TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: M Date: ^(^(l i 

Address: K h [hC^ ^ "l ^ 

Remediation Contractor; Coastal Environmental Group Year: 2010ARRA 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

y Video of property (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 

As-built sketch 

Satisfactory restoration signed by Property Owner 

/ Property close-out check list signed by EPA 

• S - Description ofareas not meeting ROD cleanup criteria 

y Utility clearances 

y Propertvjnfbrmation from Douglas County Assessor's Office 

/T 

30217919 

Superfund 
^v 

Property Access Checklist 

Property ID: lQ;3^q \ D WORK STARTED ON: __/__/ 

Property Address: ^^ ^ UlcXfa\ | 5^ . D WORKCOMPELTED ON:__/__/_ 

Owner:^ ^ [^j , ^]^QC<di . Renter: /yo in 

Address. ^_ . Phone: 9Jy ^OY^ 

Fax: 

Cell/Pager: 

Phone: Additional Infomiation: 

6^ T 3i^5M 

Fax: 

Cell/Pager: 

l~l Notification Letter Sent: / / By: 

Access Agreement Signed:y t^S'J Q By: 

Restoration Agreement Signed; a l/6> I )t> By: mi/ZC^/O 

n TopsoU Sampling (if applicable) / / By: 

l~l Disposal Sampling (if applicable) / / By: 

l~] Garden Sampling (if applicable) / / By: 

fi Utility Clearance CaUed; C^b/Vh / \r-> By:o^^, ^ ^,^^ t 

£ Video/Photos (Before) On: ^iJ^lj Q ^y'.ll/c/^/r.r/S 

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

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

n Video/Photos (30-Day) On: / / Byt 

|~| Property Completion Agreement Signed: / / By: 

D Final Report Issued: / / By: 

Air Monitoring (as appUcable) 

Q Conununity QCrew On: / / By:

Results: 

• Community QCrew On: / / By: 

Results: 

Q Community QCrew On: / / By; 

Results; 

Omaha Lead Site 

 1 
)ouglas County Account Inforaotio rjM^c n Page 1 of2 

Douglas County, Nebraska Property Record - R1524550000 

Print Report 

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

New Feature ->->-> Auto Sales Search 

Owner 

KLINKACEK THOMAS 

ETAL 

13426 EDNA ST 

OMAHA NE 68138-0000 

Property Informatio n 

Key Number: 2455 0000 15 

Account Type: Residential 

Parcel Number: 1524550000 

Parcel Address: 1113 HICKORY ST 

OMAHA NE 68108-0000 

Legal Description: KOUNTZE 5TH ADD LOT 19 BLOCK 4 E 37 N 1/2 LT 18 & E 37 FT 34 X 87-37 X 

68 

Value Informatio n 

2009 

2008 

2007 

2006 

Land 

$3,100.00 

$3,100.00 

$3,100.00 

$3,100.00 

Improvement 

$39,100.00 

$39,100.00 

$39,100.00 

$35,500.00 

Total 

$42,200.00 

$42,200.00 

$42,200.00 

$38,600.00 

2005 

2004 

$3,100.00 

$3,100.00 

$35,500.00 

$35,500.00 

$38,600.00 

$38,600.00 

Sales Informatio n 

Sales Date:

Deed Type: 

Price: 

Grantor: 

 1999-01-11 

$33,500.00 

Book: 2111 Paga: j 573 

Grantee: 

Valid/Invalid: valid 

Exclusion Reason: \ 

Land Informatio n 

Acres ! SF Units Depth Width Vacant 

0.05 2516.0 1.0 68.0 37.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-onUne.com/DouglasCoNe/static/accoimtinfo.jsp?accountno=Rl... 12/30/2009 
)ouglas County Account Infortajdon Page 2 of2 r|Mgc 

Building 1 

EnelSeMWM 60 0 s r 

; ««; a u 

WC 

Rrd Floor i 874.0 S F. 

self 10 ff 

L, 

12 Of 

Slab Roof Ceiling 

140 sq I 

11/2 Story Unfinished 

BsmnI BlMli 8 H 

874 a S F 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 874.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: [ Fair 

Unit Type: Condition: Fair 

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

HVAC: 1 Forced Air Rooms: 5.0 

Exterior: Frame Aluminum Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: ; 1.5 

Floorcover: Allowance Foundation: I Block 

Sprinkler Square Footage: { 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1908 0% 1908 102 

Detail Type Detail Description Units 

Add On Unfinished Attic W/floor 864.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 874.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Porch End Screen 60.0 

Porch Slab Roof Ceiling 140.0 

User POOR ROOF 1.0 

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

"> 

[; Greate^Anothe£Ticket J ] L „_ Bj^ckjojrth internet I I Send Email 

• YOUR TICKET NUMBER IS 2569551. 

Original Call Date: 8/17/10 Time: 9:23 am Op: ELIZABETH18790 


Work to Begin Date: 8/19/10 Time: 10:00 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1113 Street: HICKORY ST 


Twp: 15N Rng: 13E Sect-Qtr: 27-NE 


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 


ATTNEBRl CXCATV LEVEL3 MCINEB MUD02 OMAHACOF 0PPDGPR6 


QLNNEIF 


Service Area Contact Phone Number 

Utmty 

Type 

ATTNEBRl ATT/T 

Day: 80024136249 

Alt: 

Emerg: 80024136249 

CXCATV COX COMMUNICATIONS, WC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVEL3 LEVELS COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MCINEB MCI 

NO CALL PER 

MEMO 

Day: 8002893427 

Alt: 

Emerg: 8002893427 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 8/17/2010 
Page 2 of2 

MUD02 

OMAHACOF 

0PPDGPR6 

QLNNEIF

METROPOLITAN UTILITIES 

DISTRICT 

CITY OF OMAHATRAFFICSEWER 

OMAHA PUBLIC POWER 

DISTRICT 

 QWEST LOCAL NETWORK 

SANDY 

RICH/TRAFFIC 

ELM LOCATING 

ELM LOCATING 

Day: 4025047823 


Alt: 


Emerg: 4025047970 

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,.. 8/17/2010 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

QL$#: 19391 

Date Excavated: 8/11/2010 

Date USEPA Siqned Off: 10/19/2Q1Q 

Ar?? $<fW^n: 214Q §q ft 

Name: lh^.,<^<. Kii^kare/ C Omaha Lead Site Date: ^////t - ^ NorthAfTOw 

Address: (|1 ^ tt<.-l^ ryr..'; 4 . Site Sketch Time: ^.'^ t 

Phone:, ^^(^-(,7^ 7 -> - ^ 

learn | V ( u^</HtCm{.A BVID# h^^i XRF Code •g'-S"^ / 

Sample Number Lead Concentration Confirmation Sample 

• ^Ti. i -2.0 F, Yes n No ^ ppm f l Yes n No 1^3 

fi, Yes • No o; ^ 

r^Yes ° No 2 ^ 

0 i Yes O No C ^ 

ppm Yes n No • 

ppm Yes • No • 

_L 

81 = 111 PPM ( 

DZ = 221 PPM@ 10" 

F2 = 51 PPM @ 6" 

Legen d 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with 

Sod ' ' 

Area replaced with 

Area lef t bare Rock/Mulch 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group In c 
Name: / ili,'A<'>«i KAn^ka/e/K' Omaha LeadStt6 Date: (/J/2/'0~'> North Arrow r 

Address: f | (. ^ H'ui-D r^'^, ^ , Site Sketch Time: ^/H.S 

Phone: 9^tL'G75 7 '' 4 i 

Team |.^V 11 (;ft>.^</ Ht/i^&A BVID # /I5"ff XRF Code ^^^ / 

Sample Number Lead Concentration Confirmation Sampli 

Fs Yes I^ No ^;; ^ 4^.^y ppm / 7 (^i Yes CD No ET ppm 

ppm <^, Yes D No ^ 

ppm FjYes n No 5 ^ 

ppm 0;tYes O No 1 ^ 

ppm Yes a No n

ppm Yes • No • 

-H— • -T--E ^ r * ^ }<\^ y - Y^—/I / ^C:::* ^ 

- j ^ 

^2 

Id z - if795f"3V! ;­ / N 

ftl^Ml^Ql I 

P 5 

:U 

5 \ 

/ 

r-i 

'f^-yy7^--Ar-r-i 

k 

•Ttr— • 

l<>m\^l/^ K KM

-^--^^/•^-4-i . 

\ / 

 \' \ 
% # 

Name: //lx'/''^<, IC it^^Cace/C Omaha Lead Site Date: 0^/2//o'> North Arrow 

Address: fll 3 ttlfk^r^S-^ ' Site Sketch Time: "i.'HS 

Phone: 5<^(.- 4 75 7 ^ 

Team \f^ i{\\Ci^< rk( (fT. K JL A BViD# /15^/ XRF Code 

^-^^Z 

Sample Number Lead Concentration Confirmation Sample 

F l Yes 1^ 

/c?y/9/y^y^ - /^S^ ^ 5-2.3^^ ^ PP (^2. Yes CD 

iK.t77.^^y^yy^^ /9y^ / 
Name: I k '/H*> ^ Kluisk&Ce/C Omaha Lead Site Date: North Arrow 

Address: i n ^ tti^or^54 , Site SItetch Time: 

Phone: ^BIl42l2_ ? 4 

Team ]I^.\L^./^ (m^/\ BVID# h'i'ii XRF Code ^-^^ / 

Sample Number Lead Concentration Confimnation Sample 

F» Yes CD No 2;;;]^ 

f^t Yes O No CX 

/^, Yes n No Q ^ :|jiT^pp' " fa Yes O No 2x Da-Yes n No 13 ^ 

ppm Yes n No • 

ppm Yes • No • 
,^-'^°*'*'u 

COASTA l IMVItDHRIKIILl 

c I 0 u r. IN C 

Consent fcf 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 ^ctiyijieg upon the 

following described premises: ^ 

Owner's Name Daytime Phone rs Name: ^ , n 

-^/,rr^,>^Ll//^kialy 

Address of Property 1113 H^^t^^^-^"^­ 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 removai. 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 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 perfomning 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 .J tN*IIONKfKT« l 

C « O U r I K c 

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

piles, dog houses, etc; 

e 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; 

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 

rant access to my properties 

D I do not grant access to my properties 

ly^-'bio 

Date Signature Date 

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

Page 2 of 2 
C OA S T A L 

Restoration Agreement 

The purpose of this agreement is to provide a mutxxal 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: (<f 3* ^ / 

Property Address; fffz^ l^ ldZt)r\ j 5^ 7 

Piione; c^gtcy - 3^t=,H 

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: 

(/{-WKJ^ ^\o^c. io )P1 3^ ^\!ao ^ 

Kem: VJ 

Kem: 

Kem: 

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

Kem: 

hxA ^\w^5> ^^fcu- ^ 

Kem: 

Kem: 

item: 

Pagel of y 
C O A S T A L • MVinONMINTAl . o n o u p . INC . 

Items to Be Removed By Contractor During Remediation and Replaced 

Kem: 

Kem: 

Kem: 

S^/ t

^/ /

 1=2, g/p ^ 

 P-^,^i,P 

Kem: 

Item 

Landscape Inventory 

Quantity Unit Condition/Type/Species 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Quadrants 

Number of trees > 2 inch 

trunk diameter ey Each 

Number of trees <= 2 inch 

trunk diameter 

Each 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch of the 

sprinkler layout. 

Each 

Number of and size of 

each garden/ flower bed 

area. 

Attach a sketch of relative 

sizes and locations. 

Each 

Square Feet 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Easement Area, to be 

excavated / 

Each 

tlA^ /'? Li f(ejoti~J 

Page 2 OIJL 
C OA S T A L • NVinOMMaMTAI . o a o u p , IN C 

AddKional Corhments / 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 illegal driveway or parking area on your 

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

as a driveway or partcing area, not wKhstanding 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. 

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

'5- ' a.]^o yi( Uny^^ -A 

o a liA ^ io e 

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 jf^use. including foundation cracks or fissures. 

^Contractor' Sieni !ontractor'ss Signature Date 

Page 3 of ; 
1

BVID s /^'31 1 

XRF PROPERTY SAMPLE SHEET 


' Date • /-Z6-- Z0(( Address /// 3 Hiaioi ^ & r 

Project OT,aha Lead ARRA Sample time am/pm 

XRF IDH 3'^oz^ sample length 30 sec 

 Shot # Reading ' Sample area Shot # ' Reading Sample area 

' /^ 1 ^' ^ i ^3 . BA ?^ /^L £ ^ ( Vh 

(/^ Z65i Z\ Depth ^ 8 Z5^ i Z-^ Depth 

/ / I Z63 ^ Z i /" '\'\ 2 3 / ± < ^ 10'' 

/ Average Z^3 i ^ ^ Average ZZ^ / i 2 X / 

Shot# Reading Sample area Shot # Reading Sample area 

/ ^ SO i /3 FZ 

\0(^ S^ i 13 Depth Depth 

m 4 ^ i 13 ^ " 

fwerar^e €1 i 15 / Average 

Shot# Reading Sample area Shot# Reading Sample area 

/Of 118 i n 51 

\oz Id^ i 16 Depth Depth 

105 IOS i n 4" 

Average Hi n. / Average 

RETEST AREAS 

Shot # Reading Sample area 

Average 

Depth 

. 

Signature 

Prin 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 112 

Mode SOIL 

Time 2011-01-26 12:12 

Duration 91.60 

Sequence Final 

Flags 

AVERAGE Avg of 109-111 

ADDRESS 1113 HICKORY ST 

QUADRANT EA 

DEPHT 1" 

XRF TECH C.PADILLA 

MISC CONFIRMATION 

NOTE CLEAR 

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 240.830 

Supervised By: 

Certificate of Verification 

109 

SOIL 

2011-01-26 12:11 

30.32 

Final 

19391 

1113 HICKORY ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 23.682 
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 255.589 

Supervised By: 

Certificate of Verification 

110 

SOIL 

2011-01-26 12:11 

30.65 

Final 

19391 

1113 HICKORY ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

21.525 
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 263.906 

Supervised By: 

Certificate of Verification 

111 

SOIL 

2011-01-26 12:12 

30.63 

Final 

19391 

1113 HICKORY ST 

EA 

1" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 21.652 
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: 

Certificate of Verification 

108 

SOIL 

2011-01-26 12:09 

90.36 

Final 

Avg of 105-107 

1113 HICKORY ST 

F2 

6" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 105 

Mode SOIL 

Time 2011-01-26 12:08 

Duration 30.13 

Sequence Final 

Flags 

BVID 19391 

ADDRESS 1113 HICKORY ST 

QUADRANT F2 

DEPHT 6" 

XRF TECH C.PADILLA 

MISC CONFIRMATION 

NOTE CLEAR 

ppm ± Error 

Pb 50.889 ± 13.312 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Biilerica, MA 01821 

Certificate of Verification 

XL3t-39022 

Reading No 106 

Mode SOIL 

Time 2011-01-26 12:09 

Duration 30.18 

Sequence Final 

Flags 

BVID 19391 

ADDRESS 1113 HICKORY ST 

QUADRANT F2 

DEPHT 6" 

XRF TECH C.PADILLA 

MISC CONFIRMATION 

NOTE CLEAR 

ppm ± Error 

Pb 56.822 ± 13.670 

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 46.302 

Supervised By: 

Certificate of Verification 

107 

SOIL 

2011-01-26 12:09 

30.05 

Final 

19391 

iil 3 HICKORY ST 

F2 

6" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 13.425 
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 

104 

SOIL 

2011-01- 26 12:07 

90.61 

Final 

Avg of 101-103 

1113 HICKORY ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 
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 118.309 

Supervised By: 

Certificate of Verification 

101 

SOIL 

2011-01-26 12:05 

30.20 

Final 

19391 

1113 HICKORY ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 17.418 
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 106.812 

Supervised By: 

Certificate of Verification 

102 

SOIL 

2011-01-26 12:06 

30.21 

Final 

19391 

1113 HICKORY ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 16.952 
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 108.552 

Supervised By: 

Certificate of Verification 

103 

SOIL 

2011-01-26 12:07 

30.20 

Final 

19391 

1113 HICKORY ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 17.515 
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 

100 

SOIL 

2011-01-26 12:04 

90.70 

Final 

Avg of 97-99 

1113 HICKORY ST 

DZ 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 
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 192.830 

Supervised By: 

Certificate of Verification 

97 

SOIL 

2011-01-26 12:02 

30.21 

Final 

19391 

1113 HICKORY ST 

DZ 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 21.677 
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 239.829 

Supervised By: 

Certificate of Verification 

98 

SOIL 

2011-01-26 12:03 

30.25 

Final 

19391 

1113 HICKORY ST 

DZ 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 23.850 
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 231.731 

Supervised By: 

Certificate of Verification 

99 

SOIL 

2011-01-26 12:04 

30.24 

Final 

19391 

1113 HICKORY ST 

DZ 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 23.241 
/ yML \ Omaha Lead Site—Fixed Price EP-R7-07-05 

5 ^^^ ^ o Coastal Environmental Group Inc. 

V^*^! ^ www.coastalhazmat.com 

%p„oT«<^ COASTAL • NVmONMENTAL 

C a o U P, IM C 

EXECUTIVE SUMMARY: 

BVID #19391-(1113 HICKORY ST) 

No Issues or Concerns \ ^ Issues/Concerns 

Detail Explanation: 

-DAN GARVEY WALKED THE PROPERTY ON 10/27/2010 
4

EPA Property Close Out Form 

Property #: / * y>^y . Property Address: 

Date/Time: Owner's NBinr 

Quads Excavated: Contractor Group CPtftjyvz^^V 

Excavation General 

1. if neccssuy, were tlic correct quadrant(s) excavated and restored? 

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

Grading Sod and VcgcCBtioB 

1. Does the grading around the perimeier ofthe house in excavaled areas generally slope away 

from the house? 

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

i. Does the sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 

day time period) 

4. Are sodded areas generally (irm and evenly graded? 

S. Are 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^ 

r 7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and Reutalns Walb 

1. Do gates open and close freely? (If applicable) 

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

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

4. Was damage to retaining walls avoided? (Ifappiicable) 

FouDdatioD, Siding and Gntf ers 

t. Was damage to the siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

 Was dainage to windows or door screens avoided? 

5. Was damage to downspouts or downspoul extensions avoided? 

Sidewalks and Driveways (Concrete) 

I. Was damage lo driveway surfaces avoided? 

2. Was damage to wallcway surfaces avoided? 

Yes No 

y 

y 

Yes No 

/ 

J 

J 

y 

J 

y 

V 

Yes No 

J 

J 

J 

y 

\ a No 

J 

J • 1 

y 

J 

j 

Yics No JL 

V 
* 

Ort'Ders comments: 

pinspection notes: 

y^ y yRemoval and restoration activates complete including the 30-day sod warranry: 

EPA Representalive ^f^ ^ Date: to\ti^' 10 
Property Completion Agreement 

This agreement documenls the complclion of remedial aclivilies perloimed on my pioperty My signaluie 

will designate that I am satisfied with Ihe restoralion of my properly, and thai no items are in questions, 

now, or al any lime in the future, excepl Ihose ilems lisied below, if any 

Pioperty ID: f^^^^ l 

Properry Address: j f-2^ H\C,]^C\ J ^ V 

Owncr:^! ^ ^ |^ ^ j ^ UlCXCP.( c 

Phone: e^q q -3 3 6 M 

Restoration Items in Question: 

Item: 

Item: 

Item; 

item: 

Item: 

Item: 

Additional Comments: 

A r t {AM4J^ ^T y '^hfu ^ 

CM 

i( 

[rjvl Hyrcc r CKtorAlion is completed, except as noleri 

is completed 

Date Cuntiarfoi's Sicnadirc Date 
® 

# 

Propeity Owner Assessment of Performance Form 

American Recovery and Reinvestment Act (ARRA) 

Omaha Lead Superfund Site 

2009/2010 ^CEIVE D 

Remediation Contractor: Coastal Envimnme^tal Group - EP-R7-09-d6 ^^^ ^ ^ "M 

Property Identifier Number: \ *\'^^ \ SUPfiRpr TV^.. _ ^ _ 

Propert;Address: Id s H.cJ^fy^ . '"'''^DDIVISIO N 

Property Owner's Name;-Torv-y W4irACjCxr.P.i<. 

Instructions to the Property Owner: 

This fonn serves to record the Property Owner's assessment of perfonnance (Incentive 1 

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

to the Omaha Lead Site. This form documoits the timeliness of pimch list resolution, business 

relations, complaint resolution and the overall quality of woik. 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 

Performance Work Statement 

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

work by checking a numerical rating on tlie table below using the numerical definitions from 

the rating scale below, thai 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 Performance Regarding the Contractor's Work 

10 5 

9 / ^ 4 

8 3 

7 2 

6 1 

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

Property Owner Signature: (I \\)f\\{j A . J ^Date: ^0^FC>'^2J ^