TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: \0 b l t Date: V ^ \\ o 

Address: ^\\ \ ^MM^ ^ ^ \ 

Remediation Contractor: Coastal Environmental Group_ Year; _200fl 

SOIL REMEDIATION 

PROPERTY nLE FOLDER DOCUMENTS 

0 Video of property (DVD) 

E Executive Summary 

UJ EPA-provided property sketch 

IZ Signed Access Agreement for subject property 

•Q^ Signed Access Agreement(s) for adjacent property 

a/ 

Restoration Agreement 

Settlement dociunents (i.e., for damage or to replace plants, etc.) 

- B­ Confinnation data 

G Photographs V W ^ Y i^(/^^'SW^ ^ f^ M^^'fuy ^ 

/ As-built sketch 

Satisfactory restoration signed by Property Owner 

W Property close-out check list signed by EPA 

" n " Description of areas not meeting ROD cleanup criteria 

w Utility clearances 

[Y Property information from Douglas County Assessor's Office 

~T5at5 

30054471 

_J 

Superfund 
p 

Property Access Checklist 

Property ID: \<^f^-t( „ 

D WORK STARTED ON:. / / 

D WORKCOMPELTED 0N:_ / / Property Address: ^•^[ \ '$^V^U\r a 

Q^"*' Renter ^ Vl\\^tar<> \Lj^C\csrci(\ 

Address: 

Phone: 

Fax: 

Cell/Pager: 

Phone: 0\^ . IMM ^ Additioaal Information: 

Fax: 

Cell/Pagen 

D Notification Letter 

Sent: / . By: 

Acceu Agreement 

Slgned:^/R/C g By: 

^ 

[ ^ Restoration Agreement Signed:11/B./ ^ By: 

O Topsoil Sampling (If applicable) ./

 / By: 

Q Disposal Samplhig (if applicable) / /. By: 

O Garden Sampling (if applicable) 

By: 

« Utilitv Clearance Called:^/Z L 02 . By: ^mr)"^ 

O Video/Photos (Before) On: / / By: 

D Video/Pbotos (Dnring) On: / / By: 

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

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

f Property Completion Agreemait Signed By: : ^/^//9 2 

Final Report Issued: / / By: 

Air Monitorine (as applicable 

D Community DCrcw On: / / By: 

Results: 

D Comnmnity QCreir On: / / By: 

Resuhs: 

DConunnnity QCrcw On: / / By: 

Results: 

Omaha Lead SKe 
u 

Property ID #

Property 

Address: 

Initial Contact:

Second Contact:

Final Contact:

Final Action: 

W|\\\vrim

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

CONTACT FORM 

 \%/o1Co 

M?.\\ %W^f\e 

^ 

 Date: Time; Action: 

 Date; Time: Action: 

 Date: Time: Action: 

Transmit to EPA D Other Action: D 

 qS^-\Ml4X 
• • 

^v 

Property Access Checklist 

Property ID: )ftfa-?fa n WORK STARTED ON: / / 

Property Address: q^\ .svvk-i/)^ D WORKCOMPELTED ON: / / 

Owner: VilWiam Renter: KrA-cW^yirv .^r 

Address: Phone: 

^3/1 Shirlcx^ Fax: 

Cell/Pager: 

Phone:/^^Q3-) gy ^ /jy^y^ Additional Information: 

Fax: 

Cell/Pager: 

n Notification Letter Sent: / / By: 

^ Access Agreement Signed:^/11/Qq By:pc 

{A Restoration Agreement Signed: gL/l3_/<3i By= ^C . 

D Topsoil Sampling (if appUcable) / / By: 

D Disposal Sampling (if applicable) / / By: 

Q Garden Sampling (if applicable) / / By: 

n UtiUty Clearance CaUed: / / By: 

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

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

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

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

n Property Completion Agreement Siened: / / By: 

D Final Report Issued: / / By: 

Air Monitoring (as appUcable) 

IZI Community • Crew On: / / By: 1 

Results: 

n Community Q Crew On: / / 1 

Results: 

IZJ Community O Crew On: / / By: 

Results: 

Omaha Lead Site 
t)ouglas Coimty Account U^riji^on u Page 1 of2 

Douglas County, Nebraska Property Record - R2332340000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - Vle W OH Ma p Information is valid as of 2009-9-15 Treasurer's Tax Report 

New Feature ^ -> -> Auto Sales Search 

Owner 

KOTCHIAN JR ET WILLIAM F 

4311 SHIRLEY ST 

OMAHA NE 68105-0000 

Property Informatio n 

Key Number: 3234 OOOO 23 

Account Type: Residential 

Parcel Number: 2332340000 

Parcel Address: 4311 SHIRLEY ST 

OMAHA NE 68105-0000 

Legal Description: TWINRIDGE ADD LOT 3 BLOCK 14 50 X 103 

Value Informatio n 

Land Improvement Total 

2009 $5,700.00 $186,500.00 $192,200.00 

2008 $5,700.00 $162,900.00 $168,600.00 

2007 $5,700.00 $175,500.00 $181,200.00 

2006 $5,700.00 $175,500.00 $181,200.00 

2005 $5,700.00 $175,500.00 $181,200.00 

2004 $5,700.00 $120,300.00 $126,000.00 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.11 5150.0 1.0 103.0 50.0 No 

Improvemen t Informatio n 

Building 1 

No 

Image 

Available 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accotmtno=R23... 9/17/2009 
Douglas County Account I^^a^o n Page 2 of2 

# • 

UmeWoiJtwl:! ' t a 

If r c 

PC 

Fuiinnni 

IJliOrf 

t i 

ar 

jw«t»rt 

Kill* 

Tt 

n«i t Blnck S • - 1114 0 id :sil»> Rt^^ Ctil iff V. 1 

.. '' m -n,5"" IIC 

1 CUCK TO ENUVRGE IMAGE | 

Square Footage: 1797.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Fair 

Built As: 1 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Masonry Common Brick Units: 1.0 

Interior: Drywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

yearBu//f year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1938 0 0% 0 72 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Appliance Fireplace Masonry 1.0 

Basement Bsmnt Block 8 ft 1214.0 

Basement Fair Finish 324.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 2.0 

Garage Attached 180.0 

Porch Slab Roof Ceil 32.0 

Porch Slab Roof Ceil 60.0 

Porch Slab w/Steps 64.0 

Porch Wood Deck 250.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R23... 9/17/2009 
n Page 1 of2 

# • 

"> 

Create Another Ticket [ Back to Irth Internet Send Email 

• YOUR TICKET NUMBER IS 236919L 

Original Call Date: 9/21/09 Time: 5:32 pm Op: ELIZABETH18790 

Work to Begin Date: 9/23/09 Time: 6:00 pm 

State: NE County: DOUGLAS Place: OMAHA 

Address: 4311 Street: SHIRLEY ST 

Twp: 15N Rng: 13E Sect-Qtr: 29-NW 

Twp: Rng: Sect-Qtr: 

Legal Given: C 


Type of Work: LEAD REMEDIATION 


Location of Work: INCLUDE ALL EASEMENTS LOCATE ENTIRE PROPERTY 


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


: UNSURE OF CORNER LOT 


Company : COASTAL ENVIRONMENTAL SERVICE 


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


Work Being Done For: COASTAL 


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


Involves Tunneling or Horizontal Boring : N Explosives: N 


ALTS72 BSHPCLKS CXCATV MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Number UtUity Type 

Day: 4067289343 

ALT872 WINDSTREAM COMMUNICATION NA Alt: 4062071494 

Emerg: 8887289343 


Day: 4025523460 

BSHPCLKS NEBRASKA HEALTH SYSTEM NA Alt: 4025523347 

Emerg: 4025595111 

Day: 4029340469 


CXCATV COX COMMUNICATIONS, INC HEIDI Alt: 4029340469 

Emerg: 4029329757 


Day: 4025047823 

MUD02 METROPOLITAN UTILITIES DISTRICT SANDY Alt: 

Emerg: 4025047970 


http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/21/2009 
• • • • 

Page 2 of2 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RON 

0PPDGPR6 OMAHA PUBLIC POWER DISTRICT NA 

QLNNEIF QWEST LOCAL NETWORK NA 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/21/2009 
As-Built Drawing 

COASTA L Omaha Lead Superfiind Site 

18676 

Omah a Lea d Site Exterior Paint North Arrow Owner Name: WILLIAM F KOTCHIAN JR ET 

Site Sketc h • Good Address : 4311 SHIRLEY ST • Ppor Phone : H: 402-932-1442 W: [2^o t paint 

Sample Number Samples Collectedi , LAB Firm: frOA Moe.-(iiQ-rfl/Jovkii 

RYASCPXA-18676 Fl Date: rX ^ IZ I j ^ 4 

RYBSCPXA-18676 F2 Time: 12-2 ^ 

RYCSCPXA-18676 B1 

Samples Analyzed RYDSCPXA-18676 B2 3 ^ 

RDZSCPXA-18676 DZ XRF Unit: ^ \ \ Book^VP \ 

Lab RYDSCPLA-18676 ~l 3,- Date: 

Result 309ppm Time: 

Staff: 

D 

Number of Samples = cjp- eg- : ^ 

OLS#: 18676 

3ate Excavated:9/30/09 

ENTERED; 

Date JSEPA Sioned Off: 10/19/09 J U N 2 R 'iuu* \rea Sodden: 603 so ft 

J ! ^ 

^tnxr 

Retaining Wall 

umana Leaa iite 46130 

Legen d 

Concret e k/>ol Dri p Zone Excavate d IQOOI Quadrants Excavate d 

Area replace d wit h Area replace d wit h 

Are a lef t bar e Sod ' ' Rock/Mulch 

Contrac t #: EP-R7-07-05 Coast^al Environment:al Group Inc . 
18676 

46130 
I t ^[I'h 

18676 

Omaha Lead Site Exterior Paint North Arrow Owner Name: WILLIAM F KOTCHIAN JR ET 

Site Sketch • Good 

Address: 4311 SHIRLEY ST • Ppor 

Phone: H: 402-932-1442 W: I [2^o t paint 

Sample Number 

RYASCPXA-18676 

RYBSCPXA-18676 

RYCSCPXA-18676 

RYDSCPXA-18676 

RDZSCPXA-18676 

Fl 

F2 

B1 

B2 

DZ 

Lead 

Concentration 

ppm 

i \ " ^ ppm 

ppm 

ppm 

_t4-2x2>ppm 

ppm 

Sample Samples Collected J , LAB Collected Firm: f^ ^ KJQt^-rilCutJ/JCni^i \S 

D Date: bCp/2( ( /04 

D Time: \2'2 A 

Samples Analyzed 

D XRF Unit; T N I \ Book: VP \ 

D 

n D 

46130 
18676 

Omaha Lead Stte Exteitor Paint NoHh Anow Ovvner Name: WILLIAM F KOTCHIAN JR ET Stte Sketch D Good Address: 4311 SHIRLEY ST 

gppo r Phone: H: 402-932-1442 w. GS^Iot paint 

Sample Number Lead 

Conce tnceritrati n o 

Sample 

Collectml LAB Samples Collected 

Firm: f<OA Klofc-tUcurt/JgAH; tS 

RYASCPXA-18676

RYBSCPXA-18676

 F1 

 F2 

ppm 

ppm 

D 

D Date:rXP/^(|r? 4 

Time: / 7. ' 2.A 

RYCSCPXA-18676

RYDSCPXA-18676

 Bl 

 B2 _

ppm 

. PP"TM 

sr 

Samples Analyzed 

RDZSCPXA-18676 DZ 

Lab RYDSCPLA-18876 

_J^_2L2>ppm 

ppm n 

D 

D 

XRF Unit: ^ \ \ BookiVP \ 

Result 309 ppm ppm D D 

CP-gZ- Number of Samples = |cir' 4 | I 

ENTEBED 

JUN 2 8 iWh 

(q ^ 

#•4 Sf. \ ) 

a. 

5 

. \ ^ x ^ IP 

^ 

f ^ : 

V * 

^S3 \ 2i-: \ ot- potZC^rt : 

s ^ ^v-(^"-) ^ 

Oinaha Lead Site 46130 
? 

W COASTA l IHVtItOMKIKT& l 

CROUP . IN C 

Consent for Access To Property 

RIGHT OF ENTRY TO PREMISES 

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

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

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

following described premises: 

Owner's Name: Daytime Phone: 

VCo-VieJrv'ta n A r <M\\liam 

Address of Property 

covered by this 

Agreement: 

PURPOSE OF RESPONSE AcTivrriEs 

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 wilt 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 perfomied, the Grantor will have an 

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

before it begins. Once the work is finished, the Grantor wili be asked to review the wod^ 

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

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

has been remediated. 

ENVIRONMENTAL RESPONSE ACTIONS 

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

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

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

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

agrees to: 

Page 1 of 2 
^^':r'>» 

COASTA L trfrmoNHiKTAL '*V.P«o.v/ 

CROU P I *( 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; 

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

necessary subsequent to an initial watering period by EPA; 

e 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. 

e 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 

k1 grant access to my properties G I do not grant access to my properties 

Tddu A^lu ^ 9'//-^}? 

SIgnati Date Signature Date 

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

Page 2 of 2 
«-- * 

:c:» 

COASTA L 

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 ofthe property owner and the United States Environmental 

Protection Agency (EPA). 

Property ID: V^dQ , 

Proper^ Addi^^^2iV\_;^l^ir \ 

Owaer: vsfsWx^iunn XUMUoyj^ ^ r 

Phone: qB^^tl4M2, 

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 lemoval. storage, disposal, and/or return of these items is the Owner's responsibiiity. 

Kem: 

Kvvu btv^KXU <p\ojrv^ k> <Qe^ ^^£x>ted 

Item: 

Item: 

Item: 

Items to be Removed by the pohtractor During Remediation and Wot Replaced^ 

Item: 

/ W SimM ^\ojnAS VeP4- Vy^ ^ 

Item: tf 

Item: 

Item: 

Pagel Ofi 
i«S& COASTA L 

C k' «• I) V IH I 

Kerns to Be Removed By Contractor During Remediation and Repjaced 

i Item: 

Msm: 

-^n ^ Ft QJM oe- Item: 

Item: 

u . 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

tnmk diameter 

Number of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Aii.nth n ski'icli ol llie 

i.pr'r-'kloi iHV'.nii 

Number of and size of 

each garden/ flower bed 

area. 

Aimth :i sIvL'lcli 1)1 ri.-!:itivi.' 

<\-/x-% nnd loc;lIilVl^ 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Voir l!-.i' \HIIIC V\(II ni 

i;sri..' 10 li". Ut .1 plHli; 

>OIK;R'.- t(, (he i;-0|)crl> 

on ner. 

Easement Area, to be 

excavated 

Quantity 

\ 

^ ^ \ 

vlo 

\ 

\ 

Landscape Inventory 

Unit Condition/Type/Species 

Quadrants 

Each 

Each 

Each 

Eacfa 

Square Feet 

S 

^^^^^«;5 P,e ^ v-vs Eacfa 

Page 2 ^JL 
• '""S i 

COASTA L 

O' h O U " • • « C 

f Additional Comments / Instructions: 

Qji M X--'?> dojix?) \ n cadLVOukOo^ 

L 

j ^ Check the tx)X 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. 

Q I do not agree 

Date Contractor'ss Sienatnr Signatur ee » Date

Page 3 of X 
BVID# f^la'^ C 

XRF PROPERTY SAMPLE SHEET 


Date 

Project 

'^\MO'A 

Omatia lead FP 2nd year option 

Address 

Sample time 

^4^\ \ 'SWtri^ ^ < ^ 

^ am/pm 

XRFID # 7.n^(Ji»><\ sample length 30 sec 

Shot# Reading \ifT\k Sample area 

£±. Shot# 

JMItMM . 

Readinc s^: Sample area 

EL 

lH2y^ i> 

Depth IktO 

mi­ 331 3ft > 

Depth 

Average \2f ^ J-j ^ Average 3(:M' 

Shot# Reading Sample area Shol# Reading Sample area 

MiUt 

W 3 ^ ^ 

2o

^^ 

?^

 ^ ^ 

^ 

 ^7 % 0 

J ^ 

Depth 

75 Depth 

Average ^\ ^ 9^ Average 

Shot # Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

RETEST AREAS 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

lab sample # Lab result Sample area XRF Avg. 

Signatur^OCfiMM . 

Print YjAf^^ton Cacpi^H 
/\^^ ^t Omah a I Lea .. d Site—Fixed Price EP-R7-07-0 . . . .5_ 

Coastal Environmental Group Inc. vl \m^Ui^- ' ~ ~ '' ^^S!^o^ 

V • J? www.coastalhazmat.com 

%PHOt*^ COASTA CIOUP , IH C L INVItOMMENTAl 

EXECUTIVE SUMMARY: 

BVID #18676-(4311 SHIRLEY ST) 

No Issues or Concerns Q Issues/Concerns 

Detail Explanation: 

-COASTAL TO REIMBURSE $200.00 FOR PLANTS REMOVED (COMPLETED 1/30/10) 
4

^ EPA 

EPA Property Close Out Form 

Property #; \v( p llg ^, Datc/Tlmc: ^ 

Quads Excavated: r \ ^ P ^ Contractor Group Co^'fYf l 

Yes No ExcavatioD GcBcral 

I. If necessaiy, were the correct quadrant(s) excavated and restored? 

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

Grading Sod and VcgetatJon 

I. Does the grading around the perimeter ofthe house in excavated areas generally slope away ^ 

from the house? ,^-. I P' 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 1?^ day time period) 

4. Ai« sodded areas generally fum and evenly graded? 

5. /Vre the joints between the sod strips generally tight? (Only evaluate if inspected at a 30 day 

time period) ^ 

6, Was the property graded such that water will not pool on the property*? T:^^ 

7. Was danuge to landscaping or plant materials avoided? 

Gates, Fences aad Rctafaiing Walls Ves No 

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

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

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

4. Was damage to retaining walls avoided? (Ifapplicable) 6 ^ ' 

FouDdatton, Sidiag and Gutlers Yes No 

I. Was damage lo the siding or trim avoided? i^ ' 

2. Was damage to the foundation avoided? ^ 

3. Was damage to windows avoided? L ^ 

 Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspoul extensions avoided? 

Sidewalks and Drivcwayi (Concrete) Yes No 

1. Was damage to driveway surfaces avoided? ^ ' 

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

Inspection notes: 

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

EPA Representative 
Property Completion Agreement 

This agreement documenls the completion ol remedial activities perloimect on my properly My signature 

will designate lhat I am satisfied wilh the restoradon of my propeily, and Ihal no items are in questions, 

now, or al any lime in the future, except ihose ilems listed below, ifany 

Property ID: [gl^ll , 

Proper ty Address: i^'Xi \ 4k,r IfM .S-^ 

Owner ' ti . IVi rt-^r^ V^ a^c^rCK. ^ 

Phone: 

Ho3^-^33- IMV5 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

^+'M n^eM^20C) lo ^ PlcJ-^ r^/^^<sc/->^/> 

1 )i(>rcc I Ktoraiion \% completed, except as noieri 

[ I I Ho nol «(;rec rcslorfltion is completed 

in^i Ownp/' s Signafiirr Conti artor's Signature Dale 
Property Damage Settlement 

Property ID 18676 

Property Address 4311 Shirley St 

Owner WUUaniKotchran 

Phone (402) 93^..144 1 2 

I have received from the contractor, Coastal Enviromnental CJroup Inc. (Coastal), the sum of $200.00 to 

compensate for plants and river rock that were removed during the removal of lead impacted soil from 

the property. 

Compensation type Check 1880 

Value of Check $200.00 

Check to the order of WilUam Kotchran 

DesCTiption of Damaae 

While excavating 4311 Shirley St (BVID 18676) Coastal damaged some plants beyond salvage. Property 

owner received a check for the amount of $ 200.00 dollars for the replacement ofthe plants. 

My signature below acknowledges the replacement of my plants; further, I acknowledge that this 

work was completed satisfectory and within my and release Coastal Environmental Group, Inc. from 

further obligations or liability related to this property. 

1880 COASTAL ENVIRONMENTAL GROUP INC. 27-5/1040003 2411 MARTHA STREET 6247372904 OMAHA, NE 68105 1^110 

DATE 

'c^^T^^tjMiMd^^^^trm. smf' twarirf P«Mai«* -jiA)o hiJAnaMd(ind'yj<^ . DOLLARS Q OalBllt an

Welh FwBoBank,ttA. 

Nabrala 

wtttifii flOuOOin 

... ^VID\<^lt)7lo HM^i^lO j ^^<u3tw Cfe^-^^ 

luouoooosai: E.21.737E^OU"' oiaao 

^fifyue.^ y^SD-Jid/d fOe^y^4iy^ 0^3 D jiO 

Owner's Sjenaturiree Date Contractor's Signature Date 

Page 1 of 1