TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: i'lnv Date: V Llik. Address: ffl'v v^ h<^ m

Remediation Conlractor: Coastal Environmental Group Year: 2010ARRA 

SOIL REMEDIATION 

PROPERTY FJLE FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

/ EPA-provided property sketch 

7 Signed Access Agreement for subject property 

Signed Access Agreement(s) for adjacenl property 

Restoration Agreement 

Seltlemenl documents (i.e., for damage or to replace plants, etc.) 

Confirmation data 

/ Photographs ife p^^tVTu ^ 

/ As-buill sketch 

7 Satisfactory restoration signed by Property Owner 

7 Property close-out check list signed by EPA 

Description ofareas not meeting ROD cleanup criteria 

y Utility clearances 

7 Property i«farmation from Douglas County Assessor's Office 

D 

Superfund 
Property Access Checklist 

Pro()crty ID: n WORK STARTED ON: _/ /_ '3L'\'».'3t"a^ 

Property Address: - » n WORK COMPELTED ON: / / . :bE\,TMJbkSii:K__J—, -

Owner: T> .. , *> 

^ Address: 

Phone: ^"•^ , "^H^o. JiHW., 

Fits: 

Cell/Pager: 

i^-,^.5i*EL 

O Notification Letter 

15 Access Agreement 

[^ Restoration Agreement 

D Topsoil Sampling (if applicable) 

O Disposal Sampling (if applicabie) 

0 Ctirdcn Sanipliag (if applicable) 

3 Utility Clearance 

P Video/Photos (Before) 

0 Video/Photos (During) 

n Video/Photos (After) 

D Video/Photos (30-Day) 

• Property Completion Agreement 

n FinaJ Report 

n Community Q Crew On:

Results: 

D Community' D Crew } On:

Results: 

Renter: 

Phone: 

Fnx: 

Cell/Pagei 

Additional Information: 

X 

Sent: / / 

Signed: Vo / 1 V vo 

Signed: \i> /•^.^/^ o 

/ / 

/ / 

/ / 

Called: N.V / > /v^ 

On: \ o /3L>. / \ o 

On: / / 

On: / / 

On: / / 

Siened: / / 

Issued: / / 

By: 

By:

By:

By: 

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Omaha Lead Site 
Douglas County Account In^-nation Page 1 of2 

Dougias County, Nebraska Property Record - R2206870000 

Print Reoort 

View Interactive GIS Map Information is valid as of 2010-8-30 Treasurer's Tax Report 

New Feature -fr r^ ^ Subdivision Sales Search 

Owner 

PERRY RUTHIE L 

2820 N 19 AVE 

OMAHA NE 68110-0000 

Property Informatio n 

Key Numtier: 0687 OOOO 22 

Account Type: Residential 

Parcel Numtier: 2206870000 

Parcel Address: 2813N19AV 

OMAHA NE 68110-0000 

Legal Description: SHERWOODS SUB DIV LOT 4 BLOCK 1 60 X 81 

Value Informatio n 

Land /mprovemenf Total 

2010 $500.00 $0.00 $500.00 

2009 $500.00 $0.00 $500.00 

2008 $500.00 $0.00 $500.00 

2007 $500.00 $0.00 $500.00 

2006 $500.00 $0.00 $500.00 

2005 $500.00 $0.00 $500.00 

Land Informatio n 

Acres SF Units Depth Widtii Vacant 

0.11 4860.0 0.0 81.0 60.0 Yes 

http://douglasne.mapping-online.com/DouglasCoNe/static/accotjntinfo.jsp?accountno=R22... 9/15/2010 
Douglas Coimty Account In^' "nation Page 2 of2 

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K Lake St Lake St Map data ®CQ10'Googtej 

The above map is powered by Google, and is intended to provide a general idea of a property's location. If 

you require a more exact property location, you may use the Interactive GIS Maps that are maintained by our 

office. 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R22... 9/15/2010 
Page 1 of 1 

% 

Create Another Ticket ] [ Back to Irth Intemet [ Send Email ] 

• YOUR TICKET NUMBER IS 2632024. 

Original Call Date: 11/02/10 Time: 9:38 am Op: ELIZABETH18790 


Work to Begin Date: 11/04/10 Time: 10:15 am 


State: NE Co\mty: DOUGLAS Place: OMAHA 


Address: 2813 Street: N 19TH AVE 


Twp: 15N Rng: 13E Sect-Qtr: 10-NW-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 MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number Utility Type 

Day: 4029340469 

CXCATV COX COMMUNICATIONS, INC HEIDI Ah: 4029340469 

Emerg: 4029329757 

Day: 4025047823 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY Ah: 

Emerg: 4025047970 

Day: 4024447197 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RICH/TRAFFIC Alt: 4024445161 

Emerg: 4024445160 

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/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/2/2010 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

OLS#: 29822 

Date Excavated: 11/10/2010 

Date USEPA Sianed Off: 12/9/2010 

Area Sodden: 1220 sa ft 

2?g22 

Name: Omaha Lead Stte Date: (^i/-3^/tf3 North Amnv 

Address: \lg<.^ ' N j^**^" ^ Site Sketch Time: \c J.O 

Phone: ^V(^ ­

.F*0/> HT / 

TeaffT XRF Code /<937 .go»i<:»/2.<} 

Sample Number Lead Concentration Confiimation Sample 

gyAsc/>xA-zqgz2- FlYes n No 5 ^ # # PP"! gVRSCp>tA-2.q«^ 2 rxyes • No E^ gscs<iPxA-a«?^a2 ^ ' Yes • No g 

"t^^" ^ ppm ecYes O No C3 

Z ppm Ye;, D No D 

Z ppm V65 Q N6 D 

•" ppm Ytfe tn —No a 

:] ! 1 ^ jA V I V ^ = 227 PPM @ 1" 

^"-y-v /y 

Omaha Lead Site 46130 

Legend 

Concret^e Drip Zone Excavated Quadrants Excavate d 

Area replaced with | Area replaced with 


Are a lef t bar e Sod ' Rock/Mulch 


Contrac t #: EP-R7-07-05 Coasta l Environmental Group Inc 
4^ VV/ H 

Z<^S2AZ A ^ 

Name: 

Mfi Omaha Lead Site Date: (c/^^^/c j Nortti Arrow

Address: i Site SIcetch Time: lo ' ^ 

Phone; "^y^ - "^V£i

^EM 

.-f^bA H:r/ 

TearfT XRF Code /tf3 7 ^oo*: •• /2.<^ 

Sample Number 

Lead Concentration Confirmation Sample 

RWASCfi^A-Z*]»2Z -

^<^S ppm Five s ° No Y 

ppm FZ-Yes ° No la . 

ppm e i Yes • No ^ 

LSS. 

ppm ftiYes D No ra 

ppm —YBb D 

ppm V6§ • Nfi l-J 

ppm Yes • —N o • 

m 13 ^^s^i 

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+ ^ '")jl^ U-;^-jji'- - j l ^" f^<jf ^ ^l^fT " 

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)maha Lead Site 

46130 
% % Z^S2.2, 

Name: ^Y^fr/ , Omaha Lead Site Date: 6/W^ 3 North AiTow \ 

Address: JV?/,^ >N h ^ H Site SIcetch Time: l o 2-£> 

Phone: '^%-IV W -

St^t/fiLA t>*tfci g-^l-os" TTmexpn) 

ieatfrM^u^/T^4y5*^r^brf^4^y\Dt 2'7^^ 1 XRF Code /<937 Booli.: /a<) 

Sample Number Lead Concentration Confirmation Sample 

RVASCfiyCA'Z'i»2Z. FlYes ° No 3^ gVRSgp>c^-2•qg^. 2 32 ^ ppm 

FZ-Yes a No CQ, gscsdP>cA-a«?^Z2 ^WQ ppm 

B l Yes C] No 13^ 

^ ppm eeYes C] No [^ 

1:1 ppm —^I'Hb Q NU D 

— ppm V65 Q Nfl Q 

Z ppm Ytfe • No • 

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323" 

ri F2i 

21^5 

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Omaha Lead Site 46130 

r^ 
Z^S22. 

Name: 

M Oinaha Lead Stte Date: 43 NorthAiTow —i

Address: Sito Sketch Time: g-jg ^ 

Phone: TAIT'^ 

JeaiiirFTSlti/'SAiJ\/^h.oLi 3VID#.22 ^ ^ XRF Code /<?3 7 BeokL t t2.*i 

Sample Number 

Lead Concentration Confinmation Sample 

F»Yes ° No ^ gVRSgp>tA-2.«?gg.2 F^Yes !=• No 5, g^g.sZ>jcA"g«>gZ2 

-jfg^ PP^ ja ^ ppm 6/Yes a No TM eVP^6/i>)CA>2.*!822 az.Yes CD No Ca 

r: ppm —-VHT " NO P -

V« Q ITO-& r ppm 

Vm> • —No • Z ppm 

AUG 213 » 1 

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Omaha Lead Site 46130 
>*^'^"* * 

COASTA l INVIItONMIHUl 

CROU P I h C 

Cofisentfoi Access To Froperty 

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: ^ 

^ 9 8 3 a 

Owner's Name Daytime Phone: 

TUJYX/T^ >-• P^SU^rJ/t' 3^1A yy ^ 

Address of Property 

covered by this Z^/ 3 h7 /7 ^v^ 

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

compietion, 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 work. This access shall 

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

agrees to: 

Page 1 of 2 
.^^'ir^f. 

V COASTA L . / IHVIROMHfKTAL 

••» BflO^t^ C K O U P IK C 

c Remove obstructions including boats, trailers, vehicles, playscape items, wood 

piles, dog houses, elc; 

e Remove flower bulbs or plants that the Grantor or the Grantor's tenant may wish 

to save; 

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

necessary subsequent to an initial watering period by EPA; 

c 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. 

c 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 

© ^ grant access to my properties 

D i do not grant access to my properties 

Signature Date Signature 

Date 

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

F^ge 2 of 2 
COA S T A L • MV I MONM t NTAL O n O U P , INC . 

Restoration Agreement 

The purpose ofthis agreement is to provide a mutual agreement as to conditions ofthe property prior to 

remediation activities. This will also serve as docimientation for the purpose of assuring that restoration 

activities are completed to the satisfaction of the property owner and the United States Enviroiunental 

Protection Agency (EPA). 

PropertylD; 2.//^ ^ 

Property Addregg; 7^/ 3 A / I ^ 7 UCA 

Owner: ^ ^ fj^j ^ J 7 

Phone: j ///^ J/f I ^ _ ^/ f J / / f J ? 4> 

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 dcxnmient 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 responsibiiity. 

Kem: 

yLAd> A/ ^ 

Item: 

Item: 

ttem: 

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

ttem: 

^ /l/o /ue 

ttem: 

ttem: 

ttem: 

Pagel of. 2. 
COA S T A L • NVmONMeNTAL o • o u r. INC . 

ttem: 

^ Z > '1 1 

ttem: 

^ ^ Z i 

ttem: 

ttem: 

Item Quantity 

Pre-existing property area, 

that will be excavated, that ol . 

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

Attach a

, Heads

 sketc

, etc

h o

. 

f the y sprinkler layout. 

Number of and size of 

each garden/ flower bed 

area

Attac

sizes

. 

 an

h a

d

 sketc

 locations

h of

. 

 relative y

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Not

used

e

 t

 thi

o issu

s valu

e a

e wU

 plan

l be 

t y

voucher to the property 

owner. 

Easement Area, to be 

excavated / 

Landscape Inventory 

Unit 

Quadrants 

Each 

Each 

Each 

Each 

Square Feet 

$ 

F.ach 

Condition/Type/Species 

^ AJ'^^J 17^7 0 yJ 

Page 2 M 1 
1 

vs 

COA S T A L 

Addttional Comments / Instructions: 

The ctty of Omaha ordinances may prohibtt you from using dirt or gravel areas on your property 

as driveways or vehicle parking areas. The Environmentai 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 soil does not mean that any illegal driveway or parking area on your 

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

as a driveway or parking area, not wtthstanding 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 ctty of Omaha's Planning Department at (402) 444-5150. 

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

+ 1 c<^ Y-C z*( K r n ^ y i/e 

Q 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. 

r^lagre e O I do not agree 

Owner's Signature Date Contractor's Signature Date 

Page 3 cJ 
XRF PROPERTY SAMPLE SHEET 

Date / - /f - Lon Address 

Project Omaha Lead ARRA Sample time 

XRF ID# 3'^OLZ^ sample length 

Shof# Reading Sample area Shot# 

191 Z/ ^ t Z L 3L 

\8L l(oLi / ^ Depth 

185 

Average 

Li^ i

I'n

 l ^ 

t zo 

/3" 

7 Average 

Shot# Reading Sample area Shot# 

195 L i i i LO EA 

m LZP\ t IX Depth 

\S\ 7Z>Li U f " , 

Average ZZ^ ~ Li y Average 

Shot# Reading Sample area Shot# 

Depth 

Average Average 

RETEST AREAS 

Shot# Reading Sample area Shot# 

^^ 7 Depth 

y 7 

Average Average 

Signature 

Print jjj^cn km^ i 

BVID# ZZlSZZ. 

Z0/ ^ H Z'? AUG. 

am/pm 

30 sec 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Deptti 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By 

Certificate of Verification 

184 

SOIL 

2011-01-14 11:17 

90.95 

Final 

Avg of 181-183 

2813 N 19 AVE 

B2 

13" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 219.891 

Supervised By: 

Certificate of Verification 

181 

SOIL 

2011-01- 14 11:16 

30.20 

Final 

29822 

2813 N 19 AVE 

B2 

13" 

C.PADILLA 

CONFIRMATION 

CLEAR 

Error 

± 22.584 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 162.677 

Supervised. By: 

Certificate of Verification 

182 

SOIL 

2011-01-14 11:16 

30.22 

Final 

29822 

2813 N 19 AVE 

B2 

13" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 19.384 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 214.904 

Supervised By: 

Certificate of Verification 

183 

SOIL 

2011-01-14 11:17 

30.53 

Final 

29822 

2813 N 19 AVE 

B2 

13" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 19.521 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Blllerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By: 

Certificate of Verification 

188 

SOIL 

2011-01- 14 11:20 

90.75 

Final 

Avg of 185-187 

2813 N 19 AVE 

EA 

1" 

C.PADILU 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 211.936 

Supervised By: 

Certificate of Verification 

185 

SOIL 

2011-01-14 11:18 

30.23 

Final 

29822 

2813 N 19 AVE 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 20.789 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Blllerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 239.186 

Supervised By: 

Certificate of Verification 

186 

SOIL 

2011-01-14 11:19 

30.29 

Final 

29822 

2813 N 19 AVE 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 21.765 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 232.598 

Supervised By: 

Certificate of Verification 

187 

SOIL 

2011-01-14 11:20 

30.23 

Final 

29822 

2813 N 19 AVE 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 21.725 
X 

y*^Z'*'^s 

/l0^ \ Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

•f. j ^ www.coastalhazmat.com — 

%P„oi«^ COASTAL ENVI>ONH[NT*L 

GROUP , IN C 

EXECUTIVE SUMMARY: 

BVID #29822-(2813 n 19 ave) 

No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation: 
E 

EPA Property' Close Out Form 

Property tl: O Property AddrwTy^-W-J-^!^ V^i^fS,/ 

Date/Tlrac: _ _ 

Ouadu ExcBvslfd: W^ Confractor Group __C^AVTV^VL ^ 

Ejicavatlon General •^e* ^o 

If necessary, were (he correci quadranl(s) excavated and restored'' y+-i 

2 If nctessar>', were the correct areas ofdnp ?orje excavated and rcstoied'' 

Grading Yes ^<) Sod and VctteUtion 

! I Does the grading around the perimeter ofttie house in excavaicri areas generally SIOIH- i)wa\ y y I from (be house? 

2 Has sod been laid in all areas that were excavated? y 

i Docs the sod appear to be generally healthy and gro-wing'' (Only evaluate if inspected ai a ?0 

I day time period) 

4 Are sodded areas generally firm and evenly graded'' 'y\ 

I 

V - ^ Are the joints behveen the sod strips generally fight? (Only evaluate if inspccied at a 30 day I 4 

time period) _ y r 

6 Was the property graded such thai water will nol pool on ihf propertv'' ^ Y -J - ­

7 Was dHfnige to landscaping or plam materials avoided'' ; y

I 

-J 

Gate?. Feacci and Reiaining Walls \ [-} ^l ' 

Do gates open and close freely? (If applicable) 

Were all gates oi fences taken dowti during restoration activities remsialled? (K apolicahlf i 

^ Was damage to gates or fences avoided? (Ifapplicable) A /._ .; 

'1 Was damage to retaining walls avoided'' (Ifapplicable) 

foupdaiion, Siding and Cuners _ Ves, Nc 

1 I Was diunBge to the siding or trim avoided'' T-/T"" •, 

I 2 Was damage in the foundation avoided'' 

Was damage ic windows avoided'' y-' 

d Was damage to windows or door screens avoided'' y\' ; 

Wa.s damage to downspouis nr downspoui txien.sions a^•l)ldcd•' 

Sidewalki and Driveways (Copcrete) > cs >f 

 Was damage lo driveway surfaces avoided' 7' 

2. Was damage to walkway surfaces avoided'' 

I
OMper5 rommenls: 

In.spection note*;: 

ReiDOval and resloiation Htlivalf.s fompiele including lhe .^0-day .sod waniiiiry 

VrPA \t\°iVv> Hcf}respntiHtivc Date; 
V 

Property Completion Agreement 

riiii agieemeni documenls (lie complclion ol remedial aclivmes perlonned on my properly My .signaluie 

will designate thai I am satisfied wilh the restoration of my properly, and ihal no uems are m questions, 

now, or al any tune in the fuluie, excepl ihose items listed below, ifany 

Property FD: 

Property Address: /J^/ ^ A / ' /'^Al/ ^ ^ ^^^f. ^ A 7 , 

Owne: jycm;i Z /^<> ^ 

?7<7 • ?>V/K 

Restoration Items in Question: 

Item: 

Item: 

!•• • I «l | I U . 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

L 

I l y \ ayrcc I rstoralion is completed, rxccpl as noled 

[ I I rio not «i;rrc restoration 'w completed 

9 

Owiier'.<i Sicn»tiirr Date /ConOarioi' s Signadire