lab sample # 

r^Him 

Reading

\\r{.nt l^-lL 

'Il-vqvt ti-o'^ 

'^•ozt Z%M I \r\-%-h>i 'Z.L^^ 

 ^ % . OH t

Reading 

^i^.lSt K x 

^^•).nf 7^.h 

iPl.^^t IU< 

^I'^o'it Di-^ 

 ^\V-Ivt

Reading 

Reading 

Lab result 

It4l 

 Sample area 

h 

Depth 

J i l 

 ^^•^' \ 

Sample area 

fl 

Depth 

K" 

 \^.\-) 

Sample area 

Depth 

RETEST AREAS 

Sample area 

Depth 

Shot# 

v(^y~ 

aiii M . m. Average 

Shot# 

^ ^ ^ 

lav"^ 

LocL 

Average 

Shot# 

Average 

Shot# 

Average 

Sample area XRF Avg. 

PI U41 Signature 

Reading Sample area 

SbP-^3t ^'g-l;. 

tfr^.^'^Vt-l-y k 

^I'^.'lK t t^-IK Depth E^i^smzE^ 

M?t?.l<t ^^.r] 

Reading 

^l.^ U -^l­ "7^.1^t ^1(I 1 

(b-4^r n-^-^ 

^ n - ic j : Z^.7/ 

U^.^i

Reading 

Reading 

yn 

Sample area 

^ aDepth 

XVl 

 ^^T-> 

Sample area 

Depth 

Sample area 

Depth 

Print ^l^f^S . MATT^^ 

(RC i;i^f M/y^ f^f- (isn^f^^^rPTVA £Ml/i/| 

.•[^I«' .•^•..-.( .iL'lA' .-L . :.:" it.\:'.ff.-.>. 
4 

Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 2647.200 

Supervised By: 

Certificate of Verification 

1992 

SOIL 

2008-08-11 09:05 

30.30 

Final 

19815 

1310 Pine st 

Fl 

LOPEZ 

SURFACE 

UNOFFICIAL USE 

CAL.known samples 

± Error 

± 73.755 
Report Number Date Reported: /l ^ Midwest 08-290-2348 10/16/08 

Account: Date Received: 

20666 Viy 10/14/08 Laboratories, incl 

Page: 1 of 1 Date Sampled: 

13611 B Street • Omaha, Nebraska 68144-3693 • (402) 334-7770 • FAX (402) 334-9121 • www.midwestlabsf^/»|3/08 

COASTAL ENVIRONMENTAL GROUP 

MARCOS MATEUS 

2411 MARTHA ST 

OMAHA NE 68105 

OMAHA LEAD 

PO/Project #: OLS 2008 

Analysis As Detection Analyst Verifier 

Performed Received Units Limit Method Date Date 

Lab number: 1492782 Sample ID: QC-19815-F1 1310 PINE ST 

Lead (total) 1697 ppm 5 ICAP rrd/10-15 bab/10-16 

(uy^< ^ 

leather Ramig 

Client Service Representative ativew^ ' 

heattier@midwesttabs.com (402)829-9891 

The result(s) Issued on this report only reflect the analysis of the sample(s) submitted. For applicable test paramaters, Midwest Laboratories Is In compliance with NELAC requirements. Our reports and letters are for the exclusive and confidential use of our clients and may not be reproduced In wtioie or in part; nor may any reference be made 

to the work, the results, or the company in any advertising, news release, or other public announcements without obtaining our prior written authorization. 
^ y Lali@ratffiri( 

13611 B Street« Omaha, Nebraska 68144-3693 - (402) 334-7770 « FAX (402) 334-9121 <• www.midwestlabs.com 

ACCOUNTNUMBER 

CHAIN OF CUSTODY RECORD: Yes No 

PI IPrWARF nPHF R Nl JMRPR 

REPORT&BILLTO | IDENTIFICATION | COPYTO | 

y^a.sTV^X Cr\^/iroIv.Yv^.evvV£^\ 

M\\ M.AV^ 

ZIP ZIP 

PHONE PHONE ( ) (/77)^^5_V^/ ^ 

PROJ. NO. PROJECT NAME/COMPANY: Oi^tKhc^ eei 

COMPANY; (Signature) OLS :u)o2 Ceo,rh4 £n^ ' 

SAMPLER 1; (Siqnature) I j 

/O i c6(o^s. lo p e-z^ 

SAMPLE ID/LOCATION 

l>lCHtsi5-fi-mr\Di^ ioM IM. / r 

E ff Kvrztm ffi'"3R!" 

i' ff^ ^ / i ! g -'--^r1 r­

^'^ M 2g9a^ i 

Relinquished by: (Signature) Dale/Time Received by; (Signalure) Cooler arrived intacl: Yes__rrNo_ 

. femperature on Arrival C/iC): Keiinquisnea oy: (i>ignature) bate/1 ime Keceivea oy; {i^ignawre) 4^­ ^reserved in Field; Ye§_ _N0 

•Remarks; Relinquished by: (Signature) Date/Time Received in Lab by; (Signalure) 

Chaln-of-Custody will have a signature upon receipt but no subsequent signatures '^^^ 02/02 

Distribution: Original accompanies shipment; copy lo Coordinator Field Files 

•Matrix Code: SO - Soil, WA - Water, SL - Sludge, OT - Other L 

Our reporLs End Isfcsrs ere for the e);cL'ST.'6 erid conndentfal uss c" cir c.wzvnz iu i rr.ay riut te reprooL-ced •- whoie oi r. pert, .-or mcy sny refe:eriC£ bs rr.scK 

to the vi-o'-k, the rssijiis. cr Sie C0rr:pEr.j' i'l any co'vertlsing, riEW-'E'relarse, cr cthe.- public £'.-i:.CL/ricer.-,£rits "•'ithci'' oL'-ielniriC CJ: o'-ar vi-Til-er, cJfhorii.E?ior. 
 1 

A<9k Miciwest 

ir:^ •<iz: V[/ LaiioratorleSr iitcl 

13611 B Street • Omaha, Nebraska 68144-3693 • (402) 334-7770 • FAX (402) 334-9121 • www.midwestlabs.com 

ACCOUNTNUMBER 

CHAIN OF CUSTODY RECORD: Yes No 

PI IRrHA.siPnRnFRNlIMRFR 

REPORT&BILLTO IDENTIFICATION COPYTO

^O^JTCM . Cr\\/iVDIVYVA.eVV.'Vcik\ 

c^HW M^AVo . 

ZIP ZIP 

PHONE (/77)^^;2-%/ ^ PHONE ( ) 

PROJ. NO. PROJECT NAME/COMPANY; J 2 f/yj OL nC ^ 

COMPANY; • (Signature) ^^^ 1 g ^ ^ ^ 

I0L5 M02 

SAMPLER ; (Signature) / 1 

/ O i cojo^Z lo p ezLab Number/Order # 

(Internal Use] SAMPLE ID/LOCATION TIME 

/Sc-UFis-ff-mnjuist loiM %'OD / r 

Relinquished by; (Signature) Dale/Time ^Recei eceivev d (Signal Cooler amved intact; Yes No. 

qjisnea by; \^tgnattM uate/1 ime ecerveo by; {urgnawre, Temperature on Arrival ('/4C); 

^reserved in Field: Yes No 

Relinquished by; (Signalure) Date/Time Received in Lab by: (Signalure) Remarks; 

Chaln-of-Custody will have a signature upon receipt but no subsequent signatures ^^^^ 02/02 

Distribution: Original accompanies shipment; copy to Coordinator Field Files 

•Matrix CotJe: SO - Soil, WA - Water, SL - Sludge, OT - Other Our reports end letters jre for tne er,clysf\'e snd co.ifidentiEl liss cf ou- cjisnts Efic aiay not be reproo'i'ced 'n whole oi r. pert, ror rricy E-ny reference bz msce 

to the wo'li, the resulis, or tfie company ir. any ao'vertisirig, risvi'sreissse, or ether public enricuncemsnts (vitficut obieinirig C^T "j'ior writie.i EL'thoriiEtior:. 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 1982 

Mode SOIL 

Time 2008-08-09 15:30 

Duration 120.82 

Sequence Final 

Flags 

AVERAGE fAvg of 1978-1981 

ADDRESS |1310 Pine st 

QUAD/ZONE 

INSPECTOR LOPEZ 

DEPTH t3 SAMPLE TYPE 

NOTE CLEARANCE 

Supervised By 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 437.831 

Supervised By: 

Certificate of Verification 

1978 

SOIL 

2008-08-09 15:27 

30.21 

Final 

19815 

1310 Pine st 

Bl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 26.764 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 323.464 

Supervised By: 

Certificate of Verification 

1979 

SOIL 

2008-08-09 15:28 

30.17 

Final 

19815 

1310 Pine st 

Bl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 23.037 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 505.028 

Supervised By: 

Certificate of Verification 

1980 

SOIL 

2008-08-09 15:29 

30.29 

Final 

19815 

1310 Pine st 

Bl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 28.975 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 477.835 

Supervised By: 

Certificate of Verification 

1981 

SOIL 

2008-08-09 15:30 

30.15 

Final 

19815 

1310 Pine st 

Bl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 27.984 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 1987 

Mode SOIL 

Time 2008-08-09 15:35 

Duration 123.97 

Sequence Final 

Flags 

AVERAGE Avg of 1983-1986 

ADDRESS • 1310 Pine st — • 

QUAD/ZONE |B 2 

INSPECTOR 

DEPTH 

LOPEZ 

il3 

SAMPLE TYPE CLEARANCE 

NOTE 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 500.636 

Supervised By: 

Certificate of Verification 

1983 

SOIL 

2008-08-09 15:32 

30.29 

Final 

19815 

1310 Pine st 

B2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 28.329 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 472.893 

Supervised By: 

Certificate of Verification 

1984 

SOIL 

2008-08-09 15:33 

30.20 

Final 

19815 

1310 Pine st 

B2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 27.756 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 519.944 

Supervised By: 

Certificate of Verification 

1985 

SOIL 

2008-08-09 15:34 

30.63 

Final 

19815 

1310 Pine st 

B2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 28.988 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 429.562 

Supervised By: 

Certificate of Verification 

1986 

SOIL 

2008-08-09 15:35 

32.85 

Final 

19815 

1310 Pine st 

B2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 26.434 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 2002 

Mode SOIL 

Time 2008-08-11 10:25 

Duration 120.98 

Sequence Final 

Flags 

AVERAGE I Avg of 1998-2001 

ADDRESS 1310 Pine st 

QUAD/ZONE |F 1 

INSPECTOR LOPEZ 

DEPTH 

SAMPLE TYPE ^CLEARANCE 

NOTE 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 1998 

Mode SOIL 

Time 2008-08-11 10:23 

Duration 30.14 

Sequence Final 

Flags 

BVID # 19815 

ADDRESS 1310 Pine st 

QUAD/ZONE Fl 

INSPECTOR LOPEZ 

DEPTH 13 

SAMPLE TYPE CLEARANCE 

NOTE 

ppm Error 

Pb 214.184 ± 19.358 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 253.379 

Supervised By: 

Certificate of Verification 

1999 

SOIL 

2008-08-11 10:23 

30.08 

Final 

19815 

1310 Pine st 

Fl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 20.618 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 162.259 

Supervised By: 

Certificate of Verification 

2000 

SOIL 

2008-08-11 10:24 

30.48 

Final 

19815 

1310 Pine st 

Fl 

LOPEZ 

13 

CLEARANCE 

± Error 

± 16.855 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 2001 

Mode SOIL 

Time 2008-08-11 10:25 

Duration 30.28 

Sequence Final 

Flags 

BVID # 19815 

ADDRESS 1310 Pine st 

QUAD/ZONE Fl 

INSPECTOR LOPEZ 

DEPTH 13 

SAMPLE TYPE CLEARANCE 

NOTE 

ppm ± Error 

Pb 213.094 ± 18.649 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

Supervised By 

Certificate of Verification 

2007 

SOIL 

2008-08-11 10:29 

120.99 

Final 

I'Avg of 2003-2006 

1310 Pine st 

| F 2 

*LOPEZ 

§13 

•CLEARANCE 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 542.987 

Supervised By: 

Certificate of Verification 

2003 

SOIL 

2008-08-11 10:26 

30.12 

Final 

19815 

1310 Pine st 

F2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 31.900 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 375.722 

Supervised By: 

Certificate of Verification 

2004 

SOIL 

2008-08-11 10:27 

30.31 

Final 

19815 

1310 Pine st 

F2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 25.848 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 416.470 

Supervised By: 

Certificate of Verification 

2005 

SOIL 

2008-08-11 10:28 

30.26 

Final 

19815 

1310 Pine st 

F2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 27.337 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 383.107 

Supervised By: 

Certificate of Verification 

2006 

SOIL 

2008-08-11 10:29 

30.30 

Final 

19815 

1310 Pine st 

F2 

LOPEZ 

13 

CLEARANCE 

± Error 

± 26.270 
Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

www.coastalhazmat.com 

COASTA L ENVHONnENTAL 

CROUP , INC . 

EXECUTIVE SUMMARY: 

BVID # 19815 - (1310 PINE ST) 

X No Issues or Concerns I I Issues/Concerns 

Detail Explanation: 

NO ISSUES PENDING. 
^m EPA 

EPA Property Close Out Form 

Property #: \^?l ^ Property Address: \'2>\Q PtTvffi. &k 

Date/Time: Owner's Name: X'CCyCxX ^ijc r 

Quads Excavated: p t F ^ X^^ ^ Q Contractor Croup CrA'^VflLl T)r%!Mrtiwrn0r\\dif 

Excavation General V/IC^A/OT |_yo- I 

Yes No 

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

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

y 

Grading Sod and Vegetation Yes No 

1. Does the grading around the perimeter of the house in excavated areas generally slope away ^ from the house? 

2. Has sod been laid in all areas that were excavated? CofVCrc-4^ -k) b«- l>6cLred / 

3. Does die sod appear to be generally healthy and growing? (Only-evaluate if inspected at a 30 

day time period) A/i^ 

4. Are sodded areas generally fmn and evenly graded? A^ 

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? l ^ 

7. Was damage to landscaping or plant materials avoided? tlf^ 

Gates, Fences and Retaining Walls 

Yes No 

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

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

3. Was damage to gates or fences avoided? (Ifapplicable) jfe" 

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

Foundation, Siding and Gutters 

1

Vts No 

1. Was damage to the siding or trim avoided? 

2. Was damage to the foundation avoided? ; 

0 

1 

3. Was damage to windows avoided? 

4. Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? 

Sidcwallts and Driveways (Concrete) 

Yes No 

1. Was damage to driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

/ - ^ 
j O rners comments: ^ P ^ ^ 

1 

;l 

'^ 

*v 

'\ 

f 

1 ' 

1 Inspection notes: 

• 

1 j 

1 i 

j 

• 

j 1 

•j 

• i f 

f 

f 

.1 

;;[ 

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

EPA Representat ^^^^^^^^^L. -^4^ ^ Date: y/o/d 3 
'«i^ 

Property Completion Agreement 

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

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

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

Property ID: / QV I C 

Property Address: J}/ ^ ^IJJ E SJ­

^"^' JTrtxcy /C yA>-

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

agree restoration Is completed, except as noted ^ 

 I I do not ajjMC restoration is completed 

y 

Owner's Signature / J 

I