TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: TVJTI/ZS Date: 3//7/fe 

Address: Jis7:3 3/7)7)Jc?S+ 

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 

Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

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

4 Confirmation data 

Photographs 

4 As-built sketch 

7 Satisfactory restoration signed by Property Owner 

7 Property close-out check list signed by EPA 

Description of areas not meeting ROD cleanup criteria D 

Utility clearances D 

Property information from Douglas County Assessor's Office D 

D 

D , 

a 

4 ^ 

40317774 

Superfund 
Final Report Property Check List (pieasc place n^idi each nie) Q ^ 9i^7:> 

Hard Copy, nformatioo ^5^<^, /3|^c/c/c ^ 

1. Property Check I.i.sl ^ 

2. Site Wori<ing Drawing Map 

.1 HPA originals Map 

4. Douglas County Assessor's Map 

5. Property ContacI Sheet 

Ajireenieiit 

1. Aeeess Agrceinenl 

2. Resloration Agreement 

Miscellaneous Documents 

1. Final Map ft-oin the Field 

2. Change Orders 

.1 XRF Data 

4. Any emails or PO correspondences 

Property Completion 

1. Executive Summary 

2. AS BUILT 

,v Propeity Completion Agieement 

4. Any buyout into or reimbursement into 

5. Check or money order copies 

6. F.PA Propetty Ck)se Out Form 

7. Attaehed Begin Video 

I^Jectronic Documentatio n 

I)rawiii<»,s 

1. liPA original 

2. Working Drawing 

.1 AS Built.vso 

4. AS Built.jpg 

Photos 

1 Begin PhotOvS 

2 During/F'lxcavation Photos 

-^ Sod Photos 

'1 .10-Day Sod Photos 

Scanned Documents 

Final Documents 

'' Fxeculive Summary 

Videos 

' Begin Video 

2 My Movie 
« • 

Property Access Checklist 

'^'"^*L'^:_2Z2fc^5

Property Address: ;^eO g

 1 

fe^QO^Q ^ . 

•

D

 WOUKSTAUTliD

 WOKK COMPELTED

 ON:

 ON:

I/

 /

 I;

 / 

i 

Omicr: jfSjg^ l l^e V Ao(3ls» _ ,1.1.1 I .Addres.s 

6/) ySS-zTz^ Phone: 

l-'iix: 

Renter: 

Phone: 

Eax: 

Cell/Pawr: 

Additional Infonnation: 

Cell/Paoer; 

n Notification Letter 

1 ^ Acces.s A<i;reenient 

jytj Restoration A{>;ieenient 

n To|)soil Sam|)liiit; (if a|)plical)le) 

I I Dis|)osal Saniplinji (if applieahle) 

CU Garden Samplin<4 (if applieahle) 

Utilitv Clearance 

M Video/Photos (Before) 

U Video/Photos (Durinji) 

n Video/Photos (After) 

n Video/Photos (30-Dav) 

I I Pro|)eit.v Completion A<ireenient 

n Final Report 

Sent: 

Signed: | 0 / ^ / 0 7 

Signed: 10/4/^ 7 

Bv: 

»•>• CJqr.' s 

Bv: 

Called: [0_/_^/bl l 

On: 10/ 4 ^ 07 

On: 

On: / / 

On: / / _ 

Si"ne(l: / / 

Bv: 

Bv: 

B>ijim@joo5.^j3_ 

J^octKcott 

Bv: 

Bv: 

Issued: / / 

Bv: 

Bv: 

Bv: 

Ail- IMonitorinj; (as ap|)lical)le) 

1 CU Comnuinity CU Crew 

Results: 

On: / / By: 

CD Community

ResuKs: 

 E] Cin \ On: / / Bv: 

1 cn Community

Results: 

 CD Creiv On: / / By: 

,. . . .... =.. ... ,„. 

Omaha Lead Site 

i 
^ ^ o"^ ^ 

27263 

Owner Name: NEAL L REYNOLDS 

Address: 2508 BLONDO ST 

Phone: H:

Sample Number 

RYASCPXA-27263 F1 

RYBSCPXA-27263 F2 

RYCSCPXA-27263 Bl 

RYDSCPXA-27263 82 

RDZSCPXA-27263 DZ 

RGZSCPXA-27263 GZ 

RPZSCPXA-27263 PZ 

 W: 

Lead 

Concentration 

yy 

Omaha Lead Site 

Site Sketch 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

Sample 

Collected 

uy 

\ ^ 

n 

D 

D 

Number of Samples '• y 

^^^$ ^ 

LAB 

D 

D 

D 

D 

n 

n 

• 

L 

Exterior Paint North Arrow 

• Good 

• Poor 

P~| Not paint 

Samples Collected 

Firm: 

Date: 

Time: OS 

Samples Analyzed 

XRF Unit: J)\ \ Book: M 4 ; 

Date: "^5^1/ ^ \ _

Time: 

^ 

Staff: 

^ 

ENTERED 

SEP 2 0 2004 

^.^^m 

B.I.QKi.PQ 

Omaha Lead Site 46130 
27263 

Omaha Lead Site Owner Name: NEAL L REYNOLDS 

Site Sketch Address: 2508 BLONDO ST 

Phone: H: W. 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

RYASCPXA-27263 Fl 7^ \ % ppm D 

RYBSCPXA-27263 F2 C^[jl % ppm D 

RYCSCPXA-27263 B1 ?> Li)Q ^ ppm n 

RYDSCPXA-27263 82 C\C\ I n ppm n 

RDZSCPXA-27263 DZ ppm D n 

RGZSCPXA-27263 GZ ppm D D 

RPZSCPXA-27263 PZ ppm D n 

Number of Samples = TL 

^ 

• ^ ^ 

5u^ y\\v 

- ^ ^ 

7 t ^a 

SI'S TXM 

.BIo^JPO S T; 

Exterior Paint North Arrow 

• Good 

• Poor 

• Not paint 

Samples Collected 

Firm: f [X/CN I | (^ T 

Date: Og | O[A ^ 

Time Q\Qi 

Samples Analyzed 

XRF Unit 

Date ^TAII.€^V-( 

Time £v^ 

Staff: 

^ 

ENTEEED 

SEP 2 0 21)04 

Omaha Lead Sile 461.30 
Douglas County Account Informatio nforn n Page 1 of 1

Douglas County, Nebraska Property Record - R1944500000 

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 

Owner 

REYNOLDS NEAL L •i/y/^ z y 

37211 MILLFORDCT - ^ ^ ^ ^ ^ ^ ^ 

''^y)73^y'y^y ^ 

PALMDALE CA 93550-0000 

Property Information 

Key Number: 4450 0000 19 

Account Type: Residential 

Parcel Number: 1944500000 

Parcel Address: 2508 BLONDO ST 

OMAHA NE 68111-0000 

Legal Description: PARKERS ADD LOT 2 BLOCK 2 W 31 FT 31 X 63 

Value Informatio n 

Land Improvement Total 

2007 $200.00 $0.00 $200.00 

2006 $200.00 $0.00 $200.00 

2005 $200.00 $0.00 $200.00 

2004 $0.00 $0.00 $0.00 

2003 $200.00 $0.00 $200.00 

2002 $0.00 $0.00 $0.00 

Sales Information 

Land Informatio n 

Acres SF FF Units Depth Width Vacant 

0.04 1953.0 31.0 0.0 63.0 31.0 Yes 

Land Attributes 

Attribute Attribute Description 

Improvemen t Information 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R19... 9/27/2007 
Douglas County NE GIS Map 

y 

LEGEND 

Minor Streets 

Out 

Major Streeu 

y Mj(ofai«Mi 

Interstates 

X IntantAtes 

Parcels n parcelZ 

• Hydro 

DrtvenbylVd^GUiD 

Disclaimer: This map is not guaranteed 

to be accurate, correct, current, or 

complete and conclusions drawn 

are the responsibility of the user. 

dz) y ,y3J% c>io'" 
CONTACT FORM 

Property ID # 

Property -

Address: 

Initial Contact: Date: Time: Action: 

Second Contact: Date: Time: Action: 

Final Contact: Date: Time: Action: 

Final Action: Transmit to EPA D Other Action: D 

Comment: 

Owner 

Comment (s): 

^

if^a^^^7<^ 

 9f7'C^ ^ 

dTtry/yyyTn^/yi^/^^y^" 7Sy<7/ '^^ ' 

Site 

Coordinator 

fJl^AC l!2e^7U>L6^ 

Comment (s): 

Q>^7 733 7yz(^ 
X 

it O ST.,. 

- * 

Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

www. coastal hazm at. com 

COASTA L ENVIRONMENTA L 

G B 0 LJ P . IN C 

EXECUTIVE SUMMARY: 

27263—2508 BLONDO ST 

No Issues or Concerns I I Issues/Concerns 

Detail Explanation: 
As-Built Drawing 

COASTA L Oinaha Lead Superfund Site 

27263 

Ejdj&fiL.M Pi'Airii t>.i|Vi Afiuwv ri Owne Omaha Lead Site r Name : NtA.L L HtYNULDS 

Sit C Good e Sketch Arfdrcss : ^ 0 BLONDO ST • r-oor 

• Mil l IIMIIII 

Sairpl e Number Leut! Sample 

CurioerKriMion 

LAB F,r. ^ CN|G j 

RYASCPXA 777fi l F l a Dale: 

RY3SCPXA-272C.? F2 n Time: 

RVC5CPXA-7776 3 R1 •SL f ^ IL. PP<" a a-5 s 

Sflmplfts Ari.-jlyj'tHj RYDSCFXA-2726 3 B2 C^ C"i| 'l p ppm n 

Kn7SCPX A /TJtii i DZ ppm a n XRF Unit %\ \ BoofciH '- | 

RGZSCO)CA-27263 « / ppm a 

RPZSCPXA-2??e3 PZ ppm • n 

Staff: i._ Ct Q . Nurribs'- of Sampfaa = ^ 

ENTERED Little trees present in B1 and 

SEP 2 fl i m B2. Big tree Is present in Fl . j 

Utnaha LLSC Silc Jdl.UJ 

OLS#: 27263 

Date Excavated: 10/28/07 

Date USEPA Signed Off: 12/5/07 Legen d 

Area not Excavated Dripzone Excavated Quadrants Excavated 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
I»EPA« 

EPA Property Close Out Form 

Property tt: 0.7^^ ^ 

Property Address: Zl '^ A g ifilcVU^C) ^-f, 

Date/Time: 

Owner's Name: l\J(^r^ I /^<"\f^ / ~ 

Quad actor Group Cj^rT^^a i ' 1 s Excavated: 

Contractor' 

Excavatioa General 

Yes No 

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

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

Gradins Sod and Vesetation 

Yes No 

1. 

Does the grading around the perimeter ofthe house in excavated areas generally slope away y from the house? 

* y 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 l y 

day time period) 

4. 

Are sodded areas generally firm and evenly graded? t y 

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 Retainins Wails Yes No 

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

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

3, Was damage to gates or fences avoided? (If applicable) ^A 

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

FouDdation, Sidinn and Gutters 

Yes No 

I. Was damage to the siding or trim avoided? 

^ 

2. Was damage to the foundation avoided? tlL 

3. Was damage to windows avoided? Pk 

4. Was damage to windows or door screens avoided? 7Ar 

5. Was damage to downspouts or downspout extensions avoided? kJDr 

Sidewaiits and Driveways (Concrete) Yes No 

1. Was damage to driveway surfaces avoided? iJl^ 

2. Was damage to walkway surfaces avoided? A / ^ 

s/7zc^>^ 7-7^7 
Owners comments: 

Inspection notes: 

771/s/o y ^ £Py ^ y^specyfron prio r 4tp HO Zf^-^f7 

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

EPA Representatiy^-:::^^^^::^,^L,^c^^fcW^ Date: 
^'m 

Property Completion Agreement 

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

will designate that I am satisfied with 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. 

Pn>pmyID^^'^^^ 3 

Property Address: ;^^^Q^^ 9^\nnd n g y 

Owner: l^^^^ y P PjJ . V^Q (CJ <;; 

^"»"--f/.(.i) T7T^-;;)i^q 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

L 

I I I afjree rtsloration is completed, except as noted 

I I I do not aj>ree restoration is completed 

,^^ . /^//-ny, £> C^f H:^y CjKlB h I' ^ I - 0V 

Owner's Date 0>ntra(3^'s Signature Date 
^^^7"^"^ f^ii^-l^ ^ ./967o5y ^77i^^j^y'' ' 7?^^>^c^ 

2726 ^%^^L\y4y Omaha Lead Site Exterior Paint North Arrow Owner Name: NEAL L REYNOLDS 

Site Sl<etch • Good 

Address: 2508 BLONDO ST • Poor 

Phone: H: W: 

\~] Not paint 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

RYASCPXA-27263 F1 D 

RYBSCPXA-27263 F2 y^ \ % ppm D 

RYCSCPXA-27263

RYDSCPXA-27263

 Bl 

B2 C\C ?S Lo ^ \M pppppmm 

uy D 

D 

RDZSCPXA-27263 DZ ppm D D 

RGZSCPXA-27263 GZ ppm D n 

RPZSCPXA-27263 PZ ppm D n 

Number of Samples = 3 J 

^ 

Siy3>.

-/;/V7 

^ 

lo-lcch-i./Qy 

%y 

^^y^

qqu (5^,1 

y7.7.^ 

'yu% 

-feigT^.e 

Samples Collected 

Firm m ^ Date: 

Time: 

Samples Analyzed 

XRF Unit •^11 BockM 

Date: _ ^TAU.^4 

Time: _ 

Staff: 

E-NTEEEDSEP 2 0 t m 

B.I.OKi-DQ.^. 

Omaha Lead Site 46130 
m PROPERTY CLEARANCE WORKSHEET 

Date Property ID 27 Z6^ ] 0-7 8-^1 

Property Project Omaha Lead -- Fixed Price Address Zfo& H<^cL s r 

Measurement 

XRF ID 0107-SI Count/Time 

Field Shots 

Reading Sample Area Shot * Reading Sample Area Shot # 

: g ^ 2Z 

MX ^ 

Sample Area 61 H'iP 

In Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent Number Results 1 (Baq) Sieved) (Bag) N l ? 

2 /t/7 lOh 

3 loi 2 < tV 4 l</3 /.O 

XRF Corrected Value —> 

5 ^3 (use calibration chart or add 

20% to ualue) 

w 

Sample Area / ^p ^-(./" Pass/Fai l ? 

In Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical 

Reading Average (Dried & Spilt Sent (Bag) Number Results 1 O y (Bag) Sieved) 

2 49- i\i ^ 3 / e P %^ j 

4 1 7 

7 

XRF Corrected'valu 1 e - > 

5 (use calibration chart or add 

y 20% to ualue) Ipd 

Sample Area Pass/Fai l ? 

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 

4 

XRF Corrected Value - > 

5 (use calibration chart or add 

20% to ualue) 

Sample Area Pass/Fai l ? 

I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Bag) Sieved) • > 

2 

3 

4 • 

XRF Corrected Value —> 

5 (use calibration chart or add 

20% to ualue) 

Sample Area Pass/Fail ? 

Aliquo I n Situ Composite Composite Analytical t Readin Composite Readings Lab Analytical q Average (Dried & Spilt Sent (Bag) 1 Number Results (Baq) Sieved) ? 

2 

3 

4 

XRF Corrected Value —> 

5 (use calibration chart or add 

20% to ualue) 

iisi AUDI I IIIHAI imii i i i 

XRF Technician's Siqniture .^^zy^^y H f f III II 
- » " 

^ 

COASTA L 

ENVIRONHENTAL "tPBOt*" CROUP . INC . 

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: 

7[/eyz^ 

Owner's Name Daytime Phone: ^ ^ "7^^ ^ ^7^/ 7 Ee//!yz^yM5 

Address of Property -ZSoBSooy^bo 57 ^ 

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 
%7"'T> ^ COASTAL ENVIRONMENTA L 

C R 0 U r , IN C 

• 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 

I2f I grant access to my properties D I do not grant access to my properties 

iO-i-79n 

Signature y , Date Signature Date 

p'/> ^fZTy^r 7/'fi> 'S7srtf7^ r ^ ^. ,. _ ./?^ . ^ ^. 

T7^Y^^r7ey. V^^?) ss^ ' y9y7 

O I would like to be present during any sampling that is required. 
COASTA L < | 

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: "^/ ^ <^ 3 

Property Addrrss^^^^ g 7^^/Ui)(}^7 ^ 

Owner: /^ ^ /^eLZAZ(7Cd 3 

Phone: y<^^ o p.^s^^y^^y 

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

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 removal, storage, disposal, and/or return of these items is the Owner's respcnsibilitx-. 

Item: 

r4cM^ 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of. 

1 
COASTA L 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: 

^^yt 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 2 of. 
COASTA L (MWIMONMKMTtW i 

Items To Be Removed By Contractor During Remediation An d Replaced 

(Use additional sheets as necessary) 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 of. 
COASTA L 

Landscape Inventory 

(Use additional sheets as necessary) 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

i 

1 • 

Number of trees > 2 inch 

trunk diameter 

Nuinber of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control VaK'es. 

Timers. Heads, etc. 

.Atiach a sketch: ot' ;"e 

sprinkler kivoui. 

Number of and size of 

each garden/ flower bed 

area. 

.-\ti;K'|i. ;: skeic!) oi re!ai!\e 

Quantity 

y 

7 

7 

Unit Condition/Type/Species 

Square feet 

Each 

! 

Each 

Each 

Each 

Square Feet 

^!7e-- anJ kicaiioni. 

. . 

Page 4 of 
COASTA L 

Item 

Agreed upon value of 

plant materials not to be 

replaced bv contractor. 

Note this \alue will be 

used to issue a plant 

\oucher to the property 

owner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a skeich of were 

each plant will be placed 

b\ the coniracior. 

Agreed upon area of 

propert>' to be replaced 

with grass sod. 

'!ic!i:de a sketch oi' ihc 

ai'ea(s) lo be ieplaccc \\ :in 

evass sod. 

.Area of City or Count)' 

propert> to be landscaped 

per their requirements. 

Ipcl.kie ;, ^keu'!; ..i' :\y 

.Ilea IS.! 

Easement .Area, to be 

excavated 

Quantity Unit Condition/Type/Species 

7> $ 

y Each 

SF 

0 

SF 

SF 

Page 5 of 
COASTA L 

Additional Comments / Instructions: ^_ n/) i l ^/^>c^./>, >^^ \ <• 

>)c PTT) ^/z^^yt^ 7yt^ S/s7 ^ fyi6i//e^^^ ^ 

n 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. 

134 agree nn I do not agree 

,^3, > w ^ 779 >^-//v . J''7y7<^-) 

Date Contractor's Signature Date 

Page 6 of.