## TRANSMITTA Lof OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAID# : 5"^b4 H Date : U/siS/ w Address : . a\\r > \ o \'r . 5^- V Remediatio nContractor : _Coflstal Environmenta l Group ^ Year : ^ o V v SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S KiAVide o o f propert y (DVD ) [ ^ Executiv e Summar y \

/ EPA-provide dproperty sketc h 2 ^ SignedAcces s Agreement fo r subject property N£/ ^ Signe dAcces s Agreement(s } fo r adjacen t propert y 

### [ /

Restoratio nAgreemenl tsn \Settlemen t docimient s (i.e. , for damag e or t

o replac e plants , etc. ) VI

A Confinnatio ndat a
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T As-buil t sketc h l/ T Satisfactor y restoratio nsigne db y Propert y Owne r lA Propert y close-ou t chec k lis t signe db y EP A VI'

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Descriptio no f area s no t meetin g RO D cleanu p criteri a ^ Utilit y clearance s Wl K

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## Propert yAcces s Checklis t Propert y ID : .^^ ^ C y ^ nWOR K STAR ! E D ON : / / Propert y Address : ;^,, ^ A i / < sA nWOR K COMPELTE D ON: . / / Owner : ^ 5>, 0 Renter : Address : Phone : Fax : Cell/Pager : Additiona l Inforniation : Phone : c/^^.
- IHG . Z.2,0 0 Fax : Cell/Pager :

nNotificatio nLette r Sent : / / By : l ^ Acces s Agreeinen t Signed: ^ /Ir^ / i l By : K/

l Restoratio nAgreemen t 

## Signed : y_/15/I T By : D Topsoi l Samplin g (i f applicable ) / / By : D Disposal Samplm g (i f applicable ) / / By : D Garde nSamplin g (i f applicable ) / / By : 0 6 Utility Clearanc e Called : .^/^/JL By : H Video/Photo s (Before ) On:M / \^ / \. \ By : nVideo/Photo s (During ) On : / / By : D Video/Photo s (After ) On : / / By : D Video/Photo s (30-Day ) On : / / By : H Propert y Completio nAgreemen t Signed : w 1 \ a1 \ < By : 0 Fina l Repor t Issued : \ 0 / w / v . By : Ai r Monitorin g (a s applicable )
• Communit y • Cre w On : / / By : i Results : nConununit v nCre w On : / / By : 1 Results :

• Communit y • Cre w On : / / By : 1 Results :
Omah a Lea d Sit e

## N 

# aT<^HQ'eno N i6st 

# A Printed : Aug 24 , 20 1 www.dcgis.org/dogi s

### IRT H On e Cal l Pag e 1 o f 1 Digaer a Hotlin * O f 

### Nebrask a Hom e Ticke t Ticke t Creatio n Logou t I Create Anothe rTicket G o t o Hom e Pag e Sen d Emai l

• YOU R TICKE TNUMBE R I S 2861875 . Origina l Cal l Date : 9/28/1 1 Time : 10:3 2 a m Op : WENDY1879 0 Wor k t o Begi n Date : 9/30/1 1 Time : 10:4 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 211 0 Street : N15T H S T Twp : 15 NRng : 13 E Sect-Qtr : 10-SE,15-N E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D REMEDIATIO N Locatio n o f Work : ENTIR E PROPERTY , INCLUDIN G EASEMENTS , AN D U P T O TH E : PEDESTALS . Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : EMAI L AL L CLEAR S TO : WLARA@COASTALGRP.NE T : UNSUR E I F CORNE R LOT . Compan y COASTA L ENVIRONMENTA L SERVIC E Contac t Nam e WEND Y LAR APhone : (402)991-119 9 Alt . Contac t JOS E CARDENA S Phone : (402)504-098 1 Wor k Bein g Don e For : COASTA L Dept h o f Excavation : 4 F T Corne r Lot : NFront : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V LEVEL 3 MCINE B MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Cod e Servic e Are a Nam e Contac t Phon e Number s Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEID I CO X COMMUNICATION S Day : Alt : (402 ) 93 4 ­ 046 9 (402 ) 93 4 - 046 9 Emerg : (402 ) 93 2 - 975 7 LEVEL 3 LEVEL 3 LEVEL 3 LEVEL 3 Day : (877 ) 36 6 - 834 4 COMMUNICATIONS , LL C Emerg : (877 ) 36 6 - 834 4 MCINE B MC I MCINE B MCINE B Day : (800 ) 28 9 ­ 342 7 Emerg : (800 ) 28 9 ­ 342 7

• at ir ^ A^ < —>Bir>.i # ••iir^A j 

### http://www.dhon.org/IRTHOneCall/Ticket/TicketCreation.aspx?VievyTicketID=84293 3 9/28/201 1

## Wend yLara From : IRTHNet@level3.co m Sent : Wednesday , Septembe r28 , 201 1 10:3 9 A M To : Wend yLar a Subject : Respons e t o Di g Reques t

To : COASTA L ENVIRONMENTA L SERVIC E Attn : WEND Y LAR A Voice : 402991119 9 Fax : 877662421 1 Re : Respons e t o Di g Reques t Thi s i s a n Impor'tan t Messag e fro mLeve l 3 Communication s replyin g t o your ' r'eques t t o locat e ou r undergroun d facilitie s i n th e are a describe d o n th e On e Cal l Cente r ticket .
Ticket : 286187 5 County : DOUGLA S Place : Omah a Address : 211 0 N15T H S T LEVEL3 : Leve l 3 Communication s ha s determine d ou r facilitie s ar e clea r o f th e di g sit e describe d b yyou r On e Cal l Cente r ticket . Leve l 3 Communication s wil l no t hav e t o locat e an yundergroun d utilitie s a t thi s di g site . I f yo u hav e an y questions , pleas e contac t Leve l 3 Communication s a t 1-800-441-0223 .

I f yo u hav e an yquestions , pleas e contac t Leve l 3' s Asse t Managemen t Team a t 1-800-441-0223 .

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .

## Wend yLar a From : agt_comm@irth.co m Sent : Wednesday , Septembe r28 , 201 1 10:48 A M To : Wend yLar a Subject : Respons e t o Di g Reques t

To : COASTA L ENVIRONMENTA L SERVIC E Attn : WEND Y LAR A Voice : 402991119 9 Fax : 877662421 1 Re : Respons e t o Di g Reques t Thi s i s a n importan t messag e fro mOmah a Publi c Work s replyin g t o you r reques t t o locat e ou r undergroun d facilitie s i n a n are a describe d o n th e on e cal l cente r ticket .
Ticket : 286187 5 County : DOUGLA S Place : Omah a Address : 211 0 N15T H S T OMAHACO F (Sewer) : Cit yo f Omah a Sewer - N o Conflic t pe r inf o o n th e on e cal l ticke t OMAHACO F (Traffic) : Th e Cit yo f Omah a Traffij C Engineerin g Divisio n ha s determine d ou r facilit yi s no t i n conflic t wit h th e di g sit e provide d b yth e on e cal l center .

I f yo u hav e an yadditiona l question s pleas e contac t Omah a Publi c Works .

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .

### n/2i/iii i K:t i mcotsm LENgimninni SENICEFNI I

### :iKijhrucgi i T« : sinnn nras t i 

## HC I mUesto nParkwa y Gary , Nort hCarolin a 2751 3 COASTA L ENVIRONHENTA L SERVIC E
Attention : UEND YLARA HC I facilitie s ar e no t i nconflic t vit hth e scop e o f nor kIdentified . I f ther e ar e change s t o th e scop e o f wor kidentifie di nth e field , pleas e contac t th e loca l HC I fiel dtechnicia no r HCI' s Nationa l Fibe r Securit ya t 1-800-840-033 6 Stat e Ticket ' i 286187 5 ^, ^ ^ ,, , ^ v Fo r furthe r question s cal l HC I a t 1-800-840-833 8 Fa xTransmissio nComplet e

## Wend yLar a From : agt_comm@irth.co m Sent : Thursday , Septembe r29 , 201 1 2:32 P M To : Wend yLar a Subject : Respons e t o Di g Reques t

To : COASTA L ENVIRONMENTA L SERVIC E Attn : WEND Y LAR A Voice : 402991119 9 Fax : 877662421 1 Re : Respons e t o Di g Reques t Thi s i s a n importan t messag e fro mCo x Communication s replyin g t o you r reques t t o locat e ou r undergroun d facilitie s i n a n are a describe d o n th e on e cal l cente r ticket . W e d o no t hav e an y undergroun d facilitie s i n you r di g are a

Ticket : 286187 5 County : DOUGLA S Place : Omah a Address : 211 0 N15T H S T CXCATV : Hello , thi s i s a n importan t messag e fro mCo x Communication s replyin g t o you r reques t t o locat e ou r undergroun d facilitie s i n a n are a describe d o n th e on e cal l cente r ticket . W e d o no t hav e an yundergroun d facilitie s i n you r di g area . I f yo u hav e an yquestion s pleas e cal l ou r offic e a t 402-934-046 9

I f yo u hav e an yquestion s pleas e contac t ou r loca l Co x Communication s offic e A T 934-0469 .

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .

## Wend yLara From : IRTH.Net@qwest.co m Sent : Thursday , Septembe r29 , 201 1 4:1 3 P M To : Wend yLar a Subject : Messag e fro m Qwes t

To : COASTA L ENVIRONMENTA L SERVIC E Voice : 402991119 9 Re : Messag e fro mQwes t Attn : Fax : WEND Y LAR A 877662421 1 Messag e fro mQwes t

Ticket : 286187 5 County : DOUGLA S Place : Omah a Address : 211 0 N15T H S T QLNNEIC : Th e describe d di g are a o f you r locat e reques t ha s bee n checke d and i s clea r fo r Qwes t Communication' s Loca l Network . I f yo u hav e an yquestion s pleas e cal l Qwes t a t 1-800-283-4237 .
Messag e fro m Qwes t

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .OLS# : 2764 9 

# ^ ^ As^uil t Drawiii g DAT E EXCAVATED:10/04/1 1 DAT E USEP ASIGNE D OF F :10/11/1 1 ARE ASODDED:270 0 

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

# Superfun d Sit e

2764 9 Extefio rPdin l OwMrNun»-^;iJiTSSAJr H ^T^Es rt n Omah a Lea d Sit e • Goo d Addr«.:2ii0Ni6S T>^«»e.^e_Sketc h n^poo < '^/ o Phone : H w •" ° \j Q No t pain t Lea d Sampl e Sample s Collecte d Concentratio n Collecte d Sampl e Numbe i Fim . FHf l ctl-(,: i RYASCPXA-2764 9 F l I Q l pp m D Dat e l b I toUi , RYBSCPX A2764 9 F 2 JLLi . pp m D Tim e /O'S h a."! . RYCSCPXA-2764 9 B 1 .3T 1 pp m D 

# i Sample s Analyze d RYDSCPXA-2764 9 B 2 ^32 - pp m D BMSCP.Y, A;7S4 0 B « ~ pp m D D XR F Uni t laCT } Boo k 11 3 nceccpx Aa704o—s e D p p m D Dat e I I -n-OG , RPZBCPX A2761 0 U p p m D D Tim e .B n Staf f/v^at, / Numbe ro t Sample s = U Legen d F l = Fron I Left
. F 2 = Fron t Right , B 1 = Bac k Left
. B 2 = Bac k Rigti t D Z = Dri p Zone . G Z = Garden
. P Z = Play A n qiwdram s t n a s viewe d tto m tt wstreet , facin g prapeft y



# D CONCRET E 

# m DRI P ZON E EXCAVATE D QUADRANT S EXCAVATE D
ARE AREPLACE D WIT H ARE ALEF TBAR E ARE AREPLACE D WIT H SO D ROCK/MULC H 

### CONTRAC T# : EP-R7-09-0 6 COASTA L ENVIRONMENTA L GROUP , INC
.

# u ^ O^[7> 0 

# C ^ ^^j,^ , i ^ \yi/i:,A^ A £TQH d Exterio rPain t Nort h Arrow 

### Omah a Lea d Sit e • Goo d Sit e SIcetc h • Poor Samplin g Address : ^11 0 A I 16 ' <9 / Q^No t paint Sampl e Numbe r Lead Sampl e 

### Sample s Collecte d LA B 

### Concentratio n Collecte d 

## Firm : /73> 4 CN^H J RYASCPXA - ^^<S^ S F 1 f O 7 pp m 

# D Date ; I D ' GT ) ' O Q RYBSCPXA- 2 r< * ^ 5 F 2 71 3 pp m 

# D Time : / Q .'jgi S r9/7 7 RYCSCPXA-^7*(?'y 5 B 1 

## 37 1 pp m 

# D 

# i Sample s Analyze d RYDSCPyA'SrC^ 3 B 2 

## V j ^ pp m 

# D RDZOCrXA- -B 2 ^ : pp m 

# D D XR F Unit : /QO f Book : /7J i JZ.JCPX A RG i 

### -S 2 _:: : pp m 

# D D Date : 11 ' I 7 ' Q a RPZOCrXA - -P2 . pp m 

# D D Time : /5a^;2 Staff : MSV\ I Numbe ro f Sample s = Legend : F 1 = Fron t Left , F 2 = Fron t Right , B 1 = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s are a s viewe d fro m th e street , facin g propert y

Rev 200 8 B l Create d16-May-0 8

## 1 Exterio rPain t Nort h Arro w 

### # Omah a Lea d Sit e • Goo d Sit e Sl<etc h • Poor Samplin g Address : <?// 0 A / 1 ^ t^ f [3 ^ No t pain t Sampl e Numbe r Lea d Sampl e Sample s Collecte d LAB Concentratio n Collecte d Firm : /^D/ i CN.Hc J RYASCPXA - arG*f9^ ^ f O 7 pp m Date : 1 0 ' € D ' O G RYBSCPXA- 2 r<?^ 5 F 2 7 1 3 pp m 

## D Time : I O : 6 & Ai m RYCSCPXA- 2 r<JV 5 B 1 3J I pp m 

## D 

# i D Sample s Analyze d

Numbe ro f Sample s = 

## M RYDSCPXA- 2 r<?'y 3 B 2 ^.3 ^

pp m 

## D RDZOCPXA ­ -^ 2 - pp m 

# u D XR F Unit : IQOTBook : 17. ^ PiGZOCPXARPZOCPXA ­ -S Z -P * _: : _: : pp m pp m 

## D 

# n D D Date : Time : 

# 11-/7'n a .BM . Staff : 

## MSIA I Legend : F 1 = Fron t Left , F 2 = Fron t Right , B 1 = Back Left , B 2 = Back Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s are a s viewe d fro m th e street , facin g property

Rev2008.B LCreated : 16-May-0 8 046141.012 3

# ill ] 27649 Exterio rPain t North Arro w 

### Omah a Lea d Sit e Owne rName:S^/;p-egA ; Tht . SrHlES rjj m 

### • Goo d Sit e Sketc h Address:21lONi5S T Phone : H : W : [v| f No t pain t Sampl e Numbe r Lea d Sampl e Sample s Collecte d LA B Concentratio n Coliecte d Fimi : FM - ai*6 5 RYASCPXA-2764 9 F 1 

## /Q 7 pp m 

## D Date : fbttoUt t RYBSCPXA-2764 9 F 2 

## JLLi . pp m 

## D Time : /o'S h g.^ . RYCSCPXA-2764 9 8 1 

## -il L pp m 

## D Sample s Analyze d RYDSCPXA-2764 9 B 2 pp m 

# i 321 . 

# n RDZSCPXAa76<1 0 9 2 pp m XR F Uni t lacr j Book : il3

_ 

## D D nOZCCPX A2764 0 6 2 pp m Date : I I no U 

## D D nPZCCPX A2764 0 P 2 pp m Time : 2a i 

## D D Staff : /*75ti / Numbe ro f Sample s = l U Legend : F 1 = Fron t Left , F 2 = Fron t Righ t 8 1 = Bac k Left , 8 2 = Bac k Righ t D Z = Dri p Zone . G Z = Garden , PZ = Pla y Al l quadrant s ar e a s viewed fro m th e street , bein g propert y T S ILTm V Si-mir a ."ir>. . .! 

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# K COASTA l cI 0 u rIN C 

# Consent , fo i Acces s T o Propfeh y 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 : yjn / iJQ f Owner' s Name : Daytim e Phone :



# A5D C
Addres s o fPropert y covere d b ythi s Agreement : 

# 5l(0U_\sS i PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EPAi s requestin g acces s t o collect soi l sample s an d 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 its 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 perfonned , 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 wori t 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 Athat th e property ha s 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 ernployees , contractors an d subcontractors th e right t o ente rth e property , at 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 wori^ . Thi s acces s shal l remai n i n effect unti l th e wori ( ha s bee n satisfactoril ycompleted . Th e Granto rals o agree s to :
Pag e 1 o f 2

# k COfcSTA l mfiaonHiicts t **'i«io«' ^ ca e u rI a c 

### cRemov 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 ; ( Wate ran d maintai n replacemen t vegetation , includin g feri:iljze rapplication , a s necessary ' subsequen t t o a n initia l waterin g perio d b yEPA ; cAbid e b yhealt h an d safet yguidanc e provide d b yEPA ; t I f th e propert yi s rented , assis t EP Ai n obtainin g tenan t approva l fo racces s t o th e propert yt o perfor m th e work . » Allo wvideotapin g and/o rphotographin g o f th 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 f th 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 f sai 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 I gran t acces s to mypropertie s D i d o no t gran t acces s t o mypropertie s 

# K-fJ'-r / Signatur e Date
O I woul d lik e t cb e presen t durin g an ysamplin g tha t i s required .

Page 2 o f 2COASTA L c« o u r. INC
. 

## Restoratio n Agreemen t Th e purpos e o f thi s agreemen t i s t o provid e amutual agreemen t a s t o condition s ofth e property prio r t o remediatio nactivities . Thi s wil l als o serv e a s documentatio nfor th e purpos e o f assurin g that restoratio n activitie s are complete dt o th e satisfactio no f th e property owne r an dth e Unite dState s Environmental Protectio nAgenc y (EPA) .

Propert y IP : Ql(aU ^ Property Address : ^H ^ H V S S ^ Owner : 

# Q£C o Phone : O nth e attache ddiagram(s ) indicate area(s ) to excavate , surfac e structure s andlandscapin g feature s and acces s location(s ) t o b e use db y th e contractors . Indicate distances , depths , material types , etc . Photographicall y an dVideographicall y document th e existin g condition s ofth e propert y an dth e basement i f necessary . Item s t o b e Remove d b yth e Owne rbefor e Star t o fRemediation : Th e removal , storage , disposal , and/o rretu m o f thes e item s i s th e Owner' s responsibility . Item : 

# KiONiV Item : Item : Item : 

# 7

Item s t o b e Remove d b yth e Contracto r Durin g Remediatio n an d No t Replace d Item :

-
• 

# Kibv\t ^ Item : ^ y Item : ^ y Item : 

### / Pag e 1 of
.COASTA L C • O U P . t N C
. 

## Item s t o B e Remove d B yContracto rDurin g Remediatio n an d Replace d Item : 

# ^o\ l 

# . 4 ^nJ i 

# F ^ c ^ R7

Item Pre-existin g propert y area , tha t wil l b e excavated , tha t i s coveredwit hgrass . Numbe r o f tree s > 2 inch trunk diamete r Numbe r o f tree s < = 2 inc h trunk diamete r Numbe r o f Sprinkle r Zones , Contro l Valves , Timers , Heads , etc . Attac hasketc ho f th e sprinkle r layout . Numbe r o f andsiz e o f eac hgarden/ flower be d area . Attac hasketc ho f relativ e size s an dlocations . Agree dupo nvalu e o f plan t material s no t t o b e replace db v contractor . Not e thi s valu e wil l b e use dt o issu e aplan t vouche r t o th e property ' owner . Easemen t Area , to b e excavate d 

## Quantity Landscap e Inventor y Unit Quadrant s

Eac h Eac h

Eac h

Eac h Squar e Fee t

S

Eac h 

## Condition/Type/Specie s

Pag e 2 of
.C O AS TAL • MVlHONnS M T AL C R O U » , INC
. Additiona l Comment s / Instructions : Th e cit yo f Omah a ordinance s ma yprohibi t yo u fro m usin g dir t o rgrave l area s o n you rpropert y a s driveway s o rvehicl e parkin g areas . Th e Environmenta l Protectio n Agenc y(EPA ) ma yb e removin g an d replacin g soi l underiyin g a grave l o rdir t are a o n you rpropert ytha t yo u ma yb e usin g a s a drivewa yo rvehicl e parkin g area . I fthi s i s th e case , yo u shoul d understan d tha t thi s removin g an d replacin g o f soi l doe s no t mea n tha t an yillega l drivewa yo rparkin g are a o n you r propert yi s mad e legal . T o th e contrary , yo u ma yb e cite d b yth e cit yi fyo u us e a grave l o rdir t are a a s a drivewa yo rparkin g area , no t withstandin g an yremova l o rreplacemen t o fsoi l b yth e EPA . I fyo u hav e an yquestio n abou t legalit yo fa certai n drivewa yo rparkin g area , yo u ma ycontac t th e cit yo f Omaha' s Plannin g Departmen t a t (402 ) 444-5150 . 

# K Pleas e chec k thi s bo xi f yo u understan d th e informatio n outline d above .

Y\,\' ^ • Chec k th e bo xi f Owne rdoe s no t wan t CE G t o documen t interio rfoundatio n wall s an d possibl e pre-existin g damage . B ycheckin g thi s bo xCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro f house , includin g foundatio n crack s o rfissures
. 

### LJI d o no t agre e
Date CoYtractor' s Signature Date Pag e 3 of
.Dat e Project XR F ID #

Shot # 

## & 1 1 -7c ? • 7 / Averag e Shot #

Averag e Slio t #

Averag e

Shot #

Averag e Signature Q»/

_ XR F PROPERT YSAMPL E SHEE T 

### lO-lA-J I Addres s Omah a Lea d ARR A Sampl e tim e 3«)CJ2 ^ sampl e lengt h Readin g | Sampl e are a Shot # 

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

# 7 3 2 3 3 j rr 2 - 5 Dept h 

## 7 ^ 2 oC^ ±

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# Z^^S2' 3 Averag e Readin g Sampl e are a Shot # Dept h Averag e Readin g Sampl e are a Shot # Dept h Averag e
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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 7 2 Mod e Soi l Tim e 2011-10-0 4 08:0 9 Duratio n 90.8 0 Unit s pp m Sigm a Valu e 2 Sequenc e Fina l Flag s AVERAG E Av g o f 69-7 1 ADDRES S 211 0 n 1 5 s t QUADRAN T B 2 DEPH T 4 " XR F TEC H KIN G MIS C confirmatio n NOT E confirmatio n
pp m ± P b ± 223.28 6 Supervise d By : 

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 229.65 3 Supervise d By : 

## Certificat e o f Verificatio n

6 9 Soi l 2011-10-0 4 08:0 7 30.2 4 pp m 2 Fina l 2764 9 211 0 n1 5 s t B 2 4 " KIN G confirmatio n confirmatio n

± Erro r ± 23.47 3SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 233.27 9 Supervise d By : 

## Certificat e o fVerificatio n

7 0 Soi l 2011-10-0 4 08:0 8 30.3 3 pp m 2 Fina l 2764 9 211 0 n1 5 s t B 2 4 " KIN G confirmatio n confirmatio n

± Erro r ± 23.45 9SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 206.92 5 Supervise d By : 

## Certificat e o f Verificatio n

7 1 Soi l 2011-10-0 4 08:0 9 30.2 3 pp m 2 Fina l 2764 9 211 0 n1 5 s t B 2 4 " KIN G confirmatio n confirmatio n

± Erro r ± 22.20 4

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

## Certificat e o f Verificatio n XL3t-3902 2 Readin g N o 7 6 Mod e Soi l Tim e 2011-10-0 4 08:1 2 Duratio n 90.6 1 Unit s pp m Sigm a Valu e 2 Sequenc e Fina l Flag s AVERAG E Av g o f 73-7 5 ADDRES S 211 0 n 1 5 s t QUADRAN T F 2 DEPH T 6 " XR F TEC H KIN G MIS C confirmatio n NOT E confirmatio n
Erro r pp m P b 45.30 9 13.12 3 Supervise d 

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

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 46.05 3 Supervise d By : 

## Certificat e o f Verificatio n

7 3 Soi l 2011-10-0 4 08:1 1 30.1 4 pp m 2 Fina l 2764 9 211 0 n 1 5 s t F 2 6 " KIN G confirmatio n confirmatio n

± Erro r ± 13.10 9SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 46.61 4 Supervise d By : 

## Certificat e o fVerificatio n

7 4 Soi l 2011-10-0 4 08:1 2 30.3 6 pp m 2 Fina l 2764 9 211 0 n1 5 s t F 2 6 " KIN G confirmatio n confirmatio n

± Erro r ± 13.33 5SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E
pp m P b 43.26 0 Supervise d By : 

## Certificat e o fVerificatio n

7 5 Soi l 2011-10-0 4 08:1 2 30.1 1 pp m 2 Fina l 2764 9 211 0 n1 5 s t F 2 6 " KIN G confirmatio n confirmatio n

± Erro r ± 12.92 5

## f^A^ \ I ^^K ^ I V^'^Ljf 

## Omah a Lea d Site—Fixe d Pric e EP-R7-09-0 6 Coasta l Environmenta l Grou p Inc . www.coastalhazmat.co m COASTA L IN«l>OHHEHTA L S 1 0 U P . IN C 

# EXECUTIV ESUMMARY : BVID #27649
- (211 0 N1 5 ST ) No Issue s o r Concern s | ^ Issues/Concern s Detai l Explanation :

## Propert yCompletio n Agreemen t l"hi i agreemen t documenl s lh e completio n o l remedia l aclivme s perloimc d o n m ypioperty . M ysignaiur e wil l designat e tha t I a m saUsfie d wit h th e rcsioraiio n o f m ypropeiiy . an d tha i n o ilem s ar e i n quesliom . now , o ra l an ylim e i n th e fuluie , excep l thos e item s liste d below , i f an y

Propert y fD ; 'p^CH ^ Propert y Addrm : 2./I A ^ L Y s4 Owner . ^ ^ j^ ^ PhoMc : u^ ^ ^^ ^ ^^ ^ Restoratio n Item s i n Question : 

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Item : Item : Item : Item : Item : Additiona l Comments :

I R|>rc crc.«torti(io n i. t compleled , excep t R S note d ^ I I d o no t a(;re cre5ior«tio n is ; complete d 

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# EP A EP APropert y Clos e Ou t For m <^.)i(^
- A J /. c s4. ^ Properl y tf : tA C V.^l . Propert y Address: * Datcrriinc : \<s/i. > / *% Owner' s Name: . /L . Q^"^, . iJ ! S" . - 1 Quad s Excavated : ^^,'ga . Contracto r Grou p r,- ^ «.4^vV Ye s N o Excavatio nGenera l I .I r necessary , were th e correc t quadrant(s ) excavate dandrestored ? 2 .If necessary , were th e correc i area s o f drip zone excavate dan drestored ? / Gradin g So dan dVegetatio n Ye s N o I .Doe s the gradin g aroun d(h e perimeier ofth e hous e i nexcavate darea s generally slop e awa y / fromth e house ? 2 .Ha s sodbee nlai dinall area s tha t wer e excavated ? / 3 .Doe s th e so dappea r t

o b e generall y healthy an dgrowing ? (Onl y evaluate i f inspecte da t a3 0 day time period ) _^_ / 4 .Ai « soddedarea s generally fuinan devenly graded ? / S .Ar e thejoint s betwee nth e so dstrip s generally tight ? (Only evaluate if inspecte da t a3 0 da y / tim e period)___ ^ 6 . Wa s the propert y grade dsuchtha t wate r wil l nol poo l o nlh e propertj' ? 

# A 7 . Wa s damage l o landscapin g o r plan t material s avoided ? 

# A Gates , Fence s an dRetainin g Wall s Ye s N o I .D o gate s ope nan dclos e freely ? (Ifapplicable ) 

# y 2 .Were all gate s or fence s takendow ndurin g restoratio nacliviiie s reinstalled ? (Ifapplicable ) / 3 .

Wa s damage t o gate s o r fence s avoided ? (Ifapplicable ) / 4 . Wa s damage t o retainin g wall s avoided ? (Ifapplicable ) / FouDdatioD , Sidia g an dGutter s Ye s N o t . Wa s damage t o th e sidin g or tri mavoided ? / 2 .Wa s damage to the foundationavoided ? / 3 .Wa s damage l o window s avoided ? 

# 1 1 4 .Wa s damage t o window s or doo r screen s avoided ? 5 .Wa s damage to downspout s o r downspou t extension s avoided ? 

# J Sidewalk s «n dDriveway s (Concrete ) Ye s N o 1 .Wa s damage l o drivewa y surface s avoided ? / 2 .Wa s damage to walkwa y surface s avoided ? 

# 7

## Owner s comments :

Inspectio nnotes :

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## Remova l an drestorationactivate s complete including the 30-da y sodwarranty : EP A Representativ e ^jQr > Date : \oV*^' ^

## Propert y Owne r Assessmen t o f Performancfi;t]p>^i*ii ^ ^ 0 ^Q U America nRecover y an dReinvestmen t Act (ARRA) ^'^t/^y^ . Omah aLea dSuperfun dSit e ^^/ n 2009/201 0 -^ Remediatio nContractor : Coastal Environmenta l Grou p - EP-R7-09-0 6 Propert y Identifie r Number : ^'^" ^ ^< y Propert y Address : Z l 1 ( p A J /.- T "^ 4 Propert y Owner' s Name : C't f

^ c . Instruction s t o th e Propert y Owner : Thi s for mserve s t o recor dthe Propert y Owner' s assessmen t o f performanc e (Incentive 1

- Qualit y Assuranc e Stirveillanc e Plan) involving the liste dremediationcontractor , a s applicable to th e OmahaLea dSite . Thi s for mdocuments the timelines s o f pimc hlis t resolution , busines s relations , complain t resolutionan dthe overall qualit y o f work . If needbe , the Propert y Owne r ma y utiliz e thi s for mto recor dproblems and/o r

issue s not specificall y tiedto a nassigned address , fo r

example , busines s relation s tha t generall y don' t follow the guideline s set fort hinthe Performance Wor k

Statement . The Propert y Owne r

will indicat e his/he r

assessmen t o f performance wit hthe contractor' s wor k

b y checkin g anumerica l ratin g o nth e tabl e belo w using th e numerica l definition s fix)m the ratin g scale below , thensign& dat e the form . 9-1 0 "excellent " 7- 8 'Ver y good " 5- 6 "acceptable " 3-4 "poor " 1-

2 "ver y poor " Propert y Owner' s Assessment o

f

Performanc e Regardin g th e Contractor' s Work 1 0 X . 5 9 4 8 • 3 7 2 6 1 Propert y Owne r Additiona l Comment s fromfoptional ; continu e onbac k pag e if needed ) Propert y Owne r Signatur e 

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