## TRANSMITTALo f

OMAHA LEAD SIT E SOI LREMEDIATIO NFIL EFOLDER 

# SAID#:_iWi
_ Date : 

# i k u Address : 'h^'^' 7 V^Wfenfy K ^ f Remediatio nContractor : Coasta l Environmenta i Grou p SOI LREMEDIATIO N PROPERT Y nLEFOLDE RDOCUM ENT S 

# e f 

# y 

# y Vide o o f propert y (DVD ) Executiv e Summary EPA-provide dpropert y sketc h Signe dAcces s Agreemen t fo r subjec t property Signe dAcces s Agreement(s ) for adjacent property 

# y Restoratio nAgreemen t Settlement docimient s (i.e. , fo r damag e o r to replac e plants , etc. ) -B - 

### Confirmatio ndat a Photograph s As-bui hsketc h Satisfactor y restoratio nsigne db y Property Owne r I 

### Property close-ou t chec k lis t signe db y EPA Descriptio nofarea s no t meetin g RO D cleanu p criteri a Utility clearance s C

J 

### Property infonnatio nfromDougla s County Assesso r' s Offic e D D 

# y ^ Year ; 200 i ' ^

3021799 1 

# mi l Superfun d



### Signature

# Propert y Acces s Checklis t Property ID : ^^^^C ] Property Address : 3^1 ^ D^^ey^y^^ + n D

WOR K STARTE D WORKCOMPELTE D ON : ON : / / / / 

# o^vnc r

Lu(^A nCh/^ive^ T Address : ^52 3 Vavtnpor'\

­ st Rente r PiMHie : Fax : 

# Phonc : 33 ^ -31^ ^ Fax : Cell/Page n Celi/Page n AddHiona l Information :

D NotHlcationLette r IZ

I Acces s Agreement Gi

ZRestoratio nAgreement D Topsoil Samplin g (if applicabte ) D Disposa l Sampiin g (if applicable ) O Garde nSamplin g (i f applicable ) P^tility Clearanc e Q ^ Video/Photo s (Before ) O Video/Pboto s (Dnring ) O Video/Plioto s (After) D Video/Photo s (30-Day ) 

# f Property Completio nAgreemoi t Final Report Sent : / / 

### Bv : Signed ; l l /J^ l 17 ^ 

### By : 

# di i SX^tinIL i k- i IB . 

## By
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### By : Signed ; 14-M^/() ^ Issued : / /
O Commnnit y Results : DCrc w On : / / 

## By : 1
D Commnnit y ResoHs : QCre w On : / / By :
D Communit y Results : QCrc w On : / / By :

Omah a Lea d Sit e

## Dougla s Count y Accoim t Infordgjip n Pag e 1 of 2 rdMi o Dougla s County , Nebrask a Propert yRecor d - R130505000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e (3 ) scal e 0-5 0 ft wes t o f52n d S t - ViewO H Ma p Informatio n i s vali d a s o f 2009-10-1 5 Treasurer' s Ta xRepor t Ne wFeatur e -> ' • ^ - ^ Aut o Saie s Searc h Owne r CHAVE Z LUCI O 352 3 DAVENPOR TS T OMAH AN E 68131-000 0 Propert yInformatio n Ke yNumber : 050 5 000 0 1 3 Accoun t Type : Residentia l Parce l Number : 130505000 0 Parce l Address : 352 3 DAVENPOR TS T OMAH AN E 68131-000 0 Lega l Description : HAWTHORN E AD D LO T6 BLOC K7 4 8 X 11 1 Valu e Informatio n Lan d Improvemen t Tota l 200 9 200 8 200 7 200 6 200 5 200 4 $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 $90,500.0 0 $90,500.0 0 $77,200.0 0 $77,200.0 0 $77,200.0 0 $77,200.0 0 $96,300.0 0 $96,300.0 0 $83,000.0 0 $83,000.0 0 $83,000.0 0 $83,000.0 0 1 Sale s Informatio n Sale s Date : 1995-05-3 1 Dee d Type : D SooAr : 200 5 Page : 40 8 Price : $60,000.0 0 Grantor : Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 2 5227. 0 1. 0 0. 0 0. 0 N o Improvemen t Informatio n 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accoimtinfo.jsp?accountno=Rl..
. 10/21/2009

### Dougla s County Accoun t Inforn|||ip n Pag e 2 of 2 rn|||i o
Buildin g 1 

## 2 STOR Y 352 3 Davenpor t S t Basemen t Tinst i 4fltX l SfF » J i T

r L i Firs t Floo r

914. 0 s q ft
. Secon d Floo r ; ^ „ 79B0i q ft

si»fli[n>»;Ar ,

CLIC KT O ENLARG E IMAG E Squar e Footage : 1712. 0 Percen t Complete : 100.0 % Perimete r0. 0 Quality : Averag e Uni t Type : En d Condition : Averag e

Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0

HVAC : Centra l Ai rt o Ai r Rooms : 8. 0 Exterior : Fram e Stucc o Units : 2. 0 interior : 1 Drywal l Baths : 3. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 4. 0

Roo fType : Stories : 2. 5 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 191 8 0 0 % 191 8 9 0 Defa/ 7 Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 f t 798. 0 Basemen t Fai rFinis h 600. 0 Fixtur e Additiona l Fixture s 2. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 3. 0 Porc h Sla b Roo f Cei l 176. 0 Porc h Woo d Dec k 182. 0 Porc h Woo d Dec k 30. 0 Storag e Woo d 208. 0 Use r Atti cFul l Finis h 319. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rl.
. . 10/21/200 9Pag e 1 of 2 #

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

YOU RTICKE T NUMBE RI S 2403303
. Origina l Cal l Date : 11/09/0 9 Time : 2:2 7 p m Op : ELIZABETH1879 0 Wor k t o Begi n Date : 11/12/0 9 Time : 3:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 352 3 Street : DAVENPOR T S T Twp : 15 NRng : 13 E Sect-Qtr : 21-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : lea d remediatio n Locatio n o f Work : INCLUD E AL L EASEMENT S LOCAT E ENTIR E PROPERT Y Remarks : FAX AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k

Bein g Don e For : Coasta l Environmenta l Grou p Dept ho f Excavation : 4 fee t Come r Lot : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V LEVEL 3 MUDO l OMAHACO F0PPDGPR 5 QLNNEIC
Servic e Are a Contac t Plion e Numbe r UtiUty Typ e
CXCAT V CO X COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7
LEVEL 3 LEVEL 3 COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4
MUDO l METROPOLITA NUTILITIE S DISTRIC T SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0
OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0

http://wvm.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.
. . 11/9/200 9

# t Pag e 2 of 2

0PPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T N A 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES T LOCA LNETWOR K N A 

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

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.
. . 11/9/200 9

## 2337 9 Omah a Lea d Sit e Exterio rPain t Nort h Arro w Sit e Sketc h • Goo d 0^oo r SamDiin g Address : 352 3 DAVENPOR TS T • No t pain t Lead Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : ?£
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## D " " pp m Time : P M La

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### M _RYBSCPXA-2337 9 F 2 pp m 

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## 2337 9 

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## B Date : S-'-S ' RYBSCPXA-2337 9 F 2 pp m B D Time : r.^'iP, ^ RYCSCFT<A-2337 9 RYDSCPXA-2337 9 B 1 8 2 

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### P n 'Resul t 35 4 pp m Numbe rof Sample s ­ | ^ | \ \

| Staff : 

## ns w Legend : F l = Fron t Left , F2 = Fron t Right , B l = Bac k Left , B2 = Baci cRigh t D Z = Dri p Zone , G Z = Garden , P Z = Play Al l quadrant s ar e a s viewe d fro m th e street , facin g propert y

R< v 20OS. NCrcalcd : 2(>-Fel>-0SCOASTA l
^ 1 ("BO" ' cI t o u rIH C 

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

### Granto r(th e propertyowner) consent s t o an d authorize s th e Unite d State s Environmenta l Protectio n Agenc y(EPA ) o rit s authorize d representatives , collectivel y th e Grantee , t o ente ran d perfor m certai n environmenta l respons e activitie s upo n th e followin g describe d premises : /^^"^—h ^ _>_____^-^=^______ „ 

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

# Wg^l/g
. CUcKV-g- Z
Addres s o fPropert y covere d b ythi s 

# 3 5 2^ 3 V^Me-i^^ocV s V Agreement : PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EP Ai s requestin g acces s t o collect soi l sample s an d remove soi l tha t contain s elevate d concentration s o flea d an d maypos e a healt h hazard
. Th e area(s ) wil l b e excavate d t o remov e contaminate d soil
. Th e remove d contaminate d soi l wil l b e replace d wit h clea n material s an d th e are a wil l b e restore d t o 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 o fCoasta l Environmenta l Group , contracte d b yUSEPA , wil l contact th e Granto rin-perso n t o discus s th e wor k t o b e perfomned , th e Granto rwil l hav e a n opportunityt o revie wan d approv e th e planne d soi l removal , an d restoratio n wor k befor e i t begins
. Onc e th e wor k I s finished , th e Granto rwil l b e aske d t o revie wth e wor k an d confir m tha t i t i s complet e an d meet s wit h th e Grantor' s approval
. Upo n completion , th e Granto rwil l receiv e writte n documentatio n fro m EP Atha t th e property has bee n remediated
. ENVIRONMENTA L RESPONS E ACTION S 

### B

ysignin g thi s Acces s Agreement , th e Granto ri s grantin g th e EPA , it s employees , contractors an d subcontractors th e righ t t o ente rth e property , a t al l reasonabl e time s an d wit h prio rnotice , fo rth e sol e purpos e o f performin g th e work
. Thi s acces s shal l remai n i n effect unti l th e wor k ha s bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :

Pag e 1 o f 2..f^ ^

COASTA L tHVtKONHIKTA L " 1 pno^* " C t O U rI H C 

## X'^^y: ^

« Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; cRemov e flowe rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma ywis h t o save ; cWate 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
. « iAllo 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 f th e wor k activities , o rwit h an y o fth e wor k done , o rwit h th e equipmen t use d o n hi s property , o rt o undertak e an y action s regardin g th e us e o fsai d propert ywhic 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 (402 ) 991-119 9



### 0 1 I gran t acces s t o mypropertie s D i d o no t gran t acces s t o m ypropertie s

Signature ^^at e ' Signature Date

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

Page 2 o f 2c.. > » , s I f<

< V I * O M M


### Th e purpos e o f thi s agreement i s to provid e amutual agreement a s t o condition s ofth e propert y prior to remediatio nactivities
. Thi s will als o serv e a s documentatio nfo r th e purpos e of assurin g that restoratio n activitie s ar e complete dto th e satisfactio no f th e propert y owner andthe UnitedState s Environmenta l Protectio nAgency (EPA)
.

Property ID : Q,* ^ '^"7 ^ Property Address:-Z^ g j£j ^ \;p(X\J^ys.O Q ^\

_ ^ . Owner : 

# ^\/jy^
. cAij.Ajs
. Ph... : <^'^^ y 3/cfi- ' ^V^
- -^U i Onth e attache ddiagram(s ) indicate area(s ) to excavate , surfac e structure s an dlandscapin g feature s an d acces s location(s ) to b e usedb y th e contractors . Indicate distances , depths , materia l types , etc . Photographically andVideographically document the existin g condition s ofth e propert y andth e basemen t i

f necessary . 

## Item s to b e Remove db y th e Ovtrne r

befor e Start ; o f

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. item : f \, 1 , ' \ ~ ~ """" ^ f • ^ ^ ^ Item : Kem : 

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## Item s t o b e Remove db y th e Contracto r Durin g Remediatio nan dNo t Replace d 

# fl^^ SlKxQv WV\0v1^A- T

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### Item : \
n Item :

Item :

Ite m Pre-existin g propert y area , tha t wil l b e excavated , tha t i s covere dwit hgrass . Numbe r o f tree s > 2 inc h trun k diamete r Numbe r o f tree s < = 2 inc h trun k diamete r Numbe r o f Sprinkle r Zones , Contro l Valves , Timers , Heads , etc . A.uac h r . sketc h o l lli e >fr',iklc i l;:\f.Li ; Numbe r o f an dsiz e o f eac hgarden / flowe r be d area . Aiiacl i u skclcl i o l rfl.itiv f bi7.o s an dloc;iii(Mis
. Agree dupo nvalu e o f plan t material s no t t o b e replace db v contractor . ••'civ - r.i' , -:li(. ' ••.il i h : JS'' C '. c'^si' C ry.an ' >oiHve v11 1 t'l' - |-,iT)v.M;' ! u< \

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. Easemen t Area , t o b e excavate d 

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Pag e 2 of
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I Additiona l Comment s / Instructions : 

# 1 - 5 <^<^ ^ ^^^ ^ ^^* ^ ^W\V\o K

j^Chec k th e bo xi fOwne rdoe s not wan t CE G t o documen t interio rfoundatio n vvall s an d possibl e pre-existin g damage
. Bycheckin g thi s boxCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro fhouse , includin g foundatio n crack s o rfissures
.

0 I agre e • I d o no t agre e 

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± Erro r ± 13.67 5

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

## Certificat e o f Verificatio n XL3t-3902 2 Readin g N o 32 3 Mod e SOI L Tim e 2010-02-2 2 16:2 2 Duratio n 30.1 1 Sequenc e Fina l Flag s BVI D 2337 9 ADDRES S 352 3 Davenpor t St
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pp m P b 45.06 6 Supervise d By : 

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. BARAJA S 1 1

± Erro r ± 13.13 5

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

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pp m P b 247.92 7 Supervise d By : 

## Certificat e o f Verificatio n

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. B l 6 O
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± Erro r ± 25.03 3

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

## Certificat e o f Verificatio n XL3t-3902 2 Readin g N o 32 7 Mod e SOI L Tim e 2010-02-2 2 16:2 7 Duratio n 30.1 9 Sequenc e Fina l Flag s BVI D 2337 9 ADDRES S 352 3 Davenpor t St
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# Therm o SCIENTIFI C Therm o Fishe r Scientifi c 90 0 Middlese x Turnpik e Bilierica , M A 0182 1 

## Certificat e o f Verificatio n XL3t-3902 2 Readin g N o 32 8 Mod e SOI L Tim e 2010-02-2 2 16:2 8 Duratio n 30.2 9 Sequenc e Fina l Flag s BVI D 2337 9 ADDRES S 352 3 Davenpor t St
. QUADRAN T B l DEPH T 6 XR F TEC H O
. BARAJA S MIS C 1 NOT E 1

pp m Erro r P b 257.36 7 ± 25.27 9 Supervise d By :

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# m iyA^' \ Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 §^^^^ ° Coasta l Environmenta l Grou p Inc
. Sr^^j ^ www.coa8talhazmat.co m '*tPBO^' ^ COASTA L EHVIIOMIIIIITA l C lO U p . IN C 

# EXECUTIV ESUMMARY : BVID #23379-(352 3 DAVENPORT ST ) No Issue s o r Concern s Q Issues/Concern s Detai l Explanation : ^
_

# P A ^	 i 

# EPA Propert y Clos e Ou t Form Propert y # Datc/Tiroe : Quad s Excavate d Contracto r Grou p f^cyv^fe g Excavatio o Geaera l 1
.If necessaiy , were th e correc t quadrantCs) excavate dandrestored ? 2
.i f necessary , were th e correc t area s ofdri p zone excavate dan drestored ? Gradiii ESo dan dVegetatioi i 1
.Doe s th e gradin g aroun dthe perimeter ofth e hous e i ncxcavaie darea s generally slop e awa y &x) mth e house ? 2
.Ha s so dbee nlai dinail area s tha t wer e excavated ? 3
.

Doe s th e sodappear to b e generally health y an dgrowing ? (Only evaluate if inspecteda t a3 0 day time period ) 4
.Are soddedarea s generally ru man devenl y graded ? 5
.

Are th e joint s betwee nth e so dstrip s generally tight ? (Only evaluate if inspecteda t a3 0 da y tim e period) 6 .Wa s the propert y grade dsuchtha t wate r will no t poo l o nth e property ? 7 .Wa s damag e t o landscapin g o r plan t material s avoided ? Gates , Fence s an dRelafailii£Wall s I I . D o gate s ope nan dclo.s e fl-eely? (Ifappiicable ) 2
.Were all gate s or fence s takendow nduring restoratio nactivitie s reinstalled ? (If applicable ) 3
.Wa s damag e to gate s or fence s avoided ? (Ifappiicable ) 4
.Wa s damag e t o retainin g wall s avoided ? (Ifappiicable ) FouDdatioD , SidioKan d Gutter s 1
.

Wa s dainag e t o th e sidin g o rtri m avoided ? 2
.

Wa s damag e t o th e foundatio n avoided ? 3
.Wa s damag e t o window s avoided ? 4Wa s damag e t o window s o rdoo rscreen s avoided ? 5
.Wa s damag e l o downspout s o rdownspou l extension s avoided ? Sidewalk s an dDriveway s (Concrete ) 1
.Wa s damag e to drivewa y surface s avoided ? 2
.Wa s damag e to walkwa y surface s avoided ? gVffVCj p Ye s N o 

### y / Ye s N o 

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## J y Ves N c 

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## J J Ye s N o J 

## J y y 

### y Ye s N o

# d ^ Ort'Dcr s comments :

Inspectio nnotes :

Remova l an dreslorationactivate s complet e including th e 30-da y sodwarranry : EP A Representaliv e '^' ^ ^ , Da(e:__|^||^'^
_

## Propert yCompletio n Agreemen t ihi s agreemen l document s Ih e complclio n of remedial acliviiie s peri'oime d on my properl y My signalur e will designal e ihal I amsatisfie dwit hth e restoralio nof my propeity , andiha l no ilem s ar e inquestions , now , or al an y lime inih e fuiure , excep t thos e ilem s liste dbelow , if an y Propert y ID : 2 ??? nQ Propert y Address : ^^ ^ ^ TyAVe.t^mrV

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# ^""%b)Qr:)CVi(r\VP Z ^""'"(MO Q 

# ?m-i\^Fi ~ Restoratio n Item s in Question :

Item : Item : Item : Item : Item : Item :

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j I a|>rccI cstamlio n Kcompleted , rxccp i as noler i [_ J I do no l »{'rt crestoratio nis completcr i 

# t^Ay Ltkcih ^ W-n-^ f M /ju0 ^ i(li^lf) ^ Owner' s Signarm rDat e rl i ' s Signatur e e Sienatur ^-^t^t i aclo Dal e

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Propert yOwne rSatisfaciior t Survey * uni / 0 3 9n{j Q Omah a Lea d Superfun d Si t Hprnediatio n Contractor : Coasta l Environmenta l Grou p oUrtnrUlv U UlVlolUi M Propert yIdentifie rNumber : /L?>y7< ^ ^__ ^ Propert yAridri>« : 35 ^

P/>.\f^£ 1 pTf^ - ^ ^ Propert yOwner' s Name : 1 \Tr.ir \ OSf^rvWe y (abov e informatio n t o b e fille d ou t b yremediatio n contracto rprio rt o deliver yof for m 1 0 PropertyOwner)
Instruction s t o Propert yOwner ; Thi s for m i s provide d t o yo u a s a mean s o f tryin g t o captur e you rleve l o f satisfactio n wit h th e wor k o f th e above-identifie d remediatio n contractor , as applicabl e t o th e soj l cleanu p actio n a t you r property
. Th e U.S
. Environmenta l Protectio n Agenc y(EPA) i s ver yIntereste d I n you ropinio n regardin g th e wor k performe d b yit s contractors
. Thi s for m i s intende d t o provid e a n easymean s fo ryo u t o expres s you ropinio n abou t th e wor k performe d o n you rproperty
. Pleas e indicat e you rleve l o fsatisfactio n wit h th e contractor' s wor k b yselectin g a numerica l ratin g (rangin g fro m 1 t o 10 ) usin g th e followin g ratin g scale , the n pleas e sig n an d dat e th e for m an d retur n I t t o th e USEP Ai n th e attache d self-addresse d & stampe d envelope , (additiona l comment s ma y als o b e provide d i n th e spac e below , a t th e optio n o f th e propert yowne r| 9-1 0 "excellent " 7- 8 "ver ygood " 5- 6 "acceptable " 3- 4 "poor " 1-2 "ver/poor " Propert yOwner' s Satisfactio n Ratin g Reeardin g Contractor' s Wor k 

# © 5

9 4 8 3 7 2 6 1 Additiona l Comment s fro m Propert yOwne r(optional : continu e t o bac k o fpag e i fneeded )

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