TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: [(^9^ Z Date: 2-/^-^/^ 1 

Address: {(p33 Chliftyi j CXu h PN ^ 

Remediation Contractor: Coastal Environmental Group_ Year: 2008 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

l y Video ofproperty (DVD) 

B ^ Executive Summary 

UK EPA-provided property sketch 

0^ Signed Access Agreement for subject property 

^ifV Signed Access Agreement(s) for adjacent property 

\y^ Restoration Agreement 

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

Q^ Confirmation data 

B^ Photographs ?)C(i-jLYraj}(Lii SA ^ £jf[r/iJr.itisri ^ fitUiA SO oK As-built sketch 

GK Satisfactory restoration signed by Property Owner 

SJ^ Property close-out check list signed by EPA 

{%^ Description ofareas not meeting ROD cleanup criteria 

( ^ Utility clearances 

5K Property information from Douglas County Assessor's Office 

w fet>&r4<^ (LOJCA^^ cJfxejddiST' 40316479 

^' r'^r^- •*•^ " Qr ^ llll ^ Iiiill l 

D Superfund 

ISienatu Ignr e Date' 

%My^4^.uy^^ fp/y^M 
• 

Property Access Checklist 

Property'ID: (^q^C( ^ 

Properly Address: {(j^ ^ Cn i KX\\ x 

LW.kLj4 ^ ^ 

• ^ O Ajr\ir \ . 

Address Idrcss: : ^ v j

D WORK STARTED

D WORK COMPELTED

Renter 

Phone: 

PiL\: 

ON: 

ON: 

_/

/

 /_ 

/ 

Phonc:_^^^.q^^ ^ 

Fax: 

Cell/Pager: 

Additional Information: 

Cell/Pager 

D

ff]

( 3

1 C

 Notification Letter 

Access Agreemenl 

Restoration Agreement 

Topsoil Sampling (if applicable) 

Sent: / / 

Signed: lL/c^/i2 6 

Signed: i \ 7^^)^/ Of, 

1 1 

By: 

\^y-Kr\c.^ 

^y P^/.a^ 

By: 

[U

[Zl

 DisposaJ Sampling (if applicable) 

Gnrdcn Sflmpliog (if applicable) 

1

1

 1 

1 

By: 

By: 

HI

D

D

D

 Utility Clearance 

Video/Photos (Before) 

VicJeo/Photos (During) 

Video/Photos (After) 

Called:

On:

On:

On:

 \\

 /

 /

 /

 l^^lC^ ) 

/ 

/ 

/ 

B}'= »QlOQ|nB 

By:/VidJc//Br.«^ 

By: 

By: 

D

n

 Video/Photos (30-Day) 

Property Completion Agreement 

On:

Signed:

 /

 /

 / 

/ 

By: 

By: 1 

D Pinal Report Issued: / / By: 

Air Monitoring {as applicable 

n Community d j Crew 

Results: 

) 

OD: / / By: 

D ComraunitA'

Results: 

• Crew On: / / By: 1 

1 D Communitj

Results: 

d ) Crov On: / / By: 

Omaha Lead Site 
Property ID #

Property 

Address:

Initial Contact:

Second Contact:

Final Contact:

Final Action: 

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

% 

CONTACT FORM 

 (c'-^^fj ^ 

U n^ ^ Pt^ e >^-r^V^.. OUx. b f^^ . 

 Date: Time: Action: 

 Date; Time: Action: 

 Date: Time: Action: 

Transmit to EPA D Other Action: D 
" Douglas County Account Infi|«|ation Page 2 of2 t 

TwoStoiy 1633 Country Club Av 

QWfiJM 

OimSldt '»« " 

S*candFlocr 

TOO 0 Sq. Fl iSsiSi%. 

IDir 

SUfcWSgatK 

CLICK TO ENLARGE IMAQE CLICK TO ENLARGE IMAGE 

Square Footage: 1440.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Good 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Masonry Face Brick Units: 1.0 

Interior: Drywall Baths: 1.5 

Roof Cover: Slate Bedrooms: 3.0 

Roof Type: Gable Stories: 2.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1930 0 0% 1930 79 

Detail Type Detail Description Units 

Add On Fence Wood 1.0 

Appliance Allowance 1.0 

Appliance Fireplace Masonry 1.0 

Basement Bsmnt Block 8 ft 700.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 

1.0 

Fixture Bath Half 1.0 

Garage Attached 300.0 

Porch End Solid Wall 240.0 

Porch Open Slab 

120.0 

Porch Open Slab 150.0 

40.0 

User Roof leaks in spots 

Porch Slab w/Steps 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO... 11/25/2008 
/•Douglas County Account InfiMBatio fiMB£ n Page 1 of2 t 

Dougla s County , Nebrask a Propert y Recor d - R084377000 0 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of QOth St - Vie w OP M a p Information is valid as of 2008-11-5 Treasurer's Tax Report 

New Feature - • •^ -> Auto Sales Search 

Owne r 

CARRIGAN JO ANN 

1633 COUNTRY CLUB AVE 

OMAHA NE 68104-0000 

Propert y Informatio n 

Key Number: 4377 0000 08 

Account Type: Residential 

Parcel Number: 0843770000 

Parcel Address: 1633 COUNTRY CLUB AV 

OMAHA NE 68104-0000 

Legal Description: COUNTRY CLUB DIST LOT 14 BLOCK 28 LT 13 & S 10 FT 67 X 123 

Valu e Info rmatio n

2008 

2007 

2006 

2005 

2004 

2003 

Land 

$22,300.00 

$22,300.00 

$22,300.00 

$22,300.00 

$22,300.00 

$22,300.00 

Improvement 

$149,300.00 

$149,300.00 

$149,300.00 

$149,300.00 

$124,900.00 

$124,900.00 

Total 

$171,600.00 

$171,600.00 

$171,600.00 

$171,600.00 

$147,200.00 

$147,200.00 

Lan d Infor m a tio n

Acres 

0.2 

SF Units 

8911.0 1.0 

Depth Width 

133.0 

Vacant 

67.0 No 

Improvemen t Inf ormatio n

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO... 11/25/2008 
Page 1 of2 

% 

"> 

Create Another Ticket Back to irth Internet Send Email 

YOUR TICKET NUMBER IS 2182227. 

Original Call Date: 11/25/08 Time: 7:11 pm Op: ELIZABETH187 90 


Work to Begin Date: 12/02/08 Time: 7:15 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1633 Street: COUNTRY CLUB AVE 


Twp: 15N Rng: 13E Sect-Qtr: 18-NE 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: lead Remediation 


Location of Work: LOCATE ENTIRE PROPERTY INCLUDING THE HOUSE ALL THE WAY TO 


: THE STREET. 


Remarks: FAX ALL CLEARS TO: (877)662-4211 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ELIZABETH Phone: (877)662-4210 


Work Being Done For: coastal 


Depth of Excavation: 4ft Corner Lot: N Front: Y Rear: Y 


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV MCLEODNE MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Utility Service Area Contact Plione Number Type 

Day: 4029340469 

_-.^.TM, COX COMMUNICATIONS, „_„ , 

CXCATV „, „ HEIDI Alt: 4029340469 INC 

Emerg: 4029329757 

Day: 8002891901 

NO NEED TO CALL OUT MCLEODNE MCLEODUSA Alt: EMERGENCY 

Emerg: 8002891901 

Day: 4025047823 

METROPOLITAN UTILITIES MUDOl SANDY Alt: DISTRICT 

Emerg: 4025047970 

Day: 4024447197 

CITY OF OMAHA- OMAHACOF RON Alt: 4024445161 TRAFFICSEWER 

Emerg: 4024445160 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT... 11 /25/2008 
Page 2 of2 

OMAHA PUBLIC POWER 0PPDGPR5 NA DISTRICT 

QLNNEIC QWEST LOCAL NETWORK NA 

% 

Day: 4067289343 

Alt: 8887289343 

Emerg: 4067289343 

Day: 4067289343 

Alt: 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT... 11/25/2008 
As-Built Drawing 

C

ENVIRONMCNTA

 OAST A L 

L Omaha Lead Superfund Site GROUP . INC . 

OLS#: 64892 

Date Excavated: 12/5/2008 

Date USEPA Signed Off: 12/12/2008 

Area Sodden: 673 sq ft 

64892 

Omati Exterior Paint Nortti Arrow a Lead Site • Good Site Sketch 

Q^Poor 

Samolina Address: 1633 COUNTRY CLUB AV — • Not paint X\

Sample Lead Sample Samples Collected Number LAB Concentratio n Collected Fim,: P F IW C n& TA 

RYASCPXA-64892 Fl _ ppm Q ^ D Date: 'I/l-S ID A 

RYBSCPXA-64892 F2 UR .ppm Q ' D Time: <^nnM^ 

RYCSCPXA-64892 81 .ppm Q ^ D Samples Arwiyzed RYDSCPXA-64892 B2 Id H .ppm Q ^ D 

RDZSCPXA-64892 DZ .ppm Q ^ D XRF Unit: 6>S''V0 Book; 2/* ^ 

nz-'-Ff/*p\/A /^Je/^'^ .ppm n D Date /0-oZ-<^ & 

nrZECPXA 64802 —P2 .ppm • D Time: /?/»i 

Staff: mS U Number of Samples = 5 0 

Legend: Fl = Front Left. F2 = Front Rigtit, 81 = Back Lett, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla; 

All quadrants are as viewed from the street, facing property 

Legend 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with Area replaced with Area left bare 
 Sod ' ' 
 Rock/Mulch 

Contrac t #: EP-R7-07-05 Coastal Environmental Group Inc . 
64892 

Omaha Lead Site Exterior Paint Nortti Arrow 

Site Sketch • Good 

Q^Poor 

Sampling Address: 1633 COUNTRY CLUB AV Q Not paint 

Sample Numt)er Lead Sample Samples Collected LAB Concentration Collected Finm: PF IM C OB T l 

RYASCPXA-64892 Fl ppm D Date: ^/2'=^IOt^ 

RYBSCPXA-64892 F2 LL8_ ppm D Time: q-inAM 

RYCSCPXA-64892

RYDSCPXA-64892

 B1 

82 

ppm 

ppm 

D 

n Samples Analyzed 

RDZSCPXA-64892 DZ 8^1 ppm u7 n XRF Unit: G^^O Book: 2/*^ 

RG20GrXA-64802 GS ppm n D Date /OOZ-02 > 

RPZSCPXA 64802 -P3 ppm n D Time A£nNumber of Samples = 5 Staff: n^i^ 

Legend: Fl = Front Left, F2 • Front Rigtit, Bl = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla> 

All quadrants are as viewed from the street, facing property 
64892 

Omah Exterior Paint Nortti Arrow a Lead Site • Good Site Sketch 

Q^Poor XX Samolina Address: 1633 COUNTRY CLUB AV — Q Not paint 

Sample Numb>er Lead Sample Samples Collected LAB Concentration Collected Firm: P f IKJ C 0& TA 

RYASCPXA-64892 Fl 13/5 ppm D Date: ^/l^/p ^ 

RYBSCPXA-64892 F2 1L£L ppm ur D Time: q./OAM 

RYCSCPXA-64892 81 <^b ppm ur D 

Samples Analyzed 

RYDSCPXA-64892 82 IQ'i ppm ur D 

RDZSCPXA-64892 DZ 

86?^ ppm u/ D XRF Unit: G^H ^ Book: 2.\°l 

ROZOCrXA 04002 G i ppm D D Date: /oo z <g8 

nPZSCPXA 64802 P2 ppm D D Time: ADDNumbe Staff: r?:5U) r of Samples = I 5> 

Legend; Fl = Front Left, F2 = Front Rigtit, Bl = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla> 

All quadrants are as viewed from ttie street, facing property 

L f»i\irrvi. y4fi?. ^y. •. Re\ ;ili;iS Crealed, 19-.\ug-iiS 1144701 01 2.3 
(•*"•«««•. 

COASTA L fNVinONflCNTftl 

CROUP , 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: 

Owner's Name: Daytime Phone: 

~1 ^ 4lrvrK rr^nCiO^^ ^ 5"S3 -?/3 ^ 

Address of Property 

covered by this 

Agreement: 

Hn^Z Cj^anJrij C/^Jb A/e , 

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 

X 
m./'^u 

V**** ^ COASTAL 

^^^. ^ 

C I 0 U P . IM 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 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 (712) 352-0188 

Jj^g Ingrant access to my properties

 D I do not grant access to my properties 

fl-2:^.<.-g 

• 7'Zl 

Signature ^ Date Signature Date 

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

a K o u >• IM C 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of the property prior to 

remediation activities. Tliis will also seiA'e as documentation for the purpose of assuring that restoration 

activities are completed to the satisfaction ofthe propert>' owner and the United States Environmental 

Protection Agency (EPA). 

Property ID: jp^ ^ ^<^Q^ 

Property Address: /(^3 ^ / ^ 

cyA rX^t j y/u b RTQ^. Owner: ^J^a 0,>r-i c Oop i 901=^ Phone: sr^'^fS^ 

On the attached diagram(s) indicate area(s) to excavated and deptli of excavation, location of all known 

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

contractor, and the direction of North. Indicate distances, depths, material types, etc. Indicate digital photos 

by referencing the photo-log number with 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 retum of these items is the Owner's responsibility. 

Kem: 

If am - < ' Item 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of ( ^ 

I 
COASTA L r»>VIMOMr<IMTAI. c M o u r . t M c 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: 

fi^s^l <^^//p/<=^^y^^ /^y^ y h^y^^ ^ 

Item: 

Item: 

Kem: 

Kem: 

Item: 

Kem: 

Kem: 

Item: 

Item: 

Hem: 

ttem: 

ttem: 

Item: 

Kem: 

Page 2 of ^ 
• ^ 

C Q A S T A L • MVinONmCNTA L 

CMOU P IN C 

Items To Be Removed By Contractor During Remediation And Replaced 

(Use additional sheets as necessary) 

Item: 

<{r.yyiy 

Item: 

sy-F/~D 

Item: 

Item: 

Kem: 

Kem: 

Item: 

Kem: 

Item: 

Item: 

Kem: 

Kem: 

Item: 

Kem: 

Kem: 

Page 3 ofA 
— <» 

COASTA L 

Landscape Inventory 

(Use additional sheets as necessary) 

Item Quantity Unit Condition/Type/Species 

F( Pre-existing property area, 

that will be excavated, that Square feet 

is covered with grass. T5Ue6-^^3^ 

Number of trees > 2 inch 

trunk diameter 

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 

Attach a sketch of relative 

sizes and locations. 

7 Each 

Square Feet 

M 8-P 0 ^ 

.#. Page 4 of yg ' 
-'- *• 

COASTA L 

> M O U P 

Item Quantity Unit Condition/Type/Species 

Agreed upon value of 

plant materials not to be 

renlaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a sketcii of were 

each plant will be placed 

by the contractor. 

Agreed upon area of 

property to be replaced 

widi grass sod. 

Include a sketch of the 

area(s) to be replaced with 

grass sod. 

Area of City or County 

property to be landscaped 

per their requirements. 

Include a sketch of the 

area (s) 

Easement Area, to be 

excavated 

f $ 

<f Each 

1 

f^ m 

SF -gluLeCr^^^s 

f SF 

L)e'> SF 

1 -y^e-Aifi-eJi^insJ 

Page 5 of. ( f f 
C O A S T A I. KMVUMOMHCMTAL 

Additional Comments / Instructions: 

D Check the box if Owner does not war\t CEG to documerrt interior fbundation walls and possible 

pre-existing damage. By checking this box CEG is not responsible for any damage done to the 

interior of house, induding foundation cracks or fissures. 

5^ . agree Q I do not agree 

^ 

OCT'S Signaturiree / Date Contractor's Sffinature Date 

Page 6 of. 
BVID# (r.AB^/ ^ 

XRF PROPERTY SAMPLE SHEET 

Date 10- (o-Oft Address I LC.3,-^ C,r< JL^^^-\ T ^ x 0 i) U V lAs/'e ^ 

Project Omaha lead FP 2nd year option Sample time O am/pm '^n-.^^-^ 

XRFID# '<^i^P> ^ sample length 30 sec 

Shot# Reading Sample area Shot# Reading Sample area 

^8^ ^ a^.ip.* ~?.ua M^^ ^ \Ci,.c-\Rtn,a « 

^R?, ^ i)^.q&t.'7,&8 b-fe HBM^. n.'-^'T 11.\ \ eu^^ y Mft?,(o 

M<-...3^tS.o^\ Depth H-H^io i^H.<4yyi.icB Depth 

^8^ 1 

c^gSRiSoQ ^ ^ ^8an a\.^\y^n.^^ 1

Average c-^J - I ^ , ^ S CIS 

Average Jdh.j o:3^i "1 - a U 

Shot# 

'^B<AH 

^B?. 0 

^BS l 

^^G ^ 

Average

Reading 

I'AiD.JQ t-ia-^i o 

\>?..n«t\?>fAe 

i^-^^.ft^ t\?>.'\i 

IfiS.ul-lU'.U? ^ 

Sample area 

] ^ \ 

Depth 

t 0 

 14^^ . V ft t \^.^L g 

Shot# 

Average 

Reading Sample area 

Depth 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading 

RETEST AREAS 

Sample area Shot# Reading Sample area 

Depth 

7 

Depth 

Average Average 

lab sample # Lab result Sample area XRF Avg. 

Signature_ 

Print M/H^<^ M'W^ i 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

Supervised By: 

Certificate of Verification 

4858 

SOIL 

2008-12-06 10:22 

122.32 

Final 

|Avg of 4854-4857 

nL633 country club ave 

# Z 

Ventry 

*^13 

CLEARANCEJI 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 22.150 

Supervised By: 

Certificate of Verification 

4854 

SOIL 

2008-12-06 10:20 

30.43 

Final 

64892 

1633 country club ave 

DZ 

Ventry 

13 

CLEARANCE 

± Error 

± 7.416 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 25.929 

Supervised By: 

Certificate of Verification 

4855 

SOIL 

2008-12-06 10:21 

30.67 

Final 

64892 

1633 country club ave 

DZ 

Ventry 

13 

CLEARANCE 

± Error 

± 7.579 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 4856 

Mode SOIL 

Time 2008-12-06 10:21 

Duration 30.44 

Sequence Final 

Flags 

BVID # 64892 

ADDRESS 1633 country club ave 

QUAD/ZONE DZ 

INSPECTOR Ventry 

DEPTH 13 

SAMPLE TYPE CLEARANCE 

NOTE 

ppm ± Error 

Pb 40.286 ± 9.085 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 28.381 

Supervised By: 

Certificate of Verification 

4857 

SOIL 

2008-12-06 10:22 

30.78 

Final 

64892 

1633 country club ave 

DZ 

Ventry 

13 

CLEARANCE 

± Error 

± 8.018 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 4848 

Mode SOIL 

Time 2008-12-06 10:15 

Duration 122.87 

Sequence Final 

Flags 

AVERAGE f Avg of 4844-4847 

ADDRESS 1633 country club ave 

QUAD/ZONE easement 

INSPECTOR Ventry 

DEPTH 1 1 

SAMPLE TYPE .CLEARANCE 

NOTE 

Pb 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 19.482 

Supervised By: 

Certificate of Verification 

4844 

SOIL 

2008-12-06 10:13 

30.38 

Final 

64892 

1633 country club ave 

easement 

Ventry 

1 

CLEARANCE 

± Error 

± 7.480 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 17.473 

Supervised By: 

Certificate of Verification 

4845 

SOIL 

2008-12-06 10:13 

30.99 

Final 

64892 

1633 country club ave 

easement 

Ventry 

1 

CLEARANCE 

± Error 

± 7.113 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 24.454 

Supervised By: 

Certificate of Verification 

4846 

SOIL 

2008-12-06 10:14 

30.68 

Final 

64892 

1633 country club ave 

easement 

Ventry 

1 

CLEARANCE 

± Error 

± 7.677 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 21.096 

Supervised By: 

Certificate of Verification 

4847 

SOIL 

2008-12-06 10:15 

30.82 

Final 

64892 

1633 country club ave 

easement 

Ventry 

1 

CLEARANCE 

± Error 

± 7.495 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

Certificate of Verification 

XL3t-32089 

Reading No 4853 

Mode SOIL 

Time 2008-12-06 10:19 

Duration 122.59 

Sequence Final 

Flags 

AVERAGE |Avg of 4849-4852 

ADDRESS '1633 country club ave 

QUAD/ZONE P=l 

INSPECTOR Ventry DEPTH 

SAMPLE TYPE ^.CLEARANCE 

NOTE 

Supervised By: 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 140.215 

Supervised By: 

Certificate of Verification 

4849 

SOIL 

2008-12-06 10:17 

30.57 

Final 

64892 

1633 country club ave 

Fl 

Ventry 

6 

CLEARANCE 

± Error 

± 14.898 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 113.080 

Supervised By: 

Certificate of Verification 

4850 

SOIL 

2008-12-06 10:17 

30.56 

Final 

64892 

1633 country club ave 

Fl 

Ventry 

6 

CLEARANCE 

± Error 

± 13.562 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 121.817 

Supervised By; 

Certificate of Verification 

4851 

SOIL 

2008-12-06 10:18 

30.84 

Final 

64892 

1633 country club ave 

Fl 

Ventry 

6 

CLEARANCE 

± Error 

± 13.914 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-32089 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID # 

ADDRESS 

QUAD/ZONE 

INSPECTOR 

DEPTH 

SAMPLE TYPE 

NOTE 

ppm 

Pb 185.605 

Supervised By: 

Certificate of Verification 

4852 

SOIL 

2008-12-06 10:19 

30.62 

Final 

64892 

1633 country club ave 

Fl 

Ventry 

6 

CLEARANCE 

± Error 

± 16.679 
Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

www.coastalhazmat.com 

COASTA L ENVIRONMENTAL 

CROUP , IN C 

EXECUTIVE SUMMARY: 

BVID # 64892 - (1633 COUNTRY CLUB AVE ST) 

I I No Issues or Concerns X Issues/Concerns 

Detail Explanation: 

CONCERNS ABOUT THE SOD. 

WILL REVISE IN SPRING 2009. 
# S30S. EPA 

EPA Property Close Out Form 

Property #: oAe^ Q Property Address: |(g?^3 CooorvVyOA C'^V ^ /W^-. 

Date/Time: Owner's Name: r'c>.^r"vcAOofx . '^^'NPV^•^^ Q 

Quads Excavaled: P\. ^ ^Tvfc Contractor Group eJOO^-VcoQ, feov^^ reoJt^^A^^^^-o^ 

Excavation General 

Yes No 

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

2. Ifnecessary, were the correct areas ofdrip zone excavated and restored? ^ 

Grading Sod and Vegetation Yes No 

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

[ ^ from tbe house? 

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

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? y 

5 Are the joints tietween 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 properry"' 

7. Was damage lo landscaping or plant materials avoided? ^ 

Gates, Fences and ReUinlog Walls Yes No 

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

2. Were all gates or fences taken down during restoration activities reinstalled? (Ifapplicable) y

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

4. Was damage to retaining walls avoided? (Ifapplicable) # 

Foundation, SidiDK and Gutters Yes No 

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

2. Was damage to the foundation avoided? L^ 

3. Was damage to windows avoided? y 

4. Was damage to windows or door screens avoided^ y 

5. Was damage to dowTispouls or downspoul extensions avoided? A 

Sidewalks and Driveways (Concrete) Yes No 

I. Was damage to driveway surfaces avoided? y 

2. Was damage to walkway surfaces avoided? 

y 
O fners comments: # 

Inspection notes: 

,y^yl^]U^U^^c9M. <^y ^ ^ / 

Removal and restoration activates complete including the 30-day sod warrant}': 

EPA Representative^^;^^^^^£^;^^^t74 ^ Date: 7yy7Py^ ^ 
% 

Property Completion Agreement 

Tliis iigreeineni documents the complclion of remedial activilies perrormed on my properly. My signalure 

will designale Ihat I am salislied wilh the restoralion of my properly, and that ao ilems are in questions, 

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

Propc. lyJD^j^t/g9P^ 

Property ATdrcss: /(^ 3.3, Qc ^ ^, ,

Owner: —r* „ /" 

Phone: - - - '-' 

5r3rJlZ3 _ 

Restoration Items in Question: 

Item: 

ttem: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

 . CL M 4 ^ • 

•7*' ly ^ aurct' rr.storalion i.s completed, except as noted 

 I I do not agree rcslnrntion k completed 

^•2--/51-og 

r«nitractor's .Sij^nature 

I