TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 5"^b4 H Date: U/siS/ w 

Address: . a\\r> \ o \'r. 5^-V 

Remediation Contractor: _Coflstal Environmental Group^ Year: ^ o Vv 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

KiA Video of property (DVD) 

[^ Executive Summary 

\ / EPA-provided property sketch 

2^ Signed Access Agreement for subject property 

N£/^ Signed Access Agreement(s} for adjacent property 

[/ Restoration Agreemenl 

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

VIA Confinnation data 

^ Photographs "VV^ K>iCn.^^V^n^ ^>^rrxwirvVrCpw^ <5.,sA 

ZT As-built sketch 

l/T Satisfactory restoration signed by Property Owner 

l A Property close-out check list signed by EPA 

VI'K Description of areas not meeting ROD cleanup criteria 

^ Utility clearances 

WlK Property infonnation from Douglas County Assessor's Oflfice 

C' 

G 

^ — y)^ 

30261696 mil 

Superfund 
Property Access Checklist 

Property ID: .^^ ^ Cy ^ n WORK STAR! ED ON: / / 

Property Address: ;^,, ^ Ai / < s A n WORK COMPELTED ON:. / / 

Owner: ^ 5>, 0 Renter: 

Address: Phone: 

Fax: 

Cell/Pager: 

Additional Inforniation: Phone: c/^^.- IHG . Z.2,0 0 

Fax: 

Cell/Pager: 

n Notification Letter Sent: / / By: 

l ^ Access Agreeinent Signed:^ /Ir^ / il By: 

K/l Restoration Agreement Signed: y_/15/IT By: 

D Topsoil Sampling (if applicable) / / By: 

D Disposal Samplmg (if applicable) / / By: 

D Garden Sampling (if applicable) / / By: 

06 Utility Clearance Called: .^/^/J L By: 

H Video/Photos (Before) On: M / \^ / \.\ By: 

n Video/Photos (During) On: / / By: 

D Video/Photos (After) On: / / By: 

D Video/Photos (30-Day) On: / / By: 

H Property Completion Agreement Signed: w 1 \a 1 \< By: 

0 Final Report Issued: \ 0 / w / v. By: 

Air Monitoring (as applicable) 

• Community • Crew On: / / By: i 

Results: 

n Conununitv n Crew On: / / By: 1 

Results: 

• Community • Crew On: / / By: 1 

Results: 

Omaha Lead Site 
N aT<^HQ'en

o N i6s t 

A Printed

: Aug 24, 201 

www.dcgis.org/dogis 
IRTH One Call Page 1 of 1 

Digaera Hotlin* 

Of 

Nebraska 

Home Ticket 

Ticket Creation Logout 

I Create Another Ticket Go to Home Page Send Email 

• YOUR TICKET NUMBER IS 2861875 . 

Original Call Date: 9/28/11 Time: 10:32 am Op: WENDY18790 

Work to Begin Date: 9/30/11 Time: 10:45 am 

State: NE County: DOUGLAS Place: OMAHA 

Address: 2110 Street: N 15TH ST 

Twp: 15N Rng: 13E Sect-Qtr: 10-SE,15-NE 

Twp: Rng: Sect-Qtr: 

Legal Given: C 


Type of Work: LEAD REMEDIATION 


Location of Work: ENTIRE PROPERTY, INCLUDING EASEMENTS, AND UP TO THE 


: PEDESTALS. 


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


: EMAIL ALL CLEARS TO: WLARA@COASTALGRP.NET 


: UNSURE IF CORNER LOT. 


Company COASTAL ENVIRONMENTAL SERVICE 


Contact Name WENDY LARA Phone: (402)991-1199 


Alt. Contact JOSE CARDENAS Phone: (402)504-0981 


Work Being Done For: COASTAL 


Depth of Excavation: 4 FT Corner Lot: N Front: Y Rear: Y 


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MCINEB MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area 

Code 

Service Area Name Contact Phone Numbers 

Utility 

Type 

CXCATV COX COMMUNICATIONS, 

INC 

HEIDI COX 

COMMUNICATIONS 

Day:

Alt:

 (402) 934 ­ 0469 

 (402) 934 - 0469 

Emerg: (402) 932 - 9757 

LEVEL3 LEVEL3 LEVEL3 LEVEL3 Day: (877) 366 - 8344 

COMMUNICATIONS, LLC Emerg: (877) 366 - 8344 

MCINEB MCI MCINEB MCINEB Day: (800) 289 ­ 3427 

Emerg: (800) 289 ­ 3427 

• a t ir ^ A ^ <— >Bir>.i # ••iir^A j 

http://www.dhon.org/IRTHOneCall/Ticket/TicketCreation.aspx?VievyTicketID=842933 9/28/2011 
Wendy Lara 

From: IRTHNet@level3.com 

Sent: Wednesday, September 28, 2011 10:39 AM 

To: Wendy Lara 

Subject: Response to Dig Request 

To: COASTAL ENVIRONMENTAL SERVICE Attn: WENDY LARA 

Voice: 4029911199 Fax: 8776624211 

Re: Response to Dig Request 

This is an Impor'tant Message from Level 3 Communications replying to your' r'equest to locate 


our underground facilities in the area described on the One Call Center ticket. 


Ticket: 2861875 


County: DOUGLAS Place: Omaha 


Address: 2110 N 15TH ST 


LEVEL3: 


Level 3 Communications has determined our facilities are clear of the dig site 


described by your One Call Center ticket. Level 3 Communications will not 


have to locate any underground utilities at this dig site. If you have any 


questions, please contact Level 3 Communications at 1-800-441-0223. 


If you have any questions, please contact Level 3's Asset Management Team at 1-800-441-0223. 


This message was generated by an automated system. Please do not reply to this email. 

Wendy Lara 

From: agt_comm@irth.com 

Sent: Wednesday, September 28, 2011 10:48 AM 

To: Wendy Lara 

Subject: Response to Dig Request 

To: COASTAL ENVIRONMENTAL SERVICE Attn: WENDY LARA 

Voice: 4029911199 Fax: 8776624211 

Re: Response to Dig Request 

This is an important message from Omaha Public Works replying to your request to locate our 


underground facilities in an area described on the one call center ticket. 


Ticket: 2861875 


County: DOUGLAS Place: Omaha 


Address: 2110 N 15TH ST 


OMAHACOF (Sewer): 


City of Omaha Sewer- No Conflict per info on the one call ticket 


OMAHACOF (Traffic): 


The City of Omaha TraffijC Engineering Division has determined our facility is 


not in conflict with the dig site provided by the one call center. 


If you have any additional questions please contact Omaha Public Works. 


This message was generated by an automated system. Please do not reply to this email. 

n/2i/iiii K:ti m cotsmL ENgimninni SENICE FNII :iKijhrucgii T«: sinnn n rast i 

HCI 


m Ueston Parkway 

Gary, North Carolina 27513 


COASTAL ENVIRONHENTAL SERVICE 


Attention: UENDY LARA 


HCI facilities are not in conflict vith the scope of nork Identified. If there 


are changes to the scope of work identified in the field, please contact the 


local HCI field technician or HCI's National Fiber Security at 1-800-840-0336 


State Ticket' 


i 2861875 ^,^ ^ ,,, ^ v 


For further questions call HCI at 1-800-840-8338 


Fax Transmission Complete 

Wendy Lara 

From: agt_comm@irth.com 

Sent: Thursday, September 29, 2011 2:32 PM 

To: Wendy Lara 

Subject: Response to Dig Request 

To: COASTAL ENVIRONMENTAL SERVICE Attn: WENDY LARA 

Voice: 4029911199 Fax: 8776624211 

Re: Response to Dig Request 

This is an important message from Cox Communications replying to your request to locate our 


underground facilities in an area described on the one call center ticket. We do not have any 


underground facilities in your dig area 


Ticket: 2861875 


County: DOUGLAS Place: Omaha 


Address: 2110 N 15TH ST 


CXCATV: 


Hello, this is an important message from Cox Communications replying to your 


request to locate our underground facilities in an area described on the one 


call center ticket. We do not have any underground facilities in your dig 


area. If you have any questions please call our office at 402-934-0469 


If you have any questions please contact our local Cox Communications office AT 934-0469. 


This message was generated by an automated system. Please do not reply to this email. 

Wendy Lara 

From: IRTH.Net@qwest.com 

Sent: Thursday, September 29, 2011 4:13 PM 

To: Wendy Lara 

Subject: Message from Qwest 

To: COASTAL ENVIRONMENTAL SERVICE

Voice: 4029911199

Re: Message from Qwest 

 Attn:

 Fax:

 WENDY LARA 

 8776624211 

Message from Qwest 

Ticket: 2861875 


County: DOUGLAS Place: Omaha 


Address: 2110 N 15TH ST 


QLNNEIC: 


The described dig area of your locate request has been checked and is clear for 


Qwest Communication's Local Network. If you have any questions please call 


Qwest at 1-800-283-4237. 


Message from Qwest 


This message was generated by an automated system. Please do not reply to this email. 

^ ^ OLS#: 27649 As^uilt Drawiiig DATE EXCAVATED:10/04/11 

DATE USEPA SIGNED OFF :10/11/11 

AREA SODDED:2700 

Envirln^i^li^Group. OlTiah a LeBC l 

Superfund Site 

27649 

Extefior Pdinl OwMrNun»-^;iJiTSSAJrH ^T^Esr t n Omaha Lead Site • Good Addr«.:2ii0Ni6ST >^«»e.^e_Sketch 

n^poo< '^/ o Phone: H w •" ° \jQ Not paint 

Lead Sample Samples Collected 

Concentration Collected Sample Numbei 

Fim. FHfl ctl-(,:i 

RYASCPXA-27649 Fl 

I Q l ppm D Date lb I toUi, 

RYBSCPXA 27649 F2 

JLLi. ppm D Time /O'Sh a."!. 

RYCSCPXA-27649 B1 .3T 1 ppm i D

Samples Analyzed RYDSCPXA-27649 B2 ^32 - ppm D 

BMSCP.Y,A ;7S40 B « ~ ppm D D XRF Unit laCT} Book 11 3 

nceccpxA a704o—se p p m D D Date II -n-OG, 

RPZBCPXA 27610 U p p m D D 

Time .Bn Staff /v^at, / Number ot Samples = U 

Legend Fl = FronI Left. F2 = Front Right, B1 = Back Left. B2 = Back Rigtit DZ = Drip Zone. GZ = Garden. PZ = Play 

An qiwdrams t n as viewed ttom ttw street, facing prapefty 

D CONCRETE m DRIP ZONE EXCAVATED QUADRANTS EXCAVATED 

AREA REPLACED WITH AREA LEFT BARE AREA REPLACED WITH SOD ROCK/MULCH 

CONTRACT #: EP-R7-09-06 COASTAL ENVIRONMENTAL GROUP, INC. 
u^ O^[7>0 C ^ ^^j,^, i^ \yi/i:,A^A £TQHd 

Exterior Paint North Arrow Omaha Lead Site • Good Site SIcetch • Poor 

Sampling Address: ^11 0 A I 16' <9/ Q^Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collected Firm: /73>4 CN^HJ 

RYASCPXA- ^^<S^S F1 f O 7 ppm D Date; I D ' GT) ' OQ 

RYBSCPXA-2 r<* ^ 5 F2 71 3 ppm D Time: / Q .'jgiS r9/77 

RYCSCPXA-^7*(?'y5 B1 37 1 ppm D i Samples Analyzed RYDSCPyA'SrC^3 B2 V j ^ ppm D 

RDZOCrXA- -B2 ^ : ppm D D XRF Unit: /QO f Book: /7J i 

RGJZ.JCPX i A -S2 _::: ppm D D Date: 11 ' I 7 ' Qa 

RPZOCrXA- -P2. ppm D D Time: /5a^;2 

Staff: MSV\I Number of Samples = 

Legend: F1 = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

Rev 2008 Bl Created 16-May-08 
1 

Exterior Paint North Arrow # Omaha Lead Site • Good Site Sl<etch 

• Poor 

Sampling Address: <?// 0 A / 1 ^ t^ f [3^ Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collected Firm: /^D/ i CN.Hc J 

RYASCPXA- arG*f9^ ^ f O 7 ppm Date: 1 0 ' € D ' O G 

RYBSCPXA-2 r<?^5 F2 7 1 3 ppm D Time: I O : 6 & Ai m 

RYCSCPXA-2 r<JV5 B1 3J I ppm i D

D 

Samples Analyzed 

Number of Samples = M 

RYDSCPXA-2 r<?'y3 B2 ^.3 ^ ppm D 

RDZOCPXA­ -^2 - ppm u D XRF Unit: IQO T Book: 17. ^ 

PiGZOCPXARPZOCPXA­-SZ 

-P * 

_::

_::

 ppm 

 ppm 

D 

n 

D 

D 

Date: 

Time: 

11-/7'n a 

.BM. Staff: MSIAI 

Legend: F1 = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

Rev2008.BL Created: 16-May-08 046141.0123 
ill] 27649 

Omah Exterior Paint North Arrow Owne a Lead Site r Name:S^/;p-egA; Tht. SrHlES r jj m • Good Site Sketch Address:21lONi5ST 

Phone: H: W: 

[v|f Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Coliected Fimi: FM- ai*65 

RYASCPXA-27649 F1 /Q7 ppm D Date: fbttoUtt 

RYBSCPXA-27649 F2 JLLi. ppm D Time: /o'Sh g.^ . 

RYCSCPXA-27649 81 -il L ppm D Samples Analyzed RYDSCPXA-2764

RDZSCPXA a76<1

9

0

 B

 9

2 

2 

321. ppm in ppm XRF Unit lacr j Book: il3 _

nOZCCPXA 27640 6 2 ppm 

D D Date: I I no U

nPZCCPXA 27640 P2 ppm D D

Time: 2a i D D Staff: /*75ti / Number of Samples = l U 

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

All quadrants are as viewed from the street, being property 

TS ILTmV Si-mira ."ir>.. .! 

:OCT 2 3 i m 

^ 

/ r f 

3i\ \ : H3Z, 

:..^j . : g2 4 f 

... IDO. J^IS .'^^ 

1 

— • ; t 1 A" y Ac f 

• E).': L...: :.F.2. f I 

l/Ql.\ ;.. ..;...nj3...: t < '. '• 

ij. If ^f. 

Rev 4 046141 
„At»*ta«i 

K COASTA l 

c I 0 u r IN C 

Consent, foi Access To Propfehy 

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: yjn / iJQf 

Owner's Name: Daytime Phone: 

A5DC 

Address of Property 

covered by this 

Agreement: 

5l(0U_\sSi 

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 perfonned, the Grantor will have an 

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

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 ernployees, 

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

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

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

agrees to: 

Page 1 of 2 
k COfcSTAl mfiaonHiictst **'i«io«'^ c a e u r I a c 

c 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; 

( Water and maintain replacement vegetation, including feri:iljzer application, as 

necessary' subsequent to an initial watering period by EPA; 

c Abide by health and safety guidance provided by EPA; 

t 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 (402) 991-1199 

I grant access to my properties D i do not grant access to my properties 

K-fJ'-r/ 

Signature Date 

O I would like tc be present during any sampling that is required. 

Page 2 of 2 
COASTA L 

c « o u r . INC . 

Restoration Agreement 

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 IP: Ql(aU ^ 

Property Address: ^H ^ H VS S ^ 

Owner: Q£Co 

Phone: 

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 Owner before Start of Remediation: 

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

Item: 

KiONiV 

Item: 

Item: 

Item: 

7 

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

Item: 

- Kibv\t^ •

Item: ^ y 

Item: ^ y 

Item: 

/ 

Page 1 of. 
COASTA L 

C • O U P . t N C. 

Items to Be Removed By Contractor During Remediation and Replaced 

Item: 

^o\l .4 ^nJi F^ c^ R7 

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. 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property' 

owner. 

Easement Area, to be 

excavated 

Quantity 

Landscape Inventory 

Unit 

Quadrants 

Each 

Each 

Each 

Each 

Square Feet 

S 

Each 

Condition/Type/Species 

Page 2 of. 
C O A S T A L • MVlHONnS M TA L C R O U » , INC . 

Additional Comments / Instructions: 

The city of Omaha ordinances may prohibit you from using dirt or gravel areas on your property 

as driveways or vehicle parking areas. The Environmental Protection Agency (EPA) may be 

removing and replacing soil underiying a gravel or dirt area on your property that you may be 

using as a driveway or vehicle parking area. If this is the case, you should understand that this 

removing and replacing of soil does not mean that any illegal driveway or parking area on your 

property is made legal. To the contrary, you may be cited by the city if you use a gravel or dirt area 

as a driveway or parking area, not withstanding any removal or replacement of soil by the EPA. 

If you have any question about legality of a certain driveway or parking area, you may contact 

the city of Omaha's Planning Department at (402) 444-5150. 

K Please check this box if you understand the information outlined above. 

Y\,\' ^ • Check the box if Owner does not want CEG to document 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. 

L J I do not agree 

Date CoYtractor's Signature Date 

Page 3 of. 
Date 

Project 

XRF ID# 

Shot# 

&1 

1 -7c? 

• 7 / 

Average 

Shot# 

Average 

Sliot # 

Average 

Shot# 

Average 

Signature Q»/_

XRF PROPERTY SAMPLE SHEET 

lO-lA-J I Address 

Omaha Lead ARRA Sample time 

3«)CJ2 ^ sample length 

Reading | Sample area Shot# 

y.-ii-t 2."^ B2. 73 

2 33 j r r2 -5 Depth 7 ^ 

2 oC^± '2'Z^ ^ " 7 S 

Z^^S2'3 Average 

Reading Sample area Shot # 

Depth 

Average 

Reading Sample area Shot # 

Depth 

Average 

RETEST AREAS 

Reading Sample area Shot# 

Depth 

Average 

•^'0' t^ ^^ - ^^ ^ 

BVID# tl'C'i ^ 

Zl' O AA /-T STam/pm 

30 sec 

Reading Sample area 

^t^^ 13 rz 

Uct l ^ Depth 

U2>^ / Z ^ ' ^ 

U£j:y^ 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Print 6.PUAR D ICljJ ^ 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 72 

Mode Soil 

Time 2011-10-04 08:09 

Duration 90.80 

Units ppm 

Sigma Value 2 

Sequence Final 

Flags 

AVERAGE Avg of 69-71 

ADDRESS 2110 n 15 st 

QUADRANT B2 

DEPHT 4" 

XRF TECH KING 

MISC confirmation 

NOTE confirmation 

ppm ± 

Pb 223.286 ±

Supervised By: £Ay 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 229.653 

Supervised By: 

Certificate of Verification 

69 

Soil 

2011-10-04 08:07 

30.24 

ppm 

2 

Final 

27649 

2110 n 15 st 

B2 

4" 

KING 

confirmation 

confirmation 

± Error 

± 23.473 
SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 233.279 

Supervised By: 

Certificate of Verification 

70 

Soil 

2011-10-04 08:08 

30.33 

ppm 

2 

Final 

27649 

2110 n 15 st 

B2 

4" 

KING 

confirmation 

confirmation 

± Error 

± 23.459 
SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 206.925 

Supervised By: 

Certificate of Verification 

71 

Soil 

2011-10-04 08:09 

30.23 

ppm 

2 

Final 

27649 

2110 n 15 st 

B2 

4" 

KING 

confirmation 

confirmation 

± Error 

± 22.204 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 76 

Mode Soil 

Time 2011-10-04 08:12 

Duration 90.61 

Units ppm 

Sigma Value 2 

Sequence Final 

Flags 

AVERAGE Avg of 73-75 

ADDRESS 2110 n 15 st 

QUADRANT F2 

DEPHT 6" 

XRF TECH KING 

MISC confirmation 

NOTE confirmation 

ppm Error 

Pb 45.309 13.123 

Supervised By: (AL ^ y^^^--^ 
o 

Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 46.053 

Supervised By: 

Certificate of Verification 

73 

Soil 

2011-10-04 08:11 

30.14 

ppm 

2 

Final 

27649 

2110 n 15 st 

F2 

6" 

KING 

confirmation 

confirmation 

± Error 

± 13.109 
SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 46.614 

Supervised By: 

Certificate of Verification 

74 

Soil 

2011-10-04 08:12 

30.36 

ppm 

2 

Final 

27649 

2110 n 15 st 

F2 

6" 

KING 

confirmation 

confirmation 

± Error 

± 13.335 
SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Units 

Sigma Value 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 43.260 

Supervised By: 

Certificate of Verification 

75 

Soil 

2011-10-04 08:12 

30.11 

ppm 

2 

Final 

27649 

2110 n 15 st 

F2 

6" 

KING 

confirmation 

confirmation 

± Error 

± 12.925 
f^A^\

I ^^K^ I

V^'^Lj f

 Omaha Lead Site—Fixed Price EP-R7-09-06 

 Coastal Environmental Group Inc. 

 www.coastalhazmat.com 

COASTA L IN«l>OHHEHTAL 

S 1 0 U P. IN C 

EXECUTIVE SUMMARY: 

BVID #27649- (2110 N 15 ST) 

No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation: 
Property Completion Agreement 

l"hii agreement documenls lhe completion ol remedial aclivmes perloimcd on my pioperty. My signaiure 

will designate that I am saUsfied with the rcsioraiion of my propeiiy. and thai no ilems are in quesliom. 

now, or al any lime in the fuluie, excepl those items listed below, if any 

Property fD; 'p^CH ^ 

Property Addrm: 2./I A ^ L Y s 4 

Owner. ^ ^ j^ ^ 

PhoMc: u^ ^ ^^ ^ ^^ ^ 

Restoration Items in Question: 

pfem: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

I R|>rcc rc.«torti(ion i.t compleled, except RS noted ^ 

 I I do not a(;rec re5ior«tion is; completed 

lZ> - DC ' A 

Ofvnvr h SipnatiirfV- Diit c A C 

I
sti. EPA 

EPA Property Close Out Form 

<^.)i(^- AJ /. c s4. ^ Properly tf: tA C V.^l . Property Address:* 

Datcrriinc: \ <s/i.> / *% Owner's Name:. /L. Q^"^,. iJ! S". -1 

Quads Excavated: ^^,'ga . Contractor Group r,- ^ «.4^vV 

Excavation Yes No General 

I. I r necessary, were the correct quadrant(s) excavated and restored? 

2. If necessary, were the correci areas of drip zone excavated and restored? / 

Grading Sod and Vegetation 

Yes No 

I. Does the grading around (he perimeier ofthe house in excavated areas generally slope away / from the house? 

2. Has sod been laid in all 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. Ai« sodded areas generally fuin and evenly graded? / 

S. Are thejoints 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 nol pool on lhe propertj'? 

A 

7. Was damage lo landscaping or plant materials avoided? 

A 

Gates, Fences and Retaining Walls 

Yes No 

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

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

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

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

/ 

FouDdatioD, Sidiag and Gutters 

Yes No 

t. Was damage to the siding or trim avoided? 

/ 

2. Was damage to the foundation avoided? / 

3. Was damage lo windows avoided? 

1

1 

4. Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? J 

Sidewalks «nd Driveways (Concrete) 

Yes No 

1. Was damage lo driveway surfaces avoided? / 

2. Was damage to walkway surfaces avoided? 7 
Owners comments: 

Inspection notes: 

. ^ * ***' 

X y 

6^ 

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

EPA Representative ^jQr> Date: \oV*^'^ 
Property Owner Assessment of Performancfi;t]p>^i*ii^ ^ 0 ^QU 

American Recovery and Reinvestment Act (ARRA) ^'^t/^y^. 

Omaha Lead Superfund Site ^^/ n 

2009/2010 -^ 

Remediation Contractor: Coastal Environmental Group - EP-R7-09-06 

Property Identifier Number: ^'^"^ ^<y 

Property Address: Zl 1 (p AJ /.-T "^4 

Property Owner's Name: C'tf ^ c . 

Instructions to the Property Owner: 

This form serves to record the Property Owner's assessment of performance (Incentive 1 

- Quality Assurance Stirveillance Plan) involving the listed remediation contractor, as applicable 

to the Omaha Lead Site. This form documents the timeliness of pimch list resolution, business 

relations, complaint resolution and the overall quality of work. If need be, the Property Owner 

may utilize this form to record problems and/or issues not specifically tied to an assigned 

address, for example, business relations that generally don't follow the guidelines set forth in the 

Performance Work Statement. 

The Property Owner will indicate his/her assessment of performance with the contractor's 

work by checking a numerical rating on the table below using the numerical definitions fix)m 

the rating scale below, then sign & date the form. 

9-10 "excellent" 

7-8 'Very good" 

5-6 "acceptable" 

3-4 "poor" 

1-2 "very poor" 

Property Owner's Assessment of Performance Regarding the Contractor's Work 

10 X . 5 

9 4 

8 • 3 

7 2 

6 1 

Property Owner Additional Comments from foptional; continue on back page if needed) 

Property Owner Signature =ffjuiL^yjky D.te= ^6 ^ y