### - 

## - TRANSMITTAL of OMAHA LEAD SITE

SOIL REMEDIATION FILE FOLDER

sAID #:

# ~t- ' 

# z, ' Date:

# _1___,(___,_~-+-f -'-'--''
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### Remediation Contractor: _Coastal Environmental Group_ Year: 201 

### OARRA


### SOIL REMEDIATION PROPERTY FILE FOLDER DOCUMENTS Video ofproperty (DVD)

----------­ Executive Summary EPA-provided property sketch Signed Access Agreement for subject property Signed Access Agreement(s) for adjacent property Restoration Agreement Settlement documents (i.e., for damage or to replace plants, etc.) Confirmation data Photographs 

# (k**~1\11~ ~** **~~~** 1" 

# ?9'Vz As-built sketch Satisfactory restoration signed by Property Owner Property close-out check list signed by EPA

0 0 

### 0 

### Description of areas not meeting ROD cleanup criteria Utility clearances Property information from Douglas County Assessor's Office


# l4

30287387
11111111111111111111111111111111111111111111111111 Superfund

### --- 

# •

Property Access Checklist Property ID: ON: I I 

### ON:_/_/_
Owner: Renter: Address: Phone: Fax:
Phone: Fax: Cell/Pager: Additional Information: Cell/Pager: 

## D Notification Letter Sent: _/_/_ 

### By: 

# () Access Agreement Signed: 

# 2,_ t!.JJ 

## J{1 By:

# ~ Restoration Agreement Signed:

### ~I 

## /i_ I/!._ 

### By: 

# )/1 ( 

# /! D Topsoil Sampling (if applicable) I I



### --­ By: 

## D Disposal Sampling (if applicable) I I



# --­ By: 

## D Garden Sampling (if applicable) I I



# --­ By: 

## D Utility Clearance CaUed: _/_!_ 

### By: 

## [] Video/Photos (Before) On:Ob I _j_g!

### ~ By:

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# ill Video/Photos (During) On:L/ 

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# f</ /tlf fr D Video/Photos (After) On: I I



### --­ By: 

## D Video/Photos (30-Day) On: I I



# --­ By: 

## D Property Completion Agreement Signed:_/_/_ By: 

## D Final Report Issued: I I



# --­ By: Air 

### Monitorin2 (as applicable)



## 0 Community Results: 

## 0 Crew 

# I On: I I



# --­ 

# I By: Ocommunity Results: Ocrew 

# I On: I I



### --­ 

# I By: Ocommunity Ocrew 

# I On: I I 

# I By: Results:

Omaha Lead Site

### Page 1 of2 Douglas County Account .ation

Douglas County, Nebraska Property Record ­ R1015620000
Information is valid as of 2009-12-31 Print ReROrt NEW Feature - Parcel Dimensions available@ scale 0-50 ft west of 52nd St- View on MaR Treasurer's Tax ReRort New Feature**~~~** Auto Sales Search 

### Owner MORA GENOVEVA ETAL 820 S 35 ST OMAHA NE 68105-0000 

### Property Information

. Key Number: 1562 0000 10 Account Type: Residential Parcel Number: 1015620000 Parcel Address: 820 S 35 ST OMAHA NE 68105-0000 Legal Description: ELLIS PLACE LOT 19 BLOCK 0 40 X 125 

### Value Info.rmation Land Improvement Total 

### 2009 $5,700.00 $104,200.00 $109,900.00 

### 2008 $5,700.00 $104,200.00 $109,900.00 

### 2007 $5,700.00 $104,200.00 $109,900.00 

### 2006 $5,700.00 $44,200.00 $49,900.00 

### 2005 $5,700.00 $44,200.00 $49,900.00 

### 2004 $5,700.00 $44,200.00 $49,900.00 

# I Sales Information Sales Date: 

### 2003-10-31 Deed Type: WD 

# I Book: 12003 

# I Page: 1217393 Price: $76,000.00 Grantor: LYNN DANAHER ETAL Grantee: GENOVEVA MORA ETAL ValldRnvalid: Valid Exclusion Reason: 

### Land Information Acres 

### SF Units Depth Width Vacant 0.11 5000.0 1.0 125.0 40.0 No 

# I Improvement Information


### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R10... 1/28/2010

### Page 2 of2 Douglas County Account
. ati on 

# I B uil din g 1

Sq u are Footage: 1628.0 Perimeter 0.0 Un it Type :

B uilt As: 1 1/2 Story Fin

H VA C: Forced Air E xterior : Frame Aluminum Interior : D rywall Roof Cover : Composition Shingle

Roof Type : Gabl e Floorcover : Allowance
Year B uilt Year Percen t Rem o deled Rem odeled 1 916 0 0% Detail T ype Detail D escripti on A p pliance Allowance Basement Bsmnt Block 8 ft F ixture Base F ixtu res Fixt ure Bath Full Garage Detached Porch Slab Roof Ceiling Porch Slab w/Steps 

# .... 1 1/2 Story F i n Bsmn t Block 8 ft



### 994
. osq n**,,** :t; 

# I ..**" ~~o~:'~** **.**



# ... Second Floor 634 0 s.q 1t

h 11t!**~- ·** **-....** ,':".:.:. n**LICI E~LARGE**  IMAGE Pe rcen t Complete : 100.0% Quality : Average Cond ition : Average Co n do Sq u are Footage : 0.0 Roo m s : 7.0

Units : 1.0 Baths: 2.0 B ed rooms : 2
. 0 Sto r ies : 1.5 Foundat i on : B lock Sprink l er Sq u are Footage : 0
. 0 Ad j usted Year Buil t P hysical Age 19 1 6 92 U nits

1.0 994.0 1.0 1
. 0 216.0 1 76.0

25.0



### http: / /douglasne.mapping-online.com /DouglasCoNe /sta tic/accountinfo.jsp?acco untno= Rl 0
.. . 1/28/2 0 l 0

# ·- ­ Page 1 of2
">

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### • YOUR TICKET NUMBER IS 2521485. Original Call Date: Work to Begin Date: 6/16/10 6/18/10 Time: 4:52 Time: 5:15 pm pm Op: ELIZABETH18790
State: NE Address: 820 County: Street: D SOUGLAS 35TH ST Place: OMAHA Twp: 1SN Rng: 13E Sect-Qtr: 21-SW Twp: Rng: Sect-Qtr: Legal Given: C Type of Work: LEAD REMEDIATION Location of Work: LOCATE ENTIRE PROPERTY, ALL EASEMENTS AND TO THE PEDESTAL Remarks: FAX ALL CLEARS TO: (877)662-4211 : UNSURE IF CORNER LOT. Company COASTAL ENVIRONMENTAL SERVICE Contact Name: ELIZABETH Phone: (877)662-4210 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 MUD01 OMAHACOF OPPDGPRS QLNNE1C

Service Area Contact Phone Number Utility Type 

### Day: 4029340469 CXCATV COX COMMUNICATIONS, INC HEIDI 

### Alt: 4029340469 Emerg: 4029329757 Day: 8773668344 LEVEL3 LEVEL3 COMMUNICATIONS, LLC NA 

### Alt: Emerg: 8773668344 Day: 4025047823 MUDOI METROPOLITAN UTILITIES DISTRICT SANDY 

### Alt: Emerg: 4025047970 Day: 4024447197 OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RICH!fRAFFIC 

### Alt: 4024445161 Emerg: 4024445160

http://www.dhon.org/irthinternet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS
... 6/16/2010

### Page 2 of2
Day: 4067289343 OPPDGPR5 OMAHA PUBLIC POWER DISTRICT ELM LOCATING 

### Alt: 4062071494 Emerg: 8887289343 Day: 4067289343 QLNNEIC QWEST LOCAL NETWORK ELM LOCATING 

### Alt: 4062071494 Emerg: 8887289343

http://www .dhon.org/irthinternet/DHONN oticeCreation!MessageText.asp?ret=<RESULTS.
.. 6/16/2010

# e As-Built Drawing 

# el

COASTAL 

# Omaha Lead Superfund Site aMVt A ONM8NTAL c a ouP . t N C..

Owner**:§E NOVEVAMORA**  A

ddteu : 820 S 35 ST
Sample Number RYASCPXA
­ 22121 F1 RYBSCPXA
- 22121 F2 RYCSC PXA-22121 81 RYDSCPXA
-22121 82 RDZSCPXA-22121 DZ RGi!SGPX.tl**i!i!~rt** GiZ RPZSeP*A 22121 PZ Lead Concentration Om aha Lead S ite Site S ketch

Sample LAB Collected

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### 0 0 ppm 0 0

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Finn: Date: rvne: Jo:oc 4r"­ Samples Analyzed XRFUn it

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81 = 324 PPM @ 8"

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4{)130



### Leqend Concrete

# ~ Drip Zone Excavated

# ~ Quadrants Excavated Area replaced with

### ~ Area replaced with Area left bare Sod Rock/Mulch 

### Contract 

### # : EP-R7-07-05 Coastal Environmental Group Inc
.__



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---­ Address: 820 S 35 ST

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# -· ••

Consent for Access lo Property RIGHT OF ENTRY TO PREMISES COASTAl UtYIItONMI MTAl G I 0 Ll I I ltf (



### 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:

Owner's Name:

### ;}-~/2-{ Daytime Phone: 

# f33
-

# 't.:, 0

# I

Address of Property 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 AcnoNS 

## 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 of2

# • • ..

COASTAL UIYIIIOiriiKfkTiol ,.GU' INC

E 

### 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 wort< 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 

## ti9-l grant access to my properties 

## 0 I do not grant access to 

### my properties

Signature Date Signature Date


# 0 I would like to be present during any sampling that is required.

Page2 of2a_ • - .., e

COASTAL 

# •

.NVIaONM.NTAL o•ouP, INC. 

## Restoration Agreement The pl.rrpose 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 property owner and the United States Environmental Protection Agency (EPA).



### Property ID:

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 return of these items is the Owner's responsibility. Item: 

## 5' {/VL {A 

## 1

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COASTAL .NVIRONM.NTAL a•ouP. INC. 

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### Lan d scape nven to 

## •ry Item Quantity Unit Condition/Type/Species Pre-existing property area, that will be excavated, that is covered with grass. 

# f**z_J~** 

# I Quadrants

Number oftrees > 2 inch trunk diameter 

# er Each
Number of trees <= 2 inch trunk diameter 

# g Each
Number of Sprinkler Zones, Control Valves, Timers, Heads, etc. Attach a sketch of the sprinkler layout. 

# g Each

Number of and size of each garden/ flower bed area. Attach a sketch of relative sizes and locations. 

# ff Each Square Feet
Agreed upon value ofplant materials not to be replaced by contractor. Note this value will be used to issue a plant voucher to the property owner. 

# p $

Easement Area, to be excavated 

# I Each

# ~Ve" J ',VI) 

# R e

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# .

COASTAL .MVI.ONM.NTAL aaou•. 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 underlying 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 soli 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 soli 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.

## ~Please check this box 

### If you understand the Information outlined above.



# D 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.



### Biagree 

# 0 I do not 

### agree

Ownlf'SSigll8t1IIO 

### Date Date Page3of_J_

# • •

BVID# 

# 22\2-\ XRF PROPERTY SAMPLE SHEET Date 

## Dll l3 /1-o \ 0 Project Omaha Lead ARRA XRF ID# 

### 0,C1 D

### L- f_..­ Address 

### <(:) 1-0 

## S

. r;.,.S s-tSample time am/pm sample length 30 sec Shot# Reading Sample area 

## "ll\ 

# uro t 

# w BA \l'"1 1{)5**~** 

# w Depth 

# '111**w~~w** \ l• Sample area Depth Reading Shot#

Average Average
Read in

Average

Average Sample area Depth Shot# Reading

Average Reading Sample area Depth Shot#

Average

Shot# Reading_ Sample area
De th Depth
Average Average

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags AVERAGE ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 714 SOIL 2010-07-13 08:37 91.83 Final Avg of 711-713 820 

## s 35 st EA 1" N. LOPEZ confirmation none

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 711 SOIL 2010-07-13 08:36 30.62 Final 22121 820 S 35 st EA 1" N. LOPEZ confirmation none

ppm ± Error Pb 208.028 ± 20.254 Supervised By:

# • • Ther111o

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 

### 712 SOIL 2010-07-13 08:37 30.61 Final 22121 820 S 35 st EA 

### 1" N. LOPEZ confirmation none

ppm ± Error Pb 205.304 ± 20.049 Supervised By:

_________________

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 713 SOIL 2010-07-13 08:37 30.60 Final 22121 820 

## s 35 st EA 

### 1" N. LOPEZ confirmation none

ppm ± Error Pb 208.063 ± 20.093 Supervised By:

_________________

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags AVERAGE ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE

Pb Supervised By: 722 SOIL 2010-07-13 08:43 91.61 Final Avg of 719-721 820 

## s 35 st F2 8" N. LOPEZ confirmation none

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 719 SOIL 2010-07-13 08:41 30.50 Final 22121 820 S 35 st F2 8" N. LOPEZ confirmation none

ppm ± Error Pb 82.023 ± 14.866 Supervised By:

# • • Thertno

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 720 SOIL 2010-07-13 08:42 30.59 Final 22121 820 S 35 st F2 8" N. LOPEZ confirmation none

ppm ± Error 

### Pb 80.859 ± 14.507 Supervised By:

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 

### 721 SOIL 2010-07-13 08:43 30.52 Final 22121 820 S 35 st F2 8" N. LOPEZ confirmation none

ppm ± Error Pb 85.286 ± 15.045 Supervised By:

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags AVERAGE ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE

Pb Supervised By: 726 SOIL 2010-07-13 08:45 91.63 Final Avg of 723-725 820 S 35 st B1 8" N. LOPEZ confirmation none

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 723 SOIL 2010-07-13 08:44 30.64 Final 22121 820 S 35 st B1 8" N. LOPEZ confirmation none

ppm ± Error Pb 297.957 ± 24.347 Supervised By:

# • • Ther111o

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

### Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 724 SOIL 2010-07-13 08:45 30.66 Final 22121 820 S 35 st B1 8" N. LOPEZ confirmation none

ppm :I: Error Pb 353.525 :I: 26.260 Supervised By:

_________________

# • • Thermo

SCIENTIFIC Thermo Fisher Scientific 900 Middlesex Turnpike Billerica, MA 01821 

## Certificate of Verification XL3t-39022 Reading No Mode Time Duration Sequence Flags BVID ADDRESS QUADRANT DEPHT XRFTECH MISC NOTE 

### 725 SOIL 2010-07-13 08:45 30.33 Final 22121 820 

## s 35 st B1 8" N. LOPEZ confirmation none

ppm Error Pb 320.713 28.652 Supervised By:

# •
Omaha Lead Site-Fixed Price EP-R7-07-05 Coastal Environmental Group Inc. www.coastalhazmat.com COASTAL IIIYIIOIIMIIITAL GIOUP, HIC. 

# EXECUTIVE SUMMARY: · BVID #22121-(820 S 35 ST) 

# ·[!) No Issues or Concerns 

# D Issues/Concerns
Detail Exolanation: -DAN GARVEY WALKED THE PROPERTY ON 8/26/10.--



### ---

-- 

### ----- --



# ----------------------------------------------

-------

--- - ..:r--· 

# SEPA 

# • •

EPA Property Close Out Form**~,**

# ~:~:7rr:!; 2..21 

# L I .

# ~~:.!~:!';0~£f~q\['fr;f**N\()~** Quads Exca-v-at.,-.t-d·-.

-------- Contractor Group_·_·

_______ Excantioa Geaeral Yes No 1. If neccssll)',.were the correct quadrant(s) excavated and restored? ./ 2. If necessary, were the comet areas of 

### drip zone excavated and restored? 

### / Yes No Gradlat Sod aad Veptattoa I. Does the arading III'OUJid lhe perimeter ofthe house in excavated areas generally slope away from the house? 

### ./ 2. Has sod boen laid in all areas that were excavated? 

### ,/

·­ 1-·- 3. 

### Does the 

### sod appear to be 

### generally healthy and growing? (Only evaluate if inspected at a 30 ,/ day time period) f-

# ,. 

# r· An: sodded 

# areas generally fum and evenly graded'? 5. Are thejoints between the sod strips generally tight7 (Only evaluate if inspected at a 30 day 

## ,/ ' 

### time period) 

# I 

# r 6. Was the property graded such that water will not pool on the prnperty? I 

## ·-

# ~- 

# --1 7. Was damage to landscaping 

### or plant materials avoided? 

### ,/ !
___.,___ 

# r
- -·

Gates, feoc:a aad Retalalaa Walls \'es No 

# I I. Do gates 

### open 

### and close

## ~ly? (lf applicable)
1--­

## ~--2_. __ w_e_re_al_l_ga_re_s_o_r_ren_. _c_es_tak_e_n_d_o_wn_d_ur_i_n_a_re_s_ro_ra_t_io_n_ac_t_iv_i_1iP_s_r_e_in_sta_lle_d_?_<_l_f a_P_P_Ii_ca_b_lf_) j 3, Was damage to gates or**fen~s** avoided? 

### (lrapplic:able) 

# I**~** 4. Was

## ~ge to retaining walls avoided? (Jhpplicable)

_.

# ___ Yes No

-·­ I. Was damage 

### to the siding or trim avoided? .......­ 2. Was damage to the foundation avoided? ,/ 

## ___, ·-·· ,/ 3. · Was damage to windows**avoided~** 

# 1 i 4 Was damage to windows or 

### door screens avoided'? """--,;"" y/ 5. Was damage 

### to downspouts or downspout extensions avoided?

---·---- .. Yes No 

### t----'-·_w_as_d_•_ma&e

__ ,_o_dri_·_v_ewa_y_s_urfi a_ces_a_vo_i_de_d_?

# ~----_-_-_-_- __ ..­ 

### __ __________ __ -

# ~--- .. _--._-·.·. 

# I**~.1.1,** 2. Wao; damage to walkway surfaces avoided?

. 

# --------------------­

# • •

------------- , Own en; 

## comments:



# I

I --- ---·-­ 

### r--Jnl!ipection notes:



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

____

# B_C>I"_~....,.r------ Date:

__8--'-/

# z.#JI'o

___

# • •

Property Completion Agreement
rtm 

### agreement documents the complcllon ot remechal activtttes performed on my property My stgnature wtll destgnate that I 

### am sat•sfied wtth the restoration 

### of my properly. and that no ttems are 111 

### quesltons. now. or at any tune mrhe 

### future. exceptlhose.ilems 

### listed below, if

### any

Restoration Items in Question:



### Item: Item: Item: Item: Item: Item:
Additional Comments:

I agree ,.cuoralion**i~** completed, t'llccpr as nored · 

# 0 I do not AJlrec rc$toratlon**i~** completed

Datf

# •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• Property Owner Assessment of Performance Form American Recovery and Reinvestment Act (ARRA) Omaha Lead Superfund Site 

## 2009/2010 Remediation Contractor: Coastal Environmental Group

- EP-R7-09-06 Property Identifier Number: 

### Z. 

## 'Z../2../ Property Address: 

# £-tLO
_**__;....;;.s~. -~:::-:::5:---;r-t-.-**  

### Property Owner's Name: 

## { 1\.e.llt)Vt.no
.. 

# fYk)ret...
. Instructions to the Property Owner: This form serves to record the Property Owner's assessment ofperformance (Incentive 1



### - Quality Assurance Surveillance Plan) involving the listed remediation contractor, as applicable to the Omaha Lead Site. This form documents the timeliness ofpunch list resolution, business relations, complaint resolution and the overall quality ofwork. Ifneed 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 ofperformance with the contractor's work by checking a numerical rating on the table below using the numerical definitions from the rating scale below, then sign & 

### date the form. 9-10 7-8**~** 

### 5-6 3-4 1-2 

### "excellent" ''very good" "acceptable" ''poor" ''very poor" Property Owner's Assessment of Performance Regarding the Contractor's Work 

# cP

. 

# 7 / 

### 5 4 

### 8 3 

### 7 

### 2 6 1 

### Property Owner Additional Comments from (optional; continue on back page if needed)

Property Owner Signature:

# --->..::Cfil/J~/6!~.- _________

### .Date: 

# e;?jr/Ju -+.·._;:,

# •
Water Bill Settlement

Property ID 22121 Property Address 820 S 35 ST Tenant MANUEL M ANDREADE-MORA



### I have received from the contractor, Coastal Environmental Group Inc. (Coastal), the sum of$ 48.58 for water usage required to maintain the sod.

Cheek Number 

### 2074 Value of Check 

### $48.58 Made Out To 

### MANUEL M ANDREADE-MORA
Description of Settlement To reimburse tenant for estimated water charges on their MUD monthly invoices. My signature below Is acknowledgement of the receipt 

### of the sum listed above, which I further acknowledge to be fair compensation and full payment for the above, and release Coastal Environmental Group Inc. from further obligations or liability.

Date Date

### P:·.'c-.=~-~--.:,< ·--=--=-- ;......·

### ~~---**·-·...!·;_;__,~_/;~;.~"'-'--.d.=....~-----.** ... 

## 2074 \ COASTAL ENVIRONMENTAL GROUP INC. ' 2411 MARTHASTREET OMAHA, NE 68105

PAYlO THE 

# MClY\W..\ . M**BrOYe~-** 

# MCYCA. ORDER OF
- · 

# stl**_lE::EEAAj~~-~~~ ~()J'l~O~~nJO'b~------oouARs**  27-511040 003 6247372904