TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID# A)^'>^ 3 DATE: 5/<=2^/u 

ADRESS: Drj U )Vl 7/) ^ 

REMEDIATION CONTRACTOR: COASTAL ENVIRONMENTAL GROUP Contract: EP-R7-09-06 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

7 Executive Summary 

/ EPA-provided property sketch 

7 Signed Access Agreement for subject property 

Assigne d Access Agreement (s) for adjacent property 

^ Restoration Agreement 

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

H Confirmation data 

A ^ Photographs SOD 

Pre-Excavation 

~"— Excavation 

/ As-Built sketch 

\\ Satisfactory restoration signed by Property Owner 

^U Property close-out check list signed by EPA 

A ^ Description of areas of areas not meeting ROD cleanup criteria 

V Utility clearances 

Property Information from Douglas County Assessor's Office / 

D 

^ 

1^ 

%^ ^ 

'Signaturee-- CaASIArv C®/ Signature- EPA ^ 

Date* ' Date 

30262911 

Superfund 
f p . 

Property Access Checklist 

Propert)ID: '2-S'3Z' ^ 

n WORK STARTED ON: / / 

D WORK COMPELTED ON: / / [PJ^pcrtv Address: ^.^j ^ ^ Q S \-

Rcnten ^'''^'--yu[[t\70f\ V\)ck\'U\'' '.Ac- Phone: 

Fa.\: 

Cell/Pager: 

Additional Int'ormntion: 

Fax: 

Notification Letter Sent: Bv: 

Access Agreement Signed: 5" /'24/ i I By: 

Restoration Agreement Signed yy^y Bv: 

--! • 

j] LJ Topsoil Sampling (if applicable) Bv: 

\ I Disi)osaJ Sampling (Ifapplicable) Bv: 

CD Gjirdcn Sfimpliflg (if ap/)l/cal))e) Bv: 

n IJtilirv'Clearance Called: By: 

D Video/Photos (Before) On: Bv: 

• Video/Photos (During) On: Bv: 

n Video/Photos (After) On: Bv; 

D Video/Photos (30-Da.v) On: Bv: 

LJ Property Corajjlefion Agreement Signed: By: 

C J Final Report Issued: Bv: 

Air Monitoring (as applicable 

O Community CU Cren I On: / ,/ 

Results; 

LJ Community' CU Crc^v On: Bv: 

Results: 

I n Communitv CU Crci> On: / - B\ : 

Result.s; 

Omaha Lead Site 

http://douglasne.mapping-online.com/Doug!asCoNe/static/accountinfo,jsp?accountno=R]40... 9/3/2010 

http://douglasne.mapping-online.coin/DougiasCoNe/static/accountinfo.jsp?accountno=R140... 9/3/2010 
o o 

o YOUR TICKET NUMBER IS 2784016. 

Original Call Date: 6/29/11 Time: 9:08 am Op: ALFONSO18 7 90 


Work to Begin Date: 7/01/11 Time: 9:45 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1126 Street: N 2OTH ST 


Twp: 15N Rng: 13E Sect-Qtr: 15-NW-SW 


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: (402)934-2811 


: PLEASE INCLUDE ALL EASEMENTS. THANK YOU! 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ALFONSO Phone: (402)934-2837 


Work Being Done For: Coastal 


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


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUDOl OMAHACOF OPPDGPR5 QLNNEIC 


Utility 
 Service Area Contact Phone Number Type 


Day: 4029340469 

COX COMMUNICATIONS, HEIDI COX CXCATV Alt: 4029340469 INC COMMUNICATIONS 

Emerg: 4029329757 

Day: 8773668344 


LEVEL3 LEVEL3 NA Alt: COMMUNICATIONS, LLC 

Emerg: 8773668344 


Day: 4025047823 


METROPOLITAN MUDOl SANDY MU D Alt: UTILITIES DISTRICT 

Emerg: 


Day: 4024447197 

CITY OF OMAHA- OMAHACOF RICH/TRAFFIC Alt: 4024446725 TRAFFICSEWER 

Emerg: 4024445160 
o 

nPDT^rDR^ OMAHA PUBLIC POWER p, . , , ^ ^ .T^,., ^ 0PPDGPR5 ELM LOCATING 

QLNNEIC QWEST LOCAL NETWORK ELM LOCATING 

o 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 
http://www.dhQa.ora^irthintemet/DHONNoticeCreation/MessageText.. anoaoi 

Create Another Ticket Back to Irth Intemet Send Email 

• YOUR TICKET NUMBER IS 2772781. 

Original Call Date: 6/16/11 Time: 8:44 am Op: ALFONSO187 90 


Work to Begin Date: 6/20/11 Time: 9:15 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1126 Street: N 20TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 15-NW-SW 


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: (4 02)934-2811 


: PLEASE INCLUDE ALL EASEMENTS. 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ALFONSO Phone: (402)934-2837 


Work Being Done For: Coastal 


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


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVELS MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Utility Service Area Contact Phone Number lype 

Day: 4029340469 


COX COMMUNICATIONS, CXCATV HEIDI Alt: 4029340469 INC 

Emerg: 4029329757 


Day: 8773668344 


LEVEL3 LEVEL3 COMMUNICATIONS, ^ ^ Alt: 


Emerg: 8773668344 

Day: 4025047823 

METROPOLITAN UTILITIES MUDOl SANDY MUD Alt: DISTRICT 

Emerg: 4025047970 

Day: 4024447197 

CITY OF OMAHA- OMAHACOF RICH/TRAFFIC Alt: 4024446725 TRAFFICSEWER 

Emerg: 4024445160 

Day: 4067289343 
 OMAHA PUBLIC POWER ELM 0PPDGPR5 DISTRIC Alt: 4062071494 
 T LOCATING 

of 2 6/16/2011 8:44 AM 
http://www.dhQiu)rg'irthintemet/DHONNoticeCreation/MessageText.. 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK

ELM 

LOCATING ^'^" 

Day:

Alt:

 4067289343 

40620714944 

Emerg: 8887289343 

2 of 2 6/16/2011 8:44 AM 
As-Built Drawing 

COASTA L Omaha Lead Superfund Sue 

Date Excavated: 7/8/2011 

Date USEPA Signed Off: 7/26/2011 

Area Sodden: 4500 sa ft 

25323 iini 

Omaha Exterior Paint Lead Site • Good 

Q Poor 

Sampling Address: ii26 N 20 ST 

Site Sketch 

M Not paint 

Sampl Lead Sample Sanriples Collected e Number LAB Concentration Collected Fimt: FOft n C\S 

RYASCPXA-25323 Fl 2H I ppm D Date: ^-^^-O ^ 

RYBSCPXA-25323 F2 Hfif t ppm D Time: ID-ff) firf\ 

RYCSCPXA-25323 Bl /AtJ ) com D 

Samples Analyzed 

RYDSCPXA-25323 B2 513—pp m I D 

RDZOCPXA-25323 B t ~ ppm D XRF Unit: IOfl/.»2. Book: 2 H / 

- 6 Z ~ ppm D D Date (>02-0 ^ 

WPZ&CPXAr2532a- -p a ~ ppm D D Time D a n - Staff: Number of Samples = | ^ | | Q \ _mwi 

Legend: Fl = Front Left, F2 = Front Rigtit, B1 = Baci( Left, B2 = Back Rigtit DZ = Drip Zone, GZ = Garden, PZ = Pla; 

AH quadrants are as viewed from the street, faang propefty 

ENTJfiKBU 

pvoB' MAV '> Q 'nno t J «.vwv ^^ " B2 = 57PPM@6" riMT B1=172PPM@6" ^^^ ^ 

f ^ ^ 

!x^ ^ KXXXJ 

._. Jxx ^ 

^241 1 

i

m 

F2 = 27 PPM @ 6" 

mmmm 

1^: IV -jf R«x->liM '.'reated ft5-NovJ)8 

Legend 

Concret e Dri p Zone Excavate d Quadrants Excavate d 

Area replace d wit:h Area replace d wit h 

Area left bare 
 Sod Rock/Mulch 

Contrac t #: EP-R7-07-05 Coasta l Environmental Group Inc . 
/^Ili<4v /U^yO ^ - ^ / / 111. J Ilillll 25323 

Exterior Paint Noflh Arrow Omaha Lead Site • Good Site Sketch 

n Poor 

Sampling Address : 1126 N 20 ST 2 Not paint 

Sample Number 

RYASCPXA-25323

RYBSCPXA-25323

RYCSCPXA-25323

RYDSCPXA-25323

 F1 

 F2 

 Bl 

 B2 

Lead 

Concentration 

2^ / 

3M . ppm 

ppm 

(A(e ppm 

-57 ^ ppm 

Sample 

Collected 

I 

U\B 

D 

D 

D 

D 

Sanf)ples Coliecled 

Fimi: FOft % y ^ 

Date: 5-9^-09 

Time: /P'.^g) fl<V\ 

Samples Analyzed 

ffDgOCrXA-2S323 BE­ " " ppm a D XRF Unit: lOfl/o l Book: 2*^ i 

f^CZCCPXA 25323 GZ ~ ppm D D Date: (g • 0 1 -Q^ ^ 

WPZ5CPXA-25323 P2 ~ ppm n D Time: P m 

Number of Samples = | ^ | | Q j Staff: f^ W 

Legend: Fi = Front Left, F2 = Front Right, 81 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla; 

All quadrants are as viewed from the street, facing property 

ENTERED 

MAV 2 9 2009 ."TdD 

L^lf 

'/ 

:;:f^l P v^- Rev 2'*')* CiejAat ns.Vov-0« (>W 70101 33 
25323 

Omah Exterior Paint North Arrow a Lead Site 

Sit • Good e Sketch n Poor 

Sampling Address: 1126 N 20 ST 2 Not paint 

Sample Number 

RYASCPXA-25323

RYBSCPXA-25323

RYCSCPXA-25323

RYDSCPXA-25323

RDZOCPXA-25323

nOZOOPXA 25323

RPZSePXA-25323

 Fl 

 F2 

 Bl 

 B2 

 BS 

 GZ 

 PS 

Lead 

Concentration 

Sample 

Collected LAB 

JM L 

.523­

ppm 

ppm 

ppm 

ppm I D 

D 

D 

D 

ppm 

ppm 

ppm 

D 

D 

D 

D 

D 

Number of Samples = | ^a | | Q 

Samples Collected 

Fimi: fdf\ n (\:S 

Date: ^-I'Jj-CM 

Time: lO'-'J) fli^ 

Samples Analyzed 

XRF Unit: \0(i(s2. Book: ZM i 

Date: (o -O l -O ^ 

Time: P m 

Staff: M^U / 

Legend: F1 = Front Lefl, F2 • Front Right, Bl = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Pla; 

All quadrants are as viewed from the street, facing property 

ENTERED e? 

MAV 2 9 2009 

573 

^ 

/ 

y 

y^')pt^ 

Re\-2iW8 Created: 05-\ov-0« 04470101.23 
25323 

Omah Exterior Paint North Arrcw a Lead Site 

Sit • Good e Sketch 

Q Poor 

Sampling Address: 1126 N 20 ST [2 Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collected Fimi: f m S>h J\S 

RYASCPXA-25323 Fl 2HI ppm n Date: ^-V-CHt 

RYBSCPXA-25323 F2 j±5a. ppm D Time: JP'- ^ f^ft\ 

RYCSCPXA-25323 Bl ^eRlp Dom a 

RYDSCPXA-2532 Samples Analyzed 3 B2 5\3 ppm I n 

RDZOCPXA-25323 BZ­ ~ ppm D XRF Unit: lOflj^gZ Book: 2H i 

RCZOGPXA 25323 GZ D "* ppm n Date: g» •Ol-O' ^ 

RP2SCPXA-25329 PS D " • ppm n Time: ? m D Staff: n$U r Number of Samples • 5] 

Legend: Fl = Front Left, F2 • Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ • GanJen, PZ = Pla; 

All quadrants are as viewed from the street, facing property 

ENTERED Q. MAV 2 9 2009 

^573 

.3.^ 

•/J l ^ . /^2 ^ 

^ 

2H\ ^58 

F.L.\..ft. 

4 

'9 1 

f^losx 

Re\- :c«j8 iVealed: n5-Kov-i;i« 
0 %^'^T^Z 

COASTA l CkvUQluilxiJi l 

c t e V r I *« c 

Conserii for Access To Froperi)' 

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: 

U Q O ' Lir a ^ 

Daytime Phone: , , ^^ ^ 

Address of Property 

covered by ttiis \iaQ9 N' 2 ^ ^V-

Asreement: 

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 perfomned, the Grantor will have an 

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

before if 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 
O O 

yy!'% 

COA.STA L 

[hVIRONH f KTAL *' y C K O U r I K C 

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

piles, dog houses, etc; 

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

to save; 

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

necessary' subsequent to an initial watering period by EPA; 

f 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 

Q I grant access to my properties G I do not grant access to my properties 

Signaturt^ Date Signature Date 

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

Page 2 of 2 
COASTA L • NVI*OMMIMT* L 

C pl O U P . IHC . 

Restoration Agreement 

The purpose of this agreement is to provide a mutual 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: ;;)53,;:;) ^ 

Property Address: |yg( ^ ^ [ g( ^ ^ 

Owner: ^(^ ^ Qr^e>XS.(^\ ^ 

Phone: 4Q ^ )^c;^^ , ^eQ;: j 

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 retum of these items is the Owner's responsibility. 

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

Page 1 of. 
o o 

Items to Be Removed By Contractor During Remediation and Replaced 

Item: 

'Sr^V ^ .-^rvl •• fil, fi^StF;:) 

Item: 

Item: 

Item: 

Landscape Inventory 

Item Quantity Unit Condition/Type/Species 

Pre-existing property area, Quadrants that will be excavated, that 

IS covered with grass. 

Number of trees > 2 inch Each 

trunk diameter ^ 

Number of trees <= 2 mch Each 

&

trunk diameter 

Number of SpnnkJer 

Zones, Control Valves, 

Each Timers, Heads, etc. s? 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed Each 

area. Square Feet 

Attach a sketch of relative 

sizes and locations. ^ 

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 

Each 

excavated f^^^ 

Page 2 of 
COASTA L o o rMVlMONMINTA l 

c n o u r IN C 

Additional Comments / Instructions: 

The city of Omaha ordinances may prohibit 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 cited by the city if you use a gravel or dirt area 

as a driveway or parking area, not withstanding 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 city of Omaha's Planning Department at (402) 444-5150. 

lease check this box if you understand the information outlined above. # 

\^a 00 9rc:^erVa% 

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. 

n 11 do not agree 

MiimiS-M-il 

Date CoFitractor' Factor'ss Signature Date' Sig 

Page 3 of