## TRANSMITTALo f

OMAH ALEA D SIT E SOILREMEDIATIO NFIL EFOLDE R
SAID# : 

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### Remediatio nContractor : Coasta l Environmenta ) Grou p Year : _20]0ARR A
SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 1 /

Vide o o f property (DVD ) ( /

Executiv e Summar y l 7 EPA-provide dproperty sketc h 1 /

Signe dAcces s Agreement fo r subjec t properl y

• ^ Signe dAcces s Agreement(s ) fo r adjacent properl y .1 / Restoratio nAgreement Settlemen t document s (i.e. , fo r damag e or t

o replac e plants , etc. ) Confirmatio ndata 7 Photograph s ff r ^CA(\jfr((a ^ ^ ^QwfiZHo ^ ^ ^ As-buil t sketc h Satisfactory restoratio nsigne db y Property Owner / 

### Property close-ou t check lis t signe db y EP A ^i y Descriptio nofarea s not meetin g RO D cleanu p criteri a Utility clearance s Property informatio nfro mDougla s County Assessor' s Offic e 

# A\iSl h "Signatur e ~ Datt 30237427 

# • i i Superfun d

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Owner : CtV > _o i OAWV ^ Renter : Address : Phone: Fax : Ccll/Pagei- : Phone ; HD1..H<<^
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. Additionii l Information : 

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r ^ Acces s Agreemen t Signed : V H/ .v t /

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# S- Restoratio nAgreemen t Signed : \ o /
. By : J^Ji- ^ ! O Topsoil Samplin g (if applicable ) By : Q Disposa l Samplin g (if applicable ) Bv : Q Garde nSamplin g (i f applicable ) By : [ ^ Utilit y Clearanc e Called : m/ ^ / \ « B v I 

### »/» - ** " * ' • — [ ^ Video/Photo s (Before ) On : w / tv

L/ v

> D Video/Photo s (During ) On : / / Bv :
• Video/Photo s (After) On : By ; D Video/Photo s (30-Day ) On : / / Bv : Q Propert y Comjiletio nAgreement Signed : / / By : D Fina J Report I.iisued : / / By :
D Community Results : QCre w On : / /
_ 

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D Community Results : D Cre w ] On : / / Bv :

c nComrounit> Results : O Crc « On : / /

Omah a Lea d Sit e

### Dougla s County Accoun t In : 

## l^i^io n Pag e 1 of 2
Dougla s County , Nebrask a Propert yRecor d Informatio n i s vali d a s o f2010-8-3 0
Owne r CITYO F OMAH A C/

O PLANNIN G DEPARTMEN T 181 9 FARNA M S T#111 1 OMAH AN E 68183-000 0 Propert yInformatio n ­ R092034000 0

Ne wFeatur e ^ ^ ^ Prin t Reoor t Vie wInteractiv e GI S IMa o Treasurer' s Ta xReoor t Subdivisio n Sale s Searcl i

Ke yNumber : Accoun t Type : Parce l Numlier : Parce l Address : Lega l Description : Valu e Informatio n Lan d 201 0 200 9 200 8 200 7 200 6 200 5 203 4 OOO O 0 9 E xGovernmen t 092034000 0 221 9 MIAM I S T OMAH AN E 68110-000 0 DENISE S AD D LO T6 BLOC K1 5 0 X 12 2

$0.0 0 $0.0 0 $0.0 0 $500.0 0 $500.0 0 $500.0 0 Improvemen t $0.0 0 $0.0 0 $0.0 0 $0.0 0 $0.0 0 $0.0 0 Tota l $0.0 0 $0.0 0 $0.0 0 $500.0 0 $500.0 0 $500.0 0 

### Sho wAl l Transaction s

Lan d Informatio n Acre s S F 0.1 4 6100. 0 Unit s Depti i Widti i Vacan t 0. 0 122. 0 50. 0 Ye s



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. . 9/3/201 0

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. . 9/3/201 0

### Pag e 1 o f 1

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### • YOURTICKE T NUMBERI S 2627870
. Origina l Cal l Date : 10/27/1 0 Titne : 2:2 8 pmOp : ELIZABETH1879 0 Wor k t o Begi n Date : 10/29/1 0 Time : 3:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 221 9 Street : MIAM I S T Twp : 15 NRng : 13 E Sect-Qtr : 09-SE,10-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEAD REMEDIATION Locatio n o f Work : LOCAT E ENTIR E PROPERTY , AL L EASEMENT S AN D T O TH E PEDESTAL Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E I F CORNE R LOT . Compan y: COASTAL ENVIRONMENTAL SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Bein g Don e For : COASTAL Dept h o f Excavation : 4 F T Corne r Lot : N Front : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V MUDO l OMAHACO F OPPDGPR S QLNNEI C
Servic e Are a Contac t Phon e Numbe r Utilit y Typ e 

### Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , INC HEIDI 

### Alt : 402934046 9 Emerg : 402932975 7 Day : 402504782 3 MUDO l METROPOLITA NUTILITIE S DISTRICT SANDY 

### Alt : Emerg : 402504797 0 Day : 402444719 7 OMAHACOFCITY OFOMAHA-TRAFFICSEWERRICH/TRAFFIC Alt : 402444516 1 

### Emerg : 402444516 0 Day : 406728934 3 OPPDGPR5 OMAH APUBLIC POWE RDISTRICT EL M LOCATINGAlt : 406207149 4 

### Emerg : 888728934 3 Day : 406728934 3 QLNNEI C QWES T LOCA LNETWOR K EL M LOCATINGAlt : 406207149 4 Emerg : 888728934 3


### http://vmw.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT.
. . 10/27/201 0

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# Omah aLea dSuperfun dSit e OLS# : 2911 7 Dat e Excavated : 11/2/201 0 Dat e USEP ASiqne d Off : 12/2/201 0 Are a Sodden : 221 9 s q f t 

### 2911 7 Exterio rPain i Nofth Arro w Omah a Lea d Sit e Owne rName : JAME S DAVIS ^ •Goo d Sit e Sketc h Addiess : ^1 9 MM U S T QPoo r

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## 2911 7 Exterio rPain t Nort h Arro w 

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## 2911 7 Exterio rPain t NorthAno w Omah a Lea d Sit e Owne rName : JAME S DAVI S •Good Sit e Sketc h Address : 221 9 MIAM I S T QPoo r Phone : ^^ ; W : 

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### Grsnto i (th e pjopert^ ' ov/nei ) conseiil^
. t o en d authoiize s th e Unite d State s Fnviionmenta l Protectio n Agenc y(FPA ) o i its suthorize d representatives , collectivel y th e Granlee , t o entei an d perfor m certai n enviioniTienta l lespons e activitie s upor i th e followin g describe d premises
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PuRPOS E O F RESPONS E ACTIVITIE S 

### Th e EP Ai s requestin g acces s t o collect sol i sample s an d remove soi l tha t contain s elevate d concentration s oflea d an d ma ypos e a healt h hazard Th e area(s ) vvil l b e excavate d t o remov e contaminate d soil
. Th e remove d contaminate d soi l v/il l b e replace d wit h clea n material s an d th e are a wil l b e restore d t o it s origina l condition
. Thi s wor k i s bein g performe d unde rth e Omah a Lea d Superfun d Sit e remediatio n progra m Arepresentativ e ofCoasta l Environmenta l Group , contracte d byUSEPA , wil l contact th e Granto rin-perso n t o discus s th e wor k t o b e performed , th e Granto rwil l hav e a n opportunit yt o revie wan d approv e th e planne d soi l removal , an d restoratio n wor k befor e i t begins
. Onc e th e wor k i s finished , th e Granto rwil l b e aske d t o revie wth e wor k an d confir m tha t i t i s complet e an d meet s v/it h th e Grantor' s approval
. Upo n completion , th e Granto rwil l receiv e writte n documentatio n fro m EPAtha t th e property ha s bee n remediated
.
ENVIRONMENTA L RESPONS E ACTION S 

### B

ysignin g thi s Acces s Agreement , th e Granto ri s grantin g th e EPA , its employees , contractor s an d subcontractor s th e righ t t o ente rth e property , a t al l leasonabl e time s an d wit h prio rnotice , fo rth e sol e purpos e ofperformin g th e worf- xThi s acces s shal l remai n i n effec t unti l th e wor k ha s bee n satisfactoril ycomplete d lh e Granto rals o agree s to :

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### I Remov e olisliuction ? incljriin g boats , iiaileis , \'(-.hiclGP , jMrys-CHp e iK'Tir , woor ' piles , do o houses , etc ;

' [Remov e flov.'e i bulb s o i piaiils , tha i ih e Granto i o i th e Giariini' s u-iic-n t niri ywis h t o save ; Wate ran d meintai n leplacernen t vegetation , includin g ferliii?.e rRpplicFiion , a s necessary ' subsequen t t o er i initia l Vv'aterin g perio d b yEPA ; < Abid e b yhealti i an d safet yguidanc e piovide d b yEPA , I fth e propert yi s rented , assis t EP Ai n obtainin g tenan t sp|.)io\'8 l fo i acces s l o th e propert yt o perfor m th e wor k •. Allo wvideotapin g and/o rphotographin g o fth e properly
. AGREEMEN TNO TT O INTERFER E 

### Th e Granto ragree s no t t o interfer e o rtampe i wit h an yo fth e wor k activities , o i wit h an y o fth e wor k done , o rwit h th e equipmen t use d o n hi s property , o rt o undertak e an y action s regardin g th e us e o fsai d property ' whic h woul d ten d t o endange rth e healt h o r welfar e o fth e Grantee s o rth e environment , o rt o allo wother s t o us e th e propert yi n suc h a manner . Shoul d yo u hav e an yquestion s abou t thi s program , pleas e contac t Coasta l Environmenta l Group , a t (402 ) 991-119 9

M l gran t acces s t o m ypropertie s •I d o no t gran t acces s t o m ypropertie s

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## Restoratio n Agreemen t Th e purpos e o f thi s agreemen t i s t o provid e amutual agreement a s to condition s o f th e property prio r to remediatio nactivities
. Thi s wil l als o serv e a s documentatio nfo r th e purpos e o f assurin g that restoratio n activitie s are complete dto th e satisfactio no f th e property owne r andth e Unite dState s Environmental Protectio nAgenc y (EPA)
.

Property ID : ^ ^// 7 PropertyAddress : ^g^ ^ ^^^
. ^^^ ^ Owner : <^ Ao< F Z7/yyQ^ly h Phone : 

## Vv^/-Vpv / O nth e attache ddiagram(s ) indicate area(s ) to excavate , surfac e structure s andlandscapin g feature s and acces s location(s ) to b e use db y th e contractors . Indicate distances , depths , material types , etc . Photographicall y an dVideographicall y document the existin g condition s ofth e propert y an dth e basement if necessary . 

### Item s t o b e Remove d b yth e Owne rbefor e Star t o fRemediation : Th e removal , storage , disposal , and/o rretur n o fthes e item s i s th e Owner' s responsibility
.



### Ite r n s t o b e Remove d b yth e Contracto r Durin g Remediatio n an d No t Replace d item :
Item :
Item :
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Pag e 1 o f3COASTA L ENVIRONM I NTA L C P O U P , IN C 

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### Landscap e Inventor y Ite m Quantit y Uni t Condition/Type/Specie s Pre-existin g property area , Quadrant s 

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# Y -.izes an diiicaiions
. Agree dupo nvalu e o f plant material s no t t o b e replace db v contractor . ^Ot c thi s Milii f "il l b e 'iscr i H i Ivsiie i l plan t MUiclu T I dtlu ' propiri x i>\

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. Easemen t Area , to b e Each excavate d 

## Uyj l cy^^ ^ Pag e 2 o f_i
.COAST/ " L

Additiona l Comment s / Instructions : Th e cit yo fOmah a ordinance s ma yprohibi t yo u fro m usin g dir t o rgrave l area s o n you rpropert y a s driveway s o rvehicl e parkin g areas . Th e Environmenta l Protectio n Agenc y(EPA ) ma yb e removin g an d replacin g soi l underlyin g a grave l o rdir t are a o n you rpropert ytha t yo u ma yb e usin g a s a drivewa yo rvehicl e parkin g area . I fthi s i s th e case , yo u shoul d understan d tha t thi s removin g an d replacin g o fsoi l doe s no t mea n tha t an yillega l drivewa yo rparkin g are a o n you r propert yi s mad e legal
. T o th e contrary , yo u ma yb e cite d b yth e cit yi fyo u us e a grave l o rdir t are a a s a drivewa yo rparkin g area , no t withstandin g an yremova l o rreplacemen t o fsoi l b yth e EPA
. I fyo u hav e an yquestio n abou t legalit yo fa certai n drivewa yo rparkin g area , yo u ma ycontac t th e cit yo fOmaha' s Plannin g Departmen t a t (402 ) 444-5150
. ' Pleas e chec k thi s bo xI fyo u understan d th e informatio n outline d above
. ^

H^hec k th e bo xi fOwne rdoe s no t wan t CE G t o documen t interio rfoundatio n wall s an d possibl e pre-existin g damage
. B ycheckin g thi s bo xCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro fhouse , includin g foundatio n crack s o rfissures
. ^ 1 

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

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## Certificat e o f Verificatio n

22 0 SOI L 2011-01-2 0 11:2 6 90.7 2 Fina l Avg of 217-21 9 221 9 MIAM I S T EA 1 " C.PADILL A CONFIRMATIO N CLEA R

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

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pp m P b 180.58 4 Supervise d By : 

## Certificat e o f Verificatio n

21 7 SOIL 2011-01-2 0 11:2 4 30.2 6 Fina l 2911 7 221 9 MIAM I S T E A 1 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r
± 20.50 0

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

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pp m P b 170.60 2 Supervise d By : 

## Certificat e o f Verificatio n

21 8 SOI L 2011-01-2 0 11:2 5 30.2 6 Fina l 2911 7 221 9 MIAM I S T EA 1 " C.PADILL A CONFIRMATIO N CLEA R

Erro r ± 19.57 2

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 163.29 5 Supervise d By : 

## Certificat e o fVerificatio n

21 9 SOI L 2011-01-2 0 11:2 6 30.2 0 Fina l 2911 7 221 9 MIAM I S T EA 1 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 19.27 6

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s AVERAG E ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

Supervise d By : 

## Certificat e o fVerificatio n

21 6 SOI L 2011-01-2 0 11:2 3 92.2 4 Fina l Av g o f213-21 5 221 9 MIAM I S T F l 4 " C.PADILL A CONFIRMATIO N CLEA R

# Therm o SCIENTIFI C Therm o Fishe r Scientifi c 90 0 Middlese x Turnpik e Billerlca , M A0182 1

XL3t-3902 2 Readin g N o Mode Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 143.75 3 Supervise dBy : 

## Certificat e o f

Verificatio n

21 3 SOIL 2011-01-2 0 11:2 1 30.1 9 Fina l 2911 7 221 9 MIAM I S T F l 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r 18.86 4

# Therm o SCIENTIFI C Therm o Fishe r Scientifi c 90 0 Middlese x Turnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mode Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 157.90 2 Supervise dBy : 

## Certificat e o fVerificatio n

21 4 SOIL 2011-01-2 0 11:2 2 30.1 8 Fina l 2911 7 221 9 MIAM I S T F l 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 19.95 7

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 175.62 6 Supervise d By : 

## Certificat e o fVerificatio n

21 5 SOI L 2011-01-2 0 11:2 3 31.8 7 Fina l 2911 7 221 9 MIAM I S T F l 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 17.51 3

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s AVERAG E ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

Supervise d By : 

## Certificat e o fVerificatio n

21 2 SOI L 2011-01-2 0 11:2 0 91.0 1 Fina l Av g o f209-21 1 221 9 MIAM I S T B l 4 " C.PADILL A CONFIRMATIO N CLEA R

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 161.03 8 Supervise d By : 

## Certificat e o f Verificatio n

20 9 SOIL 2011-01-2 0 11:1 9 30.5 7 Fina l 2911 7 221 9 MIAM I S T B l 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 17.70 3

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Blllerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 183.03 9 Supervise d By : 

## Certificat e o f Verificatio n

21 0 SOI L 2011-01-2 0 11:2 0 30.2 5 Fina l 2911 7 221 9 MIAM I S T B l 4 " C.PADILL A CONFIRMATIO N CLEA R

Erro r ± 21.26 7

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerlca , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 178.03 6 Supervise d By : 

## Certificat e o f Verificatio n

21 1 SOI L 2011-01-2 0 11:2 0 30.1 9 Fina l 2911 7 221 9 MIAM I S T B l 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 21.64 5

## f^^^^J \ Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 S ^^^ ^

I Coasta l Environmenta l Grou p Inc
. ^T^^^ ^

www.coastalhazmat.co m ^"Lno^" ^ COASTA L EHVItONHEHTA l cI I 0 u r , IN O 

# EXECUTIV ESUMMARY : BVID #2911 7 - (221 9 MIAM I ST )
No Issue s o r Concern s Issues/Concern s Detail Explanation : -DANGARVE Y WALKE D TH EPROPERT Y O N12/2/201 0^ J ^j 

## EP APropert} ' Clos e Ou t For m Proprrt j «: 3N\>^^ ^ Propert yAddrtiy
. -^^^i^^—*V'"'T ' ^^ Uate/Tlme : . Owner' s Nsiu f/:—CiAij--itt_5>»»«J<5a = Oiiad u F.xcBvstfd : __ConlrBCto rGrou p
Excavatio n Gtnera l .'^»"?.^' '

' 1 IfnfCfssarj
. ^^r cth e corrrc t quadranKs ) excavale d an d restored' ' J 

# 4

' 2 Ifnccessan,' , wer e th e correc i areas ofdn p ;on e excavale d nn d restore d 

## 7 I
Ye s Ni l 1 Doe s th e gndin g aroun d th e pcrimeie rofth e hous e in excavairr i area ? generall y".IUJ Ki)»va \ Gfadin g So d an d Vrttctatio p 

### / ; from tb e house ? 2 Ha s so d bee n lei d in al l area s tha t were excavated ? < Doe s th e so d appea rto be generall yhealth yan d growing''(Onl yevaluai e irin^prrirda i a ^0 j / " da ytitn e period ) ^
. • / \ 4 Ar e sodde d area s generall yfirm an d evenl ygraded' ' ' ^ Ar e th e joint s betwee n th e so d strip s generall ytight' ' (Onl yevaluat e irinspccie d ai a .T n da } / tim e period )
_ __ ^ 1 r" •• . . . . - -- ^ - I / f 6 Wa s th e propen ygrade d suc h that waie ruil l no l poo l on ih fprnpen v•j 7 Wa s damag e to landscapin g orplan t material s avoided' 'j / Gates
. Fence ] an d ReUinln cWall s W- ^^H Do gate s ope n an d clo.i e freely'' (I fapplitablc ) 1 / ! " rWer e al l gates oi fence s take n dow n dunn g restoralio n aiiiviiie s reinstalled' ' (1 ) apo/icahl ri 

# i/i- ­ ^ Wa s damag e lo gate s orfence s avoided' ' (Ifapplicable ; 

# i/i ­ j 4 Wa s damag e to retainin g wall s avoided ? (Ifapplicable ) j foupdation , , Sidin

Sidin g g an

an d

d Cutler

Cutler s s pdation . __ _ __yj / "^f I Wa s damag e to th e sidin g ortri m avoided' ' 

# -y\

' ? Wa s damag e tn th e foundatio n avoided' ' 

### \ 7 Wa s damag e tcwmdou- s avoided' ' ^ Wa s damag e lo window sordoo rscreen s avoided' ' 

# P\
. 'Wa.^ damag e lo downspout s nrdownspou t txiension s a^ oidcd '

• Sjdj-w^lks^n d Driveway s (Concrete )> cs ^^ I Wa s damag e 10 drivewa ysuHacr s as oided ' I / ' ?. Wa s damag e lo walkwa) - surface s avoided' ' 

## 1 7 '

# H O^ver r rom m 

## eniff^ F

|n.«;pf>ctin n note*; :



## Ren)0^•a l andresimatiui i rtiilvalf..<^ tcinplci e incliiding ih t .M)-da y .so dwanaiU ) l.-P AKc[5respniaiivt ' 0c 

# z H Date : alt(" >

### % 

# € > Propert yCompletio n Agreemen t
Ihi i aiticctnen i diicuineni fIh e lomplclio n o l iciriediit i acliviiie s pcilonntdn n m ypioperi yM y.Mgnaim t wil l designat e iha i I an t S8ii.<>fie d wil h lh e re.<iioralio n o fm yptopert yKnd ihu t n o nrin. ^ arci n que.^iion s now , o ra l anylim e i n th e fulutr
. except ihos e uem s hsle d bdow , ifan y 

## !!lPI!:!L!!L_2aAi-5
_ Propert y Addreu
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. Owner : -Cyfc<^-
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. niK^itVt b Fhoiic : .,Vf^>U^„^3,Mf c 

## . J Restoralio n Ilem s i n Question
.

Hem : Hem : Item : Hem : Hem : item : Additiona t Comments : 

# L
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