TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID# ^^<^T) Date: \ L /l] 

Address: Yjo ^ \ \ h ^ ^f 

Remediation Contractor: Coastal Environmental Group_ Year: _2010ARRA 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

4 Video of property (DVD) • 

Executive Summary 

B EPA-provided property sketch 

M Signed Access Agreement for subject property 

—9'/ Signed Access Agreement(s) for adjacent property 

B Restoration Agreement 

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

^B^ Confirmation data 

/IZ Photographs \U^ ^/!>Vt<V--^v\ ^ h^fAVAV-tr^ V f*V 

As-built sketch 

Satisfactory restoration signed by Property Owner 

/ Property close-out check list signed by EPA 

JJ— Description ofareas not meeting ROD cleanup criteria 

Utility clearances 

Property information from Douglas County Assessor's Office 

Signature "^ Date 

30218096 

iilHlllll 

Superfund 
^ 

Property Access Checklist 

PropertylD: ;:^3'=^(^(^ n WORK STARTED ON: / / 

PropertyAddress: :^^ ^ /Vl / 7 .S f n WORKCOMPELTED ON: / / 

Owner:, )^^p ^ . IAIOA^/ I Renter: 

Address: Phone: 

Fax: 

Cell/Pager: 

Phone:-7^-7_Qgq ^ Additional Inforniation: 

Fax: 

Cell/Pager: 

Same 

D Notification Letter Sent: / / By: 

r ^ Access Agreement Signed: 2^/2_// 0 By: 

pn Restoration Agreement Signed: 3 /(J_/A 9 By: 

D Topsoil Sampling (if applicable) 1 1 By: 

D Disposal Sampling (if applicable) 1 1 By: 

D Garden Sampling (if applicable) 1 1 By: 

CS^ Utility Clearance CaUed:f!)b/aL*? />0 8y= (5b>l'^^ /\ o - VOirAv . Vftrov 

j a Video/Photos (Before) On: 2-11 S'l l o By:V?^'/^?c/4/ f,c -Andly 

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

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

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

Q Property Completion Agreement Siened: / / By: 

n Final Report Issued: / / By: 

Air - • • Monitoring (as applicable) 

• community • Crew On: / / By: • 1 

Results: 

• Conmiunity • Crew On: / / By: 1 

Results: 

• Community • Crew On: / / By: 

Results: 

Omaha Lead Site 
Djouglas Cotmty Accoimt InfoiaMtion Page 1 of3 

Douglas County, Nebraska Property Record - R0701660000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJeW O n Ma p Information is valid as of 2009-12-15 Treasurer's Tax Report 

New Feature -•-•• • Auto Sales Search 

Owner 

JOHNSON JAMES C 

ETAL 

3909 N 17 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 0166 0000 07 

Account Type: Residential 

Parcel Number: 0701660000 

Parcel Address: 3909 N 17 ST 

OMAHA NE 68110-0000 

Legal Description: BOULEVARD PARK ADD LOT 12 BLOCK 9 N 40 FT 40 X 160 

Value Informatio n 

Land Improvement Total 

2009 $7,000.00 $33,300.00 $40,300.00 

2008 $7,000.00 $32,000.00 $39,000.00 

2007 $7,000.00 $32,000.00 $39,000.00 

2006 $7,000.00 $28,000.00 $35,000.00 

2005 $7,000.00 $10,300.00 $17,300.00 

2004 $7,000.00 $9,300.00 $16,300.00 

Sales Informatio n 

Sales Date: 2007-01-12 

Deed Type: WD SooIr: 2007 Page: 006292 

Price: $39,000.00 

Grantor: HOUGHTON DEWEY E ETAL 

Grantee: JOHNSON JAMES C ETAL 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1999-09-24 

Deed Type: Book: 2135 Page: 357 

Price: $12,000.00 

Grantor: 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accoimtno=RO... 12/30/2009 
Douglas County Account Infoan^io xma^ n Page 2 of3 i 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1999-04-06 

Deed Page: Type: Book: 2127 427 

Price: $10,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6400.0 1.0 160.0 40.0 No 

Improvemen t Information 

Building 1 

390SN1TST Saeond FittOf W'.(»• " t . StS.Oaq • 

FITS! Floor 

3»r Id « » 

7 111 

IIPt 1,T STORY •'- ^« T !' 

Bsmnt Blocii R II 

9ST5»«I . 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 1474.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

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

HVAC: Forced Air Rooms: 7.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Sliingie Bedrooms: 4.0 

Roof Type: Hip/Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO... 12/30/2009 
Qouglas Coimty Accoimt Infojjm|tio )ij|^ C n Page 3 of3 

Year Built 

1910 

Detail Type 

Add On 

Appliance 

Basement 

Fixture 

Fixture 

Garage 

Porch 

Porch 

Year 

Remodeled 

0 

Percent 

Remodeled 

0% 

Detail Description 

Fence Chain Link 

Allowance 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

Detached 

End Screen 

End Screen 

Adjusted Year Physical Age Built 

1910 99 

Units 

1.0 

1.0 

958.0 

1.0 

1.0 

324.0 

25.0 

147.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO... 12/30/2009 
Page 1 of2 

"> 

I; Create AnotherTjcket | , ^ Back to Irth Internet I [; Send Email ] 

• YOUR TICKET NUMBER IS 2445484. 

Original Call Date: 3/25/10 Time: 1:43 pm Op: ELIZABETH18790 


Work to Begin Date: 3/29/10 Time: 2:15 pm 


State: NE County: DOUGLAS Place: OMAHA 


Address: 3909 Street: N 17TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 03-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. Comer Lot: N Front: Y Rear: 


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV MAGELLAN MUDOl OMAHACOF OPPDGPR5 QLNNEIC 


Service Area Contact Phone Number 

UtiUty 

Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

»,MAGELLA f A ^cT T A XT MAGELLAN MIDSTREAM PARTNERS r.cDr»T> A XI N . p DEBORAH 

Day: 9185747098 

Alt: 

Emerg: 9185747098 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC.SEWER RICHA-RAFFIC

Day: 4024447197 

 AU: 4024445161 

Emerg: 4024445160 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 3/25/2010 
Page 2 of2 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT ELM 

LOCATING 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK ELM 

LOCATING 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 3/25/2010 
OLS#: 33560 As-Built Drawing ^ Date Excavated: 3/26/10 

Date USEPA Sianed Off: 7/8/10 COASTA L ENViaONHCNTAL Omaha Lead Superfund Site Area Sodden: 1353 so ft C • O U P. INC . 

Name Omaha Lead SKe Date: 9 - l^~0 ^ : North Amwr 

Address^tt^^° : ^ SHe Sketch Time: 

Phone: <r 

Team rnr.i3U/^h(^^ ^ 3^,^ ^ XRFCode ^j^g-z -

Sample Number Lead Concentration Confirmation Sample 

gyAg<^gxA- P Yes n No ^ 

- f^b<JyKK=^- h

JYes n N o ^ /?-7 i=-g7 PP B'Yes a ^ 1 ±3 \ ^ i l l ^ . eSves 

i £ ? ppm D.ies No ^ 

e ppm Yes • No a 

, Lab RYDSCPLA-33560 

ppm Yes • No • Result 263 ppm 

J S 

F2 = 156PPM@6" 

Omaha Lead Site 46130 

Legend 


Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with ^^ | Area replaced with 


Sod ' ' Rock/Mulch ^ Area left bare 


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

U- 79 sr 

Name Of \ Omaha Lead Site Date : 9- l5.-0^ North Arrow 

Addres Site Sketch Time s 

Phone 

Tttrj^5c: fexikU^hi^SffviBviD # 3:^oO XRF ^.^ZP-Z- Team Code 

Sample Number Confirmation Sample 

^ ' Yes 1^ No 

j m FJ Yes n No 

3'Ye s 2^'' ^ No 

9-- DZtes No 

Yes Q No O 

Lab RYDSCPLA-33560 Yes • No • Result 263 ppm 

Oinaha Lead Site 46130 /AhA y 
'J- i M 

Name: Omaha Lead Site Date: 9- la-O^ North Arrow —i 

Address: ^C©- Site SItetch Time 

Phone: 

<r 

Team ror^fjIrlAhf^yiO^ ^•^'y i XRF Code ^r^- ^ 

Sample Number Lead Concentration Confirmation Sample 

^ 1 Yes n No g 

W Yes CD No ^ ^ 'CPiO^^YfiK - ^<hf^Z c g'Yes n^-^ No g . An ft.ypgoPxA-^^g^ ^ ' ' •—"^-L- ppm 

DZies No " ^ :s^i^±i^ppm Yes n No a 

Lab RYDSCPLA-33560 ppm Yes • No • 

Result oc-3,. ppm 

263 ppm 

Omaha Lead Site 46130 
Omaha Lead Stte Date,:2da: : 

^ NoithArrow - i ^SL^X4?#°^ 8Ks Sketch Time»: HioICQr: 

Phone: <r 

Team rnrMj\r[/^'^h(^Jo ^ 3^^S ^ XRFCode ^^^-ZSample Number 

Lead Concentration Confirmation Sample 

lE'Yes a 

No 

FJ Yes CJ r,No o

3 3'Ye s g ^ No 

4 B^yea CT No b^ 

5 DZtes No 

ppm Yes ED No ^ Lab RYDSCPLA-33560 ppm Yes • No D "«" « 263 ppm • 

Omaha Lead Site 

46130 
# 

/••""''-v 

"< PM^ ^ 

COASTA l INVIIOHKIItU I 

C It O U P . IftC 

Consent for Access To Property 

RIGHT OF ENTRY TO PREIVIISES 

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: 707 •0^'^r 

Address of Property 3-101 A nsT 

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 wili 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 vinitten 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 ali 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 
COASTA L 

mriiioNKticiii 

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

piles, dog houses, etc; 

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

to save; 

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

necessary subsequent to an initiai 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 

y 

Slg r 

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

i ^ <^g./^2// ^ 

Date Signature 

Date 

©fwwoul o d iike to be present during any sampling that is required. 

Page 2 of 2 
^ 

COA S T A L • MVI nOM MS NTAL C 11 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 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: "zr^^^* ^ 

PropertyAddress; 37 ^ Aj /V^T^ 

Owner: J^^^flQ? ^ JiT'ty^C^'SC U; 

Plione; -707-0^^ 

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: 

Tlie removai, storage, disposai, and/or return of these items is the Owner's responsibility. 

item: 

Ail / 5 ^n (X (I p laHtj i~o le A / Kr^oj -C 

Item: 

i n cKs. /^^rJC , youe-s , 11 Ai s 

Item: 

Kem: 

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

Kem: 

/fnv r AA^^f/ n y yh \ y i i^t At\ 6 

Kem: ' / 

Kem: 

Kem: 

Pagel of J? 
COA S T A L • MVIKONMINTA L a n O U P , INC . 

Items to Be Removed By Contractor During Remediation and Replaced 

01 

Kem: 

?<» 1 / f & i , r L/ v ^ 

Kem: 

5o i 6 / 1 I 

Item: 

Item: 

Landscape Inventory 

Item Quantity Unit Condition/Type/Species 

Pre-existing property area, F^/f?^ Quadrants that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch Each 

/ trunk diameter 

Number of trees <= 2 inch Each 

/ trunk diameter 

Number of Sprinkler 

Zones, Control Valves, Each Timers, Heads, etc. ^ 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed Each 

area. i t< Square Feet 

Attach a sketch of relative 

sizes and locations. 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. $ Note this value will be 

vouclie

used t

r

o

 t

 issu

o th

e

e

 a

 propert

 plan

y 

t 0

owner. 

Easement Area, to be sjey^ Each 

excavated fe^A''V 1^^'"^'^^ 

Page 2 O.X 
COASTA L • MVinONNINTA L O ft O U P . IHC . 

AddKional Comments / Instructions: 

The cKy of Omaha ordinances may prohibK 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 soil does not mean that any iiiegai driveway or parking area on your 

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

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

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

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

I^PIease check this box if you understand the Information outlined above. 

j r Q^^^ oiic ujec^/^ nol-lce. UN^ ^ "> 

d l 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. 

01 Ia agree CD I do not agree 

Date Contractor's Signature Date 

Page 3 of / 
BVID # ^^^S (eO 

XRF PROPERTY SAMPLE SHEET 


Date ?>'Z?-l ^ Address "bHb^ yo 11. ^ r 

Project Omaha Lead ARRA Sample time am/pm 

XRF ID# sample length 30 sec '^^07^^ 

Shot# 

TF 

W 

E^ 

Average

Shot# 

'W 

2k 

Average 

Shot# 

Average 

Shot# 

Average 

Signature 

Reading Sample area Shot# 

KM ^ /? £^ . ^ L 

/Sf:^ /^ Pepth 

TT^ ^ 

S ^ ^^^ ^ / ^ 

 157 ^ Jn 1 ^ i^ Average

Reading Sample area Shot# 

/ ^ ^ I ? yj ^ 

;WD^ )>P- Depth 

/33fc iq 

^^-fii? 

^ 

Average 

Reading Sample area Shot# 

Depth 

Average 

RETEST AREAS 

Reading Sample area Shot# 

—^ Depth 

^^.- ^ / 

/ / Average 

; y7 ^ _ 

Reading Sample area 

19^ >^ ^ b^ 

Depth i ' ^ ^-Th 

m t /4 /O'f 

/ ( /S ^ ~ ZyCJ> 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Reading Sample area 

Depth 

Print \K^( ^ M/rrfv v 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Pb 

Supervised By: 

Certific 

90 

SOIL 

2010-03-27 13:03 

91.39 

Final 

r^a-OLgZrfiSJ 

3909 N 17 st 

F2 

6" 

N. LOPEZ 

confirmation 

none 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 87 

Mode SOIL 

Time 2010-03-27 13:02 

Duration 30.45 

Sequence Final 

Flags 

BVID 33560 

ADDRESS 3909 N 17 st 

QUADRANT F2 

DEPHT 6" 

XRF TECH N. LOPEZ 

MISC confirmation 

NOTE none 

ppm Error 

Pb 165.952 ± 19.264 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 158.506 

Supervised By: 

Certificate of Verification 

88 

SOIL 

2010-03-27 13:03 

30.54 

Final 

33560 

3909 N 17 st 

F2 

6" 

N. LOPEZ 

confirmation 

none 

± Error 

± 18.974 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 144.203 

Supervised By: 

Certificate of Verification 

89 

SOIL 

2010-03-27 13:03 

30.40 

Final 

33560 

3909 N 17 st 

F2 

6" 

N. LOPEZ 

confirmation 

none 

± Error 

± 18.249 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By: 

Certificate of Verification 

81 

SOIL 

2010-03-27 12:57 

91.21 

Final 

vgo f 78-8d~ l 

3909 N 17 st 

DZ 

10" 

N. LOPEZ 

confirmation 

none 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 197.133 

Supervised By: 

Certificate of Verification 

78 

SOIL 

2010-03-27 12:55 

30.44 

Final 

33560 

3909 N 17 st 

DZ 

10" 

N. LOPEZ 

confirmation 

none 

± Error 

± 19.905 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 198.599 

Supervised By: 

Certificate of Verification 

79 

SOIL 

2010-03-27 12:56 

30.16 

Final 

33560 

3909 N 17 st 

DZ 

10" 

N. LOPEZ 

confirmation 

none 

± Error 

± 22.203 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 188.970 

Supervised By: 

Certificate of Verification 

80 

SOIL 

2010-03-27 12:57 

30.61 

Final 

33560 

3909 N 17 st 

DZ 

10" 

N. LOPEZ 

confirmation 

none 

± Error 

± 19.390 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 77 

Mode SOIL 

Time 2010-03-27 12:51 

Duration 91.02 

Sequence Final 

Flags 

AVERAGE CStg-of-74-76/ 

ADDRESS 3909 N 17 st 

QUADRANT easement 

DEPHT 1" 

XRF TECH N. LOPEZ 

MISC confirmation 

NOTE none 

Supervised By 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 121.339 

Supervised By: 

Certificate of Verification 

74 

SOIL 

2010-03-27 12:50 

30.39 

Final 

33560 

3909 N 17 st 

easement 

1" 

N. LOPEZ 

confirmation 

none 

± Error 

± 16.673 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Fiags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 140.271 

Supervised By: 

Certificate of Verification 

75 

SOIL 

2010-03-27 12:51 

30.48 

Final 

33560 

3909 N 17 st 

easement 

1" 

N. LOPEZ 

confirmation 

none 

± Error 

± 17.520 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Bilierica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 133.047 

Supervised By: 

Certificate of Verification 

76 

SOIL 

2010-03-27 12:51 

30.15 

Final 

33560 

3909 N 17 st 

easement 

1" 

N. LOPEZ 

confirmation 

none 

± Error 

± 19.086 
/^A. i Omaha Lead Site—Fixed Price EP-R7-07-05 

I ^^^2L s Coastal Environmentai Group Inc. vl ^ ^ ^ \*^^ ^ www.coastalhazmat.com 

^'•t«iO^'=^ COASTAL 

mVIIOHHEIITU Ciour , IN C 

EXECUTIVE SUMMARY: 

BVID #33560-(3909 N 17 ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 

-DAN GARVEY WALKED THE PROPERTY ON 7/8/2010 
EPA Property Close Out Form 

Property #: lihS.hO . Property Addr«s: ^^^ ^ ^ , ^ ^ SV. 

Daten'lmc: Owner's Name:. /i>lrKtr\P>f.. .. ^J^fJO ^"^ ^ - -

Quads Excavated: Contractor Group 

Yes No Excavation General 

1. I r necessaiy, were the correct quadfant(s) excavated and restored? • 

2. I r necessary, were the correct areas or drip zone excavaled and restored? y 

Gradin Yes No g Sod and VegetotkiB 

I. Docs tlw grading around the perimeter ofthe house in excavated areas generally slope away y from the house? 

2. Has sod been laid in all areas that were excavated? y 3. Does the sod appear lo be generally healthy and growing? (Only evaluate if inspected ai a 30 y day time period) 

4. Arc sodded areas generally firm and evenly graded? y 

5. Are the joints between the sod strips generally tight? (Only evaluate if inspected at a 30 day y time period) ' ^_ 

6. Was the property graded such that water will not pool on the property' y 

7. Was damage to landscaping or plant materials avoided? ~y 

Gates. Fences and Remalng Walb Ves No 

I 1. Oo gates open and close freely? (tf applicable) y 

2. Were all gates or fences taken down during restoration activiiies reinsulied? (If applicable) y 

3. Was danuge to gates or fences avoided? (If applicable) 

4. Was damage to reuining walls avoided? (Ifappiicable) y 

Foundatioo, Siding and Gntlen Ves No 

1. Was damage to the siding or trim avoided? y 

2. Was damage to the foundation avoided? y 

?. Was damage to windows avoided? y 1 

4 Was dainage to windows or door screens avoided? y 

3 Was damage io downspouts or downspoul extensions avoided? y 

Sidewalks and Driveways (Concrete) Yes No 

I. Was damage to driveway surfaces avoided? / 

2. Was damage to walkway surfaces avoided? y 
Ort'Ders comments: 

Inspection notes: 

Removal and resloration activates complele including the 30-day sod warranty: 

EPA Representative QQ^ :A^ Date: z/g/A? 
Property Completion Agreement 

ihis agieemeni documenls lhe complclion of remedial activities perioimed on my pioperty My signature 

will designale llial I am satisfied with lhe restoralion of my properly, and ihal no items are in questions, 

now, or al any lime in the fuluie, excepl Ihose ilems listed below, if any 

Property ID: ~^^< 

PropertyAddress: "^^^ J] J 1 ^ 'S^T"^ ^ 

Owner: f^^^,^e' ^ ryJli^'JrYY ^ 

Restoration Items in Question: 

Item: VjefAo. M^^e Dt. Item: 

Item; 

Item: 

Item: 

Item: 

Additional Comments: 

y 

S ^ 1 HfCC Irestoralio ( n is completed, rxccpt as noted 

[_J I do nol af>rec resroratinn i> compleled 

/r^c 

Date Cunti arloi'g Sicnaliirc Dale 
Water Bill Settlement 

Property ID 33560 

Property Address 3909 N 17 St 

Tenant Janies Johnson 

1 have received from the contractor. Coastal Environmental Group Inc. (Coastal), the sum of $ 13.87 for 

water usage required to maintain the sod. 

Check Number 1954 

Value of Check $13.87 

Made Out To James Johnson 

Description of Settlement 

To reimburse tenant for estimated water charges on their MUD monthly invoices. 

IMy signature below is acknowledgement of the receipt of tlie sum listed above, wliicii I furtlier 

acknowledge to be fair compensation and fuii payment for the above, and release Coastal 

Environmentai Group Inc. from further obligations or liability. 

Contractor's Signature Date 

COASTAL ENVIRONMENTAL GROUP INC. 1954 

2411 MARTHA STREET 

OMAHA, NE 681 OS 

27-S/1040 003 

6247372904 

iHio 'o DATE 

PAY TO THE 

ORDER Of A}mfi9> Jijnnffipn $13^ 

'Vf\K^H)0(\/{\A^llOO . DOLLARS @ 

WklliFirgoSafik.MA. 

NAw b 

vwlsfai^ixom 

FOR 1^^/D 5:?fsi..r> ^^[$\ k\ n^<^y ^fius^M^ a&Qi ^ 

1:101.0000 sa n E.2l«7i7E=10l,ii' OnS U 

HartvxJOwltf 
@ ^ 

'•A:> >L 'j;! ^ 

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; .'^^ 0~C^ O 

Property Address: 3*^(3 H K i i 

Property Owner's Name u .lannfers u<?)V\f^^.(O^A 

Instructions to the Propertv Owner: 

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

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

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

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

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

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

Perfonnance Work Statement. 

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

work by checldng a nnmerical rating on the table bdow using the numerical definitions from 

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

9-10 "excellent" 

7-8 "very good" 

5-6 "acceptable" 

3-4 "poor" 

1-2 "very poor'-

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

10 5 

8 \ y 3 

7 2 

6 1 

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

Property Owner Signature; O^^/r^/fo