TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: /^7J- / Date: ^7JS^/J^7 

Address: 17^/ ^ 2Z^ Sf 

Remediation Contractor: Coastal Environmental Group_ Year: 2007 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

M Executive Summary 

M EPA-provided property sketch 

W - Signed Access Agreement for subject property 

Q Signed Access Agreement(s) for adjacent property 

^ Restoration Agreement 

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

[y Confirmation data 

o / Photographs b&(?Vg., ^ f^ n VOX^nA ^ Sr^c\ ^ ^^-0<loLi 

m As-built sketch 

M Satisfactory restoration signed by Property Owner 

0^ Property close-out check list signed by EPA ^/(^/;2<^ y 

n Descriptionof areas not meeting ROD cleanup criteria 

M Utility clearances 

W^ Property information from Douglas County Assessor's Office 

10^ 'fi?>|Wy - Qj^eS^ ["{y&yJ^il^^ 

^ PG^acJr '\bc"tY\ l 

f Date 

40317160 lllliiiil 

Superfund 
« 

Property Access Checklist 

Property ID: JTJJ ^ 

Property Addre»: /7^ / $ ^ ^ ' ^ ^ ^ 

ownen

Address:

Phone:

Fax: 

Cell/Pager: 

 /A/i^iCfo lUinckackci 

 Jy^^ ^ S • 9U ^ S h 

 Td'^'Kl^^ l 

I I Notification Letter 

0^ Access Agreement 

fcL'-ifestoration Agreement 

l~l Topsoil Sampling (if applicable) 

r~l Disposal Sampling (if applicable) 

r~l Garden Sampling (if applicable) 

E^tilit v Clearance 

Video/Photos (Before) 

^ Video/Photos (During) 

y/video/Photos (After) 

D / Video/Photos (30-Day) ^ Property Completion Agreement 

I I Final Report 

i

Air Monitoring (as applicable) 

r~l Community

Results: 

• Community

Results: 

f~1 Community

Results: 

 CD Crew On:

 • Crew On:

 [ 3 Crew On:

Sent: 

Signed:

Signed:

Called:

n WORK STARTED ON: __/__/_ 

D WORKCOMPELTED ON:__/__/ _ 

Renter: 

Phone: 

Fax: 

Cell/Pager. 

Additional Information: 

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On: 

Signed: ii' / 9 / CH 

Issued: 

/ / Bv: 

• 

/ / By: 

/ / By: 

Omaha Lead Site 

Bv: 

8>-= i^a7Cd5 

By= AMtca y 

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Bv 
19121 

Omaha Nortfi Arrow Lead Site Exterior Paint Owner Name: OSeT^iR-OfcVeaA 

Site Sketch • Good Address: 1721 S 26 ST • Poor Phone: H: j^^--^55^W : ^ 

[2''l5ot paint 

Sample Number 

RYASCPXA-19121 

Lead 

Concentration 

5-5-7 I 

LAB Firm:

Date:

Samples Collecled 

 P ^ OfJ/^T^ 

 *7-Ji-8 ' OH 

RYBSCPXA-19121 _J£2J_ \ Time. )i'-H S ^' > 

RYCSCPXA-19121 

RYDSCPXA-19121 

\H7Z

3A?> 

I 

Samples Analyzed 

RDZSCPXA-19121 8 I 0 Book: 

V'r-^C>Z5CPXA-I9121 

•—RPZ0CPXA-1Q121 

Number of Samples 

L - A 

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Parcel Search Page 1 of 1 

Results 1 - 2 of 2 

e Q Parcels 

3 MENCHACAIGNACIO 

a 1721 S 26 ST 

Parcel ID 

Owner Name 

Property Address 

City 

Zip 

Owner Address 

Owner Address 2 

Owner City 

Owner State 

Owner Zip 

Sec-Twn-Rng 

Owner Address 

Addition 

Block 

Lot 

Legal 1 

Legal 2 

Legal 3 

Legal 4 

Old Assessor Site 

New Assessor Site 

2200280000 # 

MENCHACA IGNACIO 

1721 S26ST 

OMAHA 

68105 

1721 S 26 ST 

OMAHA 

NE 

68105 

28-15-13 

SCULLYS ADD 

18 

20 

N35FTLT19& 

S10FT 

Valuation Information 

Valuation Information 

VOLQUARDSEN RANDALL 

1721 S 126 ST 

http://www.dogis.org/dogis_alias/dogis/parcelSearch.aspx?govUser=false&validUser=false 4/19/2007 
Yahoo! Mail - trishkasl(;ffivahoo.com Pa^e 1 of2 

f MAIL Print - Close Window 

From :

To!

Subject:

Date:

 "NE DIGGERS" <info@ne-diggers.com> 

 trishkasl@yahoo.com 

 Re: NE-Diggers.com ­ LOCATE Contractors Request Form 

 Mon, 30 Apr 2007 13:16:00 -0500 

DIGGERS HOTLINE PRESENTS THE 'NO WAIT N.I.T.E.S. TICKET ENTRY! 

Avoid lengthy wait time - Immediate ticket number response - User has access to all issued tickets. 

FREE training sessions. Contact Connie or Lisa at 402-330-1866 for further information. 

Ticket* 1773962 

Work Begin Date : 5-2 at 115 pm 

Utilities Notified : City of Omaha Traffic & Sewer, Cox, Mud, Oppd, Qwest Local, Levle3, Mci, McLeodusa, 

Qwest Long 

If There are any other utilities not mentioned above you will need to notify them yourself. Any privately owned 

lines will not be located. 

Thank You For Using Email. 

Original Message — 

From: trishkas1@yahoo.com 

To: info@ne-diggers.com 

Sent: Monday, April 30, 2007 12:03 PM 

Subject: NE-Diggers.com - LOCATE Contractors Request Form 

NE-Diggers.com - LOCATE Contractors Request Form 

Name: Trishka Simmons 

Alt. Name: 

Phone:402-504-2194 

Alt. Phone: 706-7322 

Email: trishkas1@yahoo.com 

Caller ID: 18790 

Company: Coastal Environmental 

Type of work: Excavation 

For Whom: Coastal Environmental 

How Deep: 3ft. Oin. 

Explosives: No 

Corner Lot: No 

Front of Property: Yes 

Rear of Property: Yes 

Tunneling/Boring: Yes 

County: Douglas 

City: Omaha 

http://us.087.mail.yahoo.com/ym/ShowLetter?box=Inbox&Msgld=1029_2346958_27400... 4/30/2007 
Yahoo! Mail - trishkasl@,yahoo.com Page 2 of 2 

Address: 1721 S. 26th. St. 

Directions: 

Where on Property: 

Overall 

Township: 

Range: 

EorW: 

Section: 

1/4 Section: 

Township: 

Range: 

EorW: 

Section: 

1/4 Section: 

http://us.fi87.mail.yahoo.com/ym/ShowLetter?box=lnbox&Msgld=1029_2346958_27400... 4/30/2007 
*'•«'>> . 

US Army Corps 

•>i.nofi^ atsasi^iaers • 

Consento para el Acesso de ia Propiedad 

DERECHO A ESTRAR UV PROPIEDAD 

Otoigante (duefio(a) de propiedad) se da consento y autoriza la Agencia para la 

Proteccion del Medio Ambiente de Los Estado Unidos (EPA) o su representantes 

autorizado, en conjunto el Cesionario, a oitrar y llevar a cabo algunas actividades 

ambieotales acerca de la propiedad describido que sigii£: 

Dueno de la Propiedad: i / J^A n 

«Owner_Na]iia» ilArT Nmnero Diario: I p^ 11 ^ ^ 

<{Second_OwnerName» M ^ H ^ UACA 

Direccion: «Propert7_^&ddress» | 

Direccion: |^^ | ^^ ^^-(l y ^ ^ 

Direcci6n de 

Propiedade Direccl6n: s Cubieto 

por este Acuerdo: Direccion: 

Direccion: 

PROP6SITO DE ACTIVIDADES AMBIENTALES 

El EPA solicita el acesso a collectar muestras de tierra y remover tierra que tiene alta 

concentraci6nes de ars^ico y/o plomo que podria ser peligroso a su salud. La tierra 

estard removido y eI(los) area(s) excavado(s) estara reanplazado con materials limpias y 

restaurado. Este trabaja estara realizado abajo del Vasquez Boulevard/I-70 Superfund 

Site programa de remediacidn. 

Un representante de EPA se contactaii el Otorgante pesonalmente a discutir el trabajo 

estar realizado, el Otorgante tendra la oportimidad a examinar y sancionar el plan de 

removimiento de tieira y el trabajo de restoraci6n antes de comenzar. Cuando el trabajo 

se termina, el Otorgante estara pedido a revisar el trabajo, confirmar su terminacion y 

cinnplir con su apFobaci6n. Despuds de terminaci6n, el Otorgante recibira un documento 

escrito por el EPA que indica la propiedad habia sido remediado. 

ACCIONES DE LA RESPONDENCIA AMBIENTAL. 

Por su firma de este Acuerdo de Acceso, el Otorgante concede el EPA, sus «npIeos, 

contractors y subcontractors el derecho a entrar la propiedad, en tiempos razonable y sin 

noticia anterior, para el unico proposito a realizar trabajo. Este acceso deberia persistir en 

efecto hasta que el trabajo habia sido terminado en un estado aceptado. EI Ortogante 

tamiben estd de acuerdo con: 

Pagina 1 of 2 «PropertylD» 
Property ID # 

Property 

Address: 

Initial Contact:

Second Contact:

Final Contact:

Final Action:

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

CONTACT FORM 

M/^l 

no^i "S^^b^si: 

 Date: "A^^^'^Time: 

 Date: Time: Action: 

 Date: Time: Action: 

 Transmit to EPA D Other Action: D 

'• 3o prv^ • 
^ u s Army Corps 

.att^ ot Engineers • 

Omaha DtsUKt 

• Remover obstruciones que incluye twtes, remolque, vehlculos, jugetes de nifios, 

montones de madera, casas de perros, etc. 

• Remover de bulbos de flores, o otras plantas que el Otorgante o inquilino del 

Otorgante quisiera guardar; 

• Regar y mantener reemplazo de vegetacion, incluso la aplicaci6n de fertilizante, 

como es necesario subsecuente de la riega inicial por el EPA, a menos que 

regando estd restringjdo por la Junta de Agua de Denver. 

• Peimanecer por la guia de Salud y Seguridad proveido por el EPA; 

• Si la propiedad cstk rentado, asiste el EPA a obtener la aprobacidn del inquilino 

para acceso a la propiedad a llevar a cabo el trabajo, si el EPA esta inhabil a 

obtener acceso; y 

• Permitir a hacer un video y/o tomar fotos de la propiedad incluyendo los areas 

exterior y interior de edificios. 

ACUERDO A No INTERFERIR 

EI Otorgante esta de acuerdo a no interferir o meterse en cualquier actividades o trabajo 

hecho, 0 el equipo usado a llevar de cabo los actividades, o hacer cualquier acciones en 

respecto de la usa de dicho propiedad que podria arriesgar la salud o bienestar de los 

Cesionarios o el medio ambiente, o peimitir otras personas a usar la propiedad en alguna 

manera. 

Si tiene preguntas sobre este programa, por &vor contacta Jennifer Chergo at 303-312-6601 

or Pat Courtney at 303-312-6631. 

0 Si yo permito acceso a mi propiedad Q No permito acceso a mi propiedad. 

dfl^l^y ^ "TTZ^ynX^^ ^H'2.yp>J 

Firma Fecha Firma Fecha 

n Me gustaria ser presento durante de cualquier coUccidn de muestras. 

Pdgina2of2 „ , , ^ 

^ ^ «Property_ID» 
Restoration Agreement 

The purpose of this agreement is to pro\ ide a mutual agreement as to conditions of property prior to 

remediation activities. This uil i also ser\e as decontamination for the purpose of assuring that 

restoralion activities are completed to the satisfaction of the property owner and the L'nited States 

En\ ironmenlal Protection .Agency (EPA). 

Property ID: \Tr2T 

Property Address: |^>^ ( (^ VQ ^ ^' ^ 

Owner: \(A^^A> S 

Phone: M^ctty^/^Qr vnip 

On the attached diagram(5) indicate area(s) to excavated and depth c f excavation, location of all known 

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

contractor, and the direction of Nonh. Indicate distances, depths, material txpes. etc. !:idicate digital photos 

bv referencing the photo-log number v\ ith an arrow indicating direction of v iew. 

items To Be Removed By Owner Before Start Of Remediaticr.: 

(Use additional sheets as necessary) 

The removal, storage, disposal, and/or return of these items is the Owrer's responsibility. 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of ^ 
i S ^ 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Page 2 of [(/ 
v(PA 

Items To Be Removed By Contractor Durin g Remediation An d Replaced 

(Use additional sheets as necessary) 

Item: 

U-^ »i^ 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 o, C 
vCP^ 

Landscap e Inventory 

(Use additional sheets as necessary) 

Item Quantity Unit Condition/Type/Species 

Pre-existing propert\ area 1<^^ Square feet that is covered vsith iirass. 

Nuniber of trees > 2 inch 

Each I trur.k diameter fl K 

N-ir.bcr cf tree^ • = 2 inch J^ ,,-ii 

irLnk d;a:7Te;er 

Number of Sprinlvler 

Zones. Control \al\es. 

Timers. Heads, etc. 

J>- Each 

Attach a sketch of the 

sprinkler lavout. 

Number of and size of 

each garden fencer bed 

area. Each 7 ^ Square Feet 

Attach a sketch of relative 

sizes and locations. 

Page 4 of 
Item Quantity Unit Condition/Type/Species 

Agreed upon value of plant 

materials not to be 

replaced by contractor. 

Note this value

used to issue

voucher to the

owner. 

 will be 

a plant 

 property 

- ^ 

Agreed upon list of plant 

matenals that will be 

replaced by contractor. Be 

very specific and delailed. Each 

Include a sketch of vsere 

each plant will be placed 

bv the contractor. 

.Agreed upon 

propertx to be 

with srass sod. 

area of 

replaced 

Include a sketch of the 

area(s) to be replaced uith 

srass sod. 

m

W SF 

Area of City or Countv 

propertv to be landscaped 

per their requirements. 

Include a sketch of the 

area (s) 

% . 

\4 

SF 

Pag ^ e 5 of 
I 

Additional Comments / Instructions: 

Wilt uifi fcfVi iMf ^ 0 i^m ( ^ Iff^miuo, 

• 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. 

• I agree n I do not agree Dl agree I 1 I do not agree 

(Owner's Signalure Date Page 6 of. ictor's Signature Dale 
PROPERTY CLEARANCE WORKSHEET 

Date 

Project 

OS/21 /n? 

Omaha Lead -­ Fixed Price 

Property ID 

Property 

Address 

\Q\2l 

IT2I ^m- ^ 

XRF ID 0101-61 

Measurement 

Count/Time 

Field Shots 

Shot # 

.42_ _SQ_ S S 

_Lr>ie_ 

IfiQ s: 

Reading 

..dk. 

^ I 

HT. :E: 

E: 

:BJ 

p ^

I g

Sample Area 

 e?AgAr-i^c^) 

 Af^Kjt^O W)\i^j£. us: 

Hot 

Shot # Reading Sample Area 

Aliquot 

1 

2 

3 

^ 

5 

Sample Area 

I n Situ 

Reading 

IS 

19- 2 3 

IZ 

Z6 

FZ 

Composite Readings 

(Bag) 

4? 

^-5 

4-5 

XRF Corrected Value - > 

(use calibration chart or add 

2 0 % to value) 

Composite 

Average 

(Bag) 

4 6 

' 6>G 

Composite 

(Dried & 

Sieved) 

Pass/Fail ? 

Analytical 

Spilt Sent 

? 

t 

Lab 

Number 

Analytical 

Results 

Aliquot 

1 

2 

3 

4 

5 

Sample Area 

I n Situ 

Reading 

G^ 

Composite Readings 

(Bag) 

4q 

l\T­ 1 

^5 ? 1 

XRF Corrected Value -- > 

(use calibration chart or add 

^20 % to value ) 

Composite 

Average 

(Bag) 

|j 5 

; 35

Composite 

(Dried & 

Sieved) 

'i 

Pass/Fail ? 

Analytical 

Spilt Sent 

7 

Lab 

Number 

Analytical 

Results 

Aliquot 

1 

2 

3 

4 

5 

Sample Area 

I n Situ 

Reading 

l l 

f^S 

f5 

f^3 

TO 

i^ 

Composite Readings 

(Bag) 

A\ 

y, 1 

4 4 

XRF Corrected Value - > 

(use calibration chart or add 

2 0 % t o value ) 

Composite 

Average 

(Bag) 

dPi 

i m 

Composite 

(Dried & 

Sieved) 

Pass/Fail ? 

Analytical 

Spilt Sent 

•> 

Lab 

Number 

Analytical 

Results 

Sample Area Bl Pass/Fail ? 

I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical Reading Average (Dried & Spilt Sent Number Results ( oag ; 1 (Bag) Sieved) lOG, 

Confidential 5/2/07 Pace 1 of 2 
2 ? s ^ 'iP 

3 ^ ::7r^ 5A 4 IS TSF. XRF Corrected Value - > 

5 ao (use calibration chart or add 

2 0% to value) ^ 1 

Sample Area D2 (^/s^AG45 ( 3 7 Pass/Fail ? 

Aliquot 

1 

I n Situ 

Reading Composite Readings 

(Bag) 

Composite 

Average 

(Bag) 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

? 

Lab 

Number 

Analytical 

Results 

2 A-4- 3 

4 2A0 IA2 

XRF Corrected Value - > 

5 (use calibration chart or add 

2 0% to value) l(iZ 

:St ADDl ' IdU L $•-[:' j : " 

XRF Technician's Signiture M;:-D 

^TTW/ (\^/fj>y> 

Confidential 5/2/07 Paqe 2 of 2 
1

XRF DAILY CALIBRATION WORKSHEET 

Date 

Project Omaha Lead -- Fixed Price 

XRF I D 

Measurement Count/Time 

Calibration Verification Checks 

High 

5532,0 ppm 

5638.4 ppm 

•4425.6 Dpm 

SlTrn 

1 

1 

1 

i 

High 

5400 

SWA 

4a/()A 

5^aD 

sosn 

6210 

SitjO 

Reading 

""rue Value 

 120 % 

8 0 % 

1 

1 

j 

IPrecisior, MeBSu'eme-its 

Ave-age 

Replicate 

-

2 

3 

£. 

-

5 

7 

'•Ice" C:^.;£';'c; c" 

SiE'-'Cc'G Deviat e 

Re-.E5-£-5-:I?.e:c ' 

•<£ 2t •. e '^'.z'Z'i.'Z 2e V =: c" -iss 

Blank Low 

0.0 ppm 18.9 ppm 

22.7 ppm 

15.1 Dpm 

1 

1 

F .-ecisicn Mea ; JLrerr.ent Ir e 

Blank Low 

Med 

1162.0 ppm 

1394.4 ppm 

929. 6 pom 

e(p-2> 

CK 

v e c 

1050 

q^lo 

n«50 

1/17n 

a/w» 

/mo 

I04A 

— \ . ^ f : ; C I Confidence Interval ? .95 --> 

Method Detection Limit JTVALUE' 

Average Confidence Interval | LVALUE I 
5 

2 —

3 

4 

XRF Corrected Value ~ > 

(use calibration chart or add 

2 0% to value) 1 

Sample Area Y)7 Pass/Fail ? Aenimn fcjso I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical Reading Average (Dried & Spilt Sent (Bag) Number Results 1 (Bag) Sieved) 7 

2 ^a 3 2-1 25 4 Z<B 

XRF Corrected Value - > 

5 (use calibration chart or add 

1 2 0% to value) 4 5 

ADDl'IOri' t • 

XR 'iEE:E D F Technician's Signiture 

//CO 

Confidential 5/2/07 Page 2 of 2 
/^;^JL\ Omaha Lead Site—Fixed Price EP-R7-07-05 

S ^^^^ 1 Coastal Environmental Group Inc. 

\y^^ ^ www.coastalhazmat.com 

'•".no^ " COASTA L ENVIRONMENTA L 

C R O U f . IN C 

EXECUTIVE SUMMARY: 

19121—1721 South 26 Street 

X No issues or concems Issues or concems 

Detail Explanation: 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

OLS#:19121 

Date Excavated:5/21/07 

Date USEPA Signed Off: 6/6/07 19121 

Omaha Exterior Paint North AiTow Lead Site Owner Name: OSCAR OLVERA • Good Site SItetch Address : 1721 %26 ST • Poor Phone : H: [g-'l^ot paint 

Omaha Lead Site 46130 

Legen d 

Area not Excavated VyA Dripzone Excavated [>223 Quadrants Excavated 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
SERQL 

Property Completion Agreement 

This agreement documents the completion of removal activities performed on the below listed property. 

The property owner's signature indicates that the property owner is satisfied with the restoration ofthe 

subject property, and that no items are in question, now, or at any time in the future, excluding any 

remaining sod warranty (30 days total) except those items listed below, if any. 

Property ID: I ^19- 1 

Property Address: TlVT~S7VW^^^ 

Plione: 

Restoration Items in Question: 

Item: 

/ l o --Lhc^^i , . -^ ^v'v/w:--S.WcS-U 

Item: j 

Item:

Item: 

Item: 

Item: t 

M l agree restoration is completed, except as noted above. 

I 1 do not agree restoration is completed 

-•9^<7^ Or^^y ^ h <o -05 - 0 ^ 

Owner's Signature Date 

 i 

I
aEPA • 

EPA Property Close Out Form 

Property #: _ jR/Q^I Property Address: 119'i S-^l^-T^TDate/Time: Owner's Name: JijIldaiO AUtWAO/'Jia.. 

Quads Excavated: Contractor Group^ 

Excavation General Yes 

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 Vegetation 

Yes

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

from the house? 

i X 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) Oy^tLors -k) be , 4o o /eJ^^bUJCU^ y cl\|^nH^I <'oo Alr^a wu>^j-^tlfe^ 

4. Are sodded areas generally Hrm 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 danuge to landscaping or plant materials avoided? 

Gates, Fences and Retaining Walls Yes 

1. Do gates open and close freely? (Ifapplicable) i)A 

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

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

4. Wasdamagetoretaining walls avoided? (Ifapplicable) . i 

Foundation, Siding and Gutters Yes 

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

2. Was damage to the foundation avoided? L ^ 

3. Was damage to windows avoided? L ^ 

4. Was damage to windows or door screens avoided? <---' 

^ 5.

 Was damage to downspouts or downspout extensions avoided? 

Sidewalks and Driveways (Concrete) Yes 

1. Was damage to driveway surfaces avoided? i ^ 

2. Was damage to walkway surfaces avoided? ^ 

No 

 No 

No 

No 

No 
Owners comments: 

Inspection notes: 

Removal and restoration activates uding the 30-day sod warranty: 

EPA Representative Date: 4 jAr^ J^OJ