r 

TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID^: ^/T^ a Date: yii/o^ 

Address: ^^2: ^ P/Zll^PlJ ^ l 

Remediation Contractor: Coastal Environmental Group Year: 2007 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

EPA-provided property sketch 

Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

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

Coniirmation date 

Photographs 

a/ As-built sketch 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Description ofareas not meeting ROD cleanup criteria 

Utility clearances 

Property infonnation from Douglas County Assessor's Office 

s7 

u 

u 

u 3//7Ag ^Datfe 

u 

40317779 

D , 

D Superfund 
% 

Final Report Property Check List (pieasc place with each nk) ^ / 77e ^ 

 C L 

^ 

Har d Cop y Informatio n ^ ^ _ ^ 77. iy

1. Property Clieck List I ^-51)77 /^A< ^

2. Site Woricing Drawing Map !| 0 

3. BPA originals Map '| 

4. Douglas Counly Assessor's Map \ 

3. i'ropcily Contact Slicci | 

Afirccnicnt :| 

1. Access Agfccmcnt :| 

2. Resloration Agreenieiil | 

I 

it' 

Miscellaneous Documents ll 

i,|t 

1. Final Map from the Field '( 

2. Change Orders If 

3. XRF Data j 

4. Any emails or PO correspondences •'; 

Property Complelioti [ 

1. Executive Summary 

2. AS BUiLT \ 

3. Property Completion Agreement [ 

4. Any buyout info or reimbursement into % 

5. Clieek or money order copies !| 

6. EPA Property Close Out Form ; 

7. Attaehed Begin Video 

Electronic Documentation 

Drawings 

1. EPA original 

2. Working Drawing 

3. AS Built.vso 

4. AS Built.jpg 

Photos 

Begin Photos 

During/Elxcavation Photos 

Sod Photos 

30-Day Sod Photos 

Scanned Documents 

Final Doeumenis 

J? Executive Summary 

Videos 

Begin Video 

2 My Movie 
% 

Property Access Checklist 

Pro.,ei-ty ID: ^/^/^ ^ D WORK STARTED ON: / _/_ 

P.«pci-t.v.A.hl.es.s: ,^^50 ^ ^,^?>^.. ^ n WORK COMPELTED ON: / /~ 

f 

Owner: Renter: yy,djy^^Tr\ 

Address: Phone: 

Fax: 

Cell/Paser: 

Additional Infoimatioiv. 

pj--(4oi) _^£5 r-^6 3 

Fax: 

Cell/Pajier: 

^ Notification Letter 

Sent: ^1^ 1 d:7- Bv: IU, \SJ: ^ 

l-S ' Access Agreement Signed: ^/^/ ^ Bv: CU-^^s 

Restoration Aj;reeinent Signed: ^ /g ^

 1 ^ Bv: CMi ^ 

r~l Top.soil Samplin" (if applicable) 

Bv: 

I i Disposal Samplin" (if applicable) 

Bv: 

r~l Garden Samplin<> (if applicable) 

Bv: 

^ Utility Cleaiii nice 

Called: )0 / 2L /o 7 ^y\0fA Z. 

..^^Video/Photos (Before) On: 4./^/! ^ Bv: K<5l£flilcCZ/' 

D Video/Photos (During) On: Bv: 

n Video/Photos (After) On: 

By: 

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

r~1 Pro|)erty Completion Afjreement Siuned: 

Bv: 

n Final Report 

Issued: Bv: 

Air IVIonilorin<> (as a|)|)licable) 

• Community • Crew On: / / 1 

Results: 

Q Community [U Crew On: / / By: 

Results: 

• Community Q Crew On: / / By: 

Results: 

Omaha Lead Site 
% (yi(x7b ([(7756 

Name; f7i\7q hn/7{XJor ^ Omaha Lead Site Date North Arrow —i 

Site Sketch Time 

Phone: (4if?J ^^'3-^/// y t 

Team pf)i'U^I^/ 1^0DiyZ BVID# 3 ! 7l^ f XRF Code 180^ 

Sample Number 

Lead Concentration Confirmation Sample 

pYe s n 

No 

ppm fTYes a No 

ppm 6/Yes a No 

B>lYes CD 

N o ^ 

No) s ^:Yes ^ 1)7^ (n2,oc^ ) ppm Yes n No CD 

ppm Yes • No • 

\..7Lill.7t.\MMM. 

r^ 

7yyyyy7yy7M..k777.-:yi 

pi' I 

^^^j< ^ 

<g^/^:€v\^ ^ 

pl^3Kn<^/ St^ 

Omaha Lead Site 

46130 
t 

• 

Name: f^ll/q 7^71/7 {/J0/ ^ Omaha Lead Site Date: ^^A?7 ^ North Arrow 

Address: 760 ^ fihlCy^y y Site Sketch Time; \Z o.€ 

Phone: (407.) ip^-^yiy ^ 

Team ^ 6^UJlO /U o DiyZ BVID#_iJ_ZM _ XRF Code ISO^ 

Sample Number 

Lead Concentration Confirmation Sample 

tax, ppm P|Yes a No 

ppm FTYes a No 

6) Yes n 

No )f- "5 ^ ppm 

g.ZYes n No rry/'/Kt^^Z^ No) S i^^Yes • 

Yes • No O

ppm 

Ye No • s 1=1 

-^j ^ -^^P^ y^i>'\>c^'- 7^ y 

t 

i5???fc?//f/^ 

V 

+V;" i ^• 

• / V i i -tf 

^ 

•!"••??• 

— < - X. 

1^^^......-^^) .^14711^. ) 

• ^ ) 

^ r^ T 

•g^ m a^ 

...^^­ •fe-4 

^

•prohr'5 y i 

\ 

/ 

^WF 

y ^£^3 y... r""Pr i\re y i 

\^^^\ \ 6y\ .k)../B...L. -wz^y 

pIlOKney St. Omaha Lead Site 

46130 
Douglas County Account 1 Q^nnation Page 1 of 2 

Dougla s County , Nebrask a Propert y Recor d - R210100000 0 

Print Report Information is valid as of 2007-8-24 View on Map Values not finalized until after Board of Equalization Treasurer's Tax Report 

Owne r 

ANDERSON ELVAV 

ETAL 

2508 PINKNEY ST 

OMAHA NE 68111-0000 

Propert y Informatio n 

Key Number: 0100 0000 21 

Account Type: Residential 

Parcel Number: 2101000000 

Parcel Address: 

Legal Description: 

2508 PINKNEY ST 

OMAHA NE 68111-0000 

REDICKS -CLARK-ADD EXT LOT 4 BLOCK 2 46 X 100 

Valu e Informatio n 

2007 

2006 

2005 

2004 

2003 

2002 

Land 

$2,300.00 

$2,300.00 

$2,300.00 

$2,300.00 

$2,300.00 

$0.00 

Improvement 

$65,100.00 

$65,100.00 

$65,100.00 

$15,400.00 

$15,400.00 

$0.00 

Total 

$67,400.00 

$67,400.00 

$67,400.00 

$17,700.00 

$17,700.00 

$0.00 

Sales Informatio n 

Lan d Informatio n 

Acres 

0.1 

SF 

4600.0 

FF 

46.0 

Units 

1.0 

Depth 

100.0 

Width 

46.0 

Vacant 

No 

Lan d Attribute s 

Attribute Attribute Description 

Improvemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfojsp?accountno=R21... 9/27/2007 
Douglas County Account IiAcnatio n^trm n Page 2 of2 

Two Story 2508 Pinkney 

1*0 

ISO! 190 

13 0' tor n v 

M.tr 19 0' 

Fk-sinoor Second Floor 

2:0 874.0 Sq. n . i. • 220 830.0 Sq Ft 

i J 

80* 1 . ' l.-» 14 0 1 ' Jal Mtr nn- BOSlabRorJCwhn.; 

98 SO ft 

BsmnlBIO'.k^ft 830CiSq F 

Click CI ick to Enlarge Image to Enlarge Image 

Square Footage: 1704.0 Percent Complete; 100.0% 

Perimeter 0.0 Quality; Fair 

Unit Type: Condition: Good 

Owner Occupied: No Condo Square Footage: 0.0 

Built As: 2 Story Rooms: 8.0 

HVAC: Central Air to Air Units: 1.0 

Exterior: Frame Siding Baths: 2.0 

Interior: Drywali Bedrooms: 4.0 

Roof Cover: Composition Shingle Stories: 2.0 

Roof Type: Gable Foundation: Block 

Floorcover: Allowance Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1915 0 0% 1915 89 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Appliance Fireplace Masonry 1.0 

Basement Bsmnt Block 8 ft 830.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 2.0 

Porch Slab Roof Ceil 88.0 

http://dougIasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R21... 9/27/2007 
• 

CONTACT FORM 

Property ID # 

Property 

Address: 

Initial Contact:

Second Contact:

Final Contact:

Final Action:

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

muL 

yyTT^^y­ Date: Time: Action: 

 Date: Time: Action: 

 Date: Time: Action: 

 Transmit to EPA D Other Action: D 
X 

i^JJL\ Omaha Lead Site—Fixed Price EP-R7-07-05 

o J^^^ L I Coastal Environmental Group Inc. 

\^^^T< ? www.c0astalha2mat.com 

%PBo->«^^ COASTA L ENVIRONMENTA L 

CROUP , IN C 

EXECUTIVE SUMMARY: 

31768—2508 PINKNEY ST 

No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation: 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

Omah ttW i Arrow Name a Lead Site Date, ^f^y ^ ^/Z7Z^ ^ : r^ /r;, f^ydiH^cN Site SHttch Tnr»; I j y^-g t 

Team Jjliti^ y ^ '^^^^ '>:^? _ BVID » pr7i^) f XRF Code. ZS ^ 

Load CocKienlratlon Connmftanion Sample 

yJl^i:.<3a

ppon 

ppm 

ppm '^ 

F'Yes 

F"^Yot 

t5.' Yes 

fc-iYes 

a 

u 

u 

u 

NO ! ^ 

.T^S^^p m 

ppcn 

Yes 

Yes 

3 

n 

No ,&3 

No a 

No O B2 dig around trees and save rose 

bushes and rock replace with white 

rock in F2. Save rose bush in DZ. i 

>1< ^ "Si r±^ 

^/Zllpi'O 

i^^i,mLk. 

/ii_y77-^ 

: ^— 1 — 

'^^^'^A.L.J^L.t..U^ 

I 

0LS# : 31768 pifoKi-,^/ <7. C«r-ia Date Excavated: 10/25/07 46J30 

Date USEPA Signed Off: 12/13/07 

Legen d 

Area not Excavated yyyj Dripzone Excavated g2S^ Quadrants Excavated 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
^ % EPA 

EPA Property Close Out Form 

Property tt: 3/7^^ 

Date/Time: 

Quads Excavated: 

Excavation General 

1. If necessary, were the correct quadrant(s) excavated and restored? 

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

Grading Sod and VegeUtion 

1. Docs the grading around the perimeter ofthe house in excavated areas generally slope away 

from the house? 

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 

day time period) 

4. Are sodded areas generally firm and evenly graded? 

5. 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? 

7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and Retaininf> Walls 

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

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

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

4. Was damage to retaining walls avoided? (If applicable) 

Foundation, Siding and Gutters 

1. Was damage to the siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

4. Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? 

Sidewalks and Driveways (Concrete) 

1. Was damage to driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

Yes No 

y 

y 

Yes No 

^ 

y 

^ y 

y 

y 

y 

y 

Yes No 

^t^ 

y 

y 

y 

Yes No 

i ^ 

y 

y 

y 

y 

Yes No 

y 

y 
Owners comments: 

Inspection notes: 

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

EPA Representatiy^^-^^^^^g,^ ;^^^^^y,X ^ Date: Z^Z^Az 
(i 

Property Completion Agreement 

This agreement documents the completion of remedial activities performed on my property. My 

signature will designate that I am satisfied v\ ith the restoration of my property, and that no items are in 

questions, now, or at any time in the future, except those items listed below, ifany. 

Property ID: ^/^g ^ 

Property Address: ^ ^ ^ /^yU/ ^ /U/ ^ T 

Owner: fy^__^y/ l /7yV/\-77 ^ O7 J 

Phone: C/^^,^/^ ^ 

Restoration Items in Question: 

Item: /l/ld-(A.i4oig- S^ 5 t ^ 4-l/U^ ^PglK/-6i^iA>ie^ 

Item: 

Kern: 

Item: 

rtem: 

Item: 

Additional Comments: 

lyf I agree restoration is completed, except as noted 

I I do not agree restoration is completed 

7/jy /±j^ _y Owner's Signature Date Contractor' jcts Signatur Signaturee Date '

I
PROPERTY CLEARANCE WORKSHEET 

Property ID 

Property 

Date 7D!y37Q>^ 3/%.^ 

Project Omaha Lead — Fixed Price Address ^yp y HyJz/T^^ ^ 

Measurement 

XRF ID 0107-51 Count/Time 

Field Shots 

Shot # Reading Sample Area Shot # Reading Sample Area 

553: 17^ ihi^"' 'fit y. ^ ^. 'W-

M Lr - y " 

L . ^ -kr tu- '9. ^'^ " 

Sample Area 7^^ 1^- n. r 

I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag ; Number Results (Bag) Sieved) 7 

j y XRF Corrected Value - > 

(use calibration chart or add 

2 0 % to value) m 

Sample Area Pass/Fai l ? 77^^^ I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Baq) Sieved) 7 

2 

3 1^'^ 

4 5V 53 

XRF Coi^cte ^ 9 a Value - > 

5 (use calibration chart or add 

20% to value) y 

Sample Area 

Aliquot 

1 

In Situ 

Reajjin Rea m d q 

e>i /^- ^ rr 

Composite Readings 

(Bag) 

sx 

Composite 

Average 

(Bag) 

Composite 

(Dried & 

Sieved) 

Pass/Fail ? 

Analytical 

Spilt Sent Lab 

Number 

Analytical 

Results 

^ 

^ 

l ^ 

m- ^s XRF Corrected Value --> 

(use calibration chart or add 

2 0 % to value) 

i^ 

ni_ -

Sample Area P5^ s^-^'^ Pass/Fai l ? 

Aliquot 

1 

2 

3 

4 

5 

I n Situ 

Z ^ y 

j '' \t l 

y i 

^ / 

Composite Readings 

(Bag) 

7b 4 9 

XRF Coi^ecte' 1 yd Valuy e ­ > 

(use calibration chart or add 

20% to value) 

Composite 

Average 

(Bag) 

iiLe 

\y 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

7 

Lab 

Number 

Analytical 

Results 

Sample Area Pass/Fai l ? 

Aliquot 

1 

I n Situ 

Readinq Composite Readings 

(Bag) 

Composite 

Average 

(Baq) 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

7 

Lab 

Number 

Analytical 

Results 

2 

3 

4 

XRF Corrected Value - > 

(use calibration chart or add 

20% to value) 

li%t ADDIIIOHAi SHtfI S IF 

XRF Technician's Signiture Hirinn 

5 
tt . ^ , l^o?)q^48 

Name: f^U/a 7\n/7{/Jor ^ 

Address"^Z^og fihICm y 

Phone: ^4^.^J ^y^y-'-Jty j 

1C^/S5' y (yu-'^y^—

Omaha Lead Site 

Site Sketch 

Date: 77/7(3 ^7z7o'> 

Time: /2^^.5" 

.CX^ 

y P.2-/^ /<^ 

North Arrow 

t 

Team ^/^J^^A^ /^/J(JU(? BV1D# 3 i 7^ ^ XRF Code IMi 

Sample Number Lead Concentration Confirmation Sample 

pYes n No 

7'y7)fz:f&ip 7>in(p^ 

,.(- ^j»y • ppm pZYes

6) Yes

g>ZYes

 a 

a 

^ 

No ^ -

No M 

Nom 

No/S 

(;/l2.ggy> ppm Yes n No n 

ppm Yes • No • 

j^i?g^ 

p I ^) Kni^ 

Omaha Lead Site 46130 
V*"***^' ' COASTAL ^ , _«C. EHVmONMJNTAl 

' »*Ol * C < O U » . 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: 

euz/^ 

Owner's Name: - ,>. ^.^ ^ ^ , Daytime Phone: 7J^3'^/Ci' ^ A7^T7>e^S07U 

Address of Property z^os /^AJ/eiV^ 

covered by this 

Agreement: 

PURPOSE OF RESPONSE ACTIVITIES 

The EPA is requesting access to collect soil samples and remove soil that contains 

elevated concentrations of lead and may pose a health hazard. The area(s) will be 

excavated to remove contaminated soil. The removed contaminated soil will be 

replaced with clean materials and the area will be restored to its original condition. 

This work is being performed under the Omaha Lead Superfund Site remediation 

program. 

A representative of Coastal Environmental Group, contracted by USEPA, will contact 

the Grantor in-person to discuss the work to be performed, the Grantor will have an 

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

before it begins. Once the work is finished, the Grantor will be asked to review the 

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

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

has been remediated. 

ENVIRONMENTAL RESPONSE 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 
S^^^/

 COASTA L 

CROUP , INC . 

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

piles, dog houses, etc; 

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

to save; 

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

necessary subsequent to an initial watering period by EPA; 

• Abide by health and safety guidance provided by EPA; 

• If the property is rented, assist EPA in obtaining tenant approval for access to 

the property to perform the work. 

• Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any ofthe 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 (712) 352-0188 

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

777,^ y /yyiyUyy yy^^^My^ 

Signature Date Signature Date 

, ^ I would like to be present during any sampling that is required. 
1 

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: ^(7<^g , 

Property Address: 2.^5^3 ^ T^V^^/g y 

Owner GLj/A z^ub-e/esai^ 

Phone: </5-3.<9r/^ 3 

On the attached diagram(s) indicate area(s) to e.xcavated and depth of e.xcavation. location of all Icnown 

utilities, subsurface features, surface structures and landscaping features, access location(s) to be used by 

contractor, and the direction of North. Indicate distances, depths, material t>'pes. etc. Indicate digital photos 

by referencing the photo-log number w ith an arrow indicating direction of view. 

Items To Be Removed By Owner Before Start Of Remediation: 

(Use additional sheets as necessary) 

The removs!. storage, disposal, and/or return of these items is the Owner's 'esponsibiiitv'. 

Item: 

^/l^yTi // Pc C/lAJIS 

Item 

UMt^ i^-ry^ 'D/zi\7eoJA(/ 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of ^ 
COASTA L 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: 

L)o/o€ 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 2 of. 
COASTA L 

P . I n ^ 

Items To Be Removed By Contractor During Remediation And Replaced 

(Use additional sheets as necessary) 

Item: 5oh 

Item: 

SOI L 

Item: 

vu^x€ TQCK- Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 of. 
COASTA L 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunic diameter 

Number of Sprinkler 

Zones, Control Valves. 

Timers. Heads, etc. 

AUUL-II il skeicl: o!' I'-'e 

sprinkler iavout. 

Number of and size of 

each garden/ flower bed 

area. 

Auacli .n skeicn o\ relative 

<i;'e- anJ locaiioni. 

Landscape Inventory 

(Use additional sheets as necessary) 

Quantity Unit Condition/Type/Species 

Square feet 

Each 

'^4Vt 4/ / 

f^5e.6t7S^^ 

Each 

Each 

Each 

Square Feet 

Page 4 of. 
Item Quantity Unit Condition/Type/Species 

Agreed upon value of 

plant materials not to be 

reolaced bv contractor. 

Note this value will be 

used to issue a plant 

\oucher to the property 

o\>ner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a sketcli of were 

each plant will be placed 

b_\ the coniracior. 

Agreed upon area of 

properr>' to be replaced 

with grass sod. 

•iiclude a ^keu:h of ihc 

area(s) lo be repl'jccc! w ;iii 

yrass >c.d. 

.Area of City or County 

propert>' to be landscaped 

per their requirements. 

liKluLie <-. -keu-ii of ;hc' 

1 rivea is) 

Easement Area, to be 

excavated 

0 $ 

l/Ji/ive 

Each ^^.^<,Cd ^ yy^^ip 

SF 1 

SF 

SF 

Page 5 of 
COASTA L 

ENVIRONMC NTAL 

Additional Comments / Instructions: 

• 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. 

j 2 I agree O I do not agree 

^_?i^:a7 

Owner's Signature Date Contractor's Signature Date 

Page 6 of.