p 

p 

TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID ,: ^G^ l 

Date: 

^ K (^ 

 an -VIAAddress , U(S ^ y 

Remediation Contractor: Coastal Environmental Group_ Year: 2001 

SOIL REMEDIATION 

PROPERTY nL E FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

el EPA-provided property sketch 

Signed Access Agreement for subject property 

-Er 

Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

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

Confinnation data 

Photographs % W ^ ^ ^CA^^iy^/y\ K W {^O^^^^^^r^ 

t / 

As-built sketch 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

J l- Description of areas not meeting ROD cleanup criteria 

Utility clearances 

Property infonnation from Douglas County Assessor's Office 

I5ate 

30054476 

Superfund 
• • 

Property Access Checklist 

PnH«rt,m: ZQID Q 1 a NVOHK STARTED ON: / / 

• WORKCOMPELTED ON;_ / / PropertyAdd««)2.|9^^27S T 

Roiten 0"«^ r/i+y>crinP: f(if)ppJ|/^nf) 

Ptione 

ftac 

Cdl/Pagen 

Additional btformation: "»««ao2..^S7..ZbQ4 

Fax: 

Cen/Pagen 

LJ Notification Letter Sent: / / By: 

^ Access Agreement SlgB«d:g_/29./2L By: 

P ^ Restoration Agreement Slgned:^/Za<H. By: 

a D>|tsoilSafflpliag(tf applicable) / / By: 

D Disposal Sanqtiing Of qipHcable) / / Br. 

D Garden SampUng 9 applicable) / / By: 

) ^ Utility Clearance Called: iL/i2/(29 ^-m/i/nq \l^'.)L 10 13 

G^deomioio s (Btfore) On: J. / :f^ / VL *3^ Dtr^'^^l'-' 

a Ytdeamotos (Dnring) On: / / B r 

D Videomiotas (After) Om / / Dy: 

D Vi|Jeofl%o«08 (30-Day) On:^/_/ _ By: 

^ ,0''Pr«perty Completloa Agreemait SigWHly^/^/ ^ By: 

( 1 D RnalRcport Issued: / / By: 

Air Mmiitorine (as apolicable 

D Comnmnity DCrew On: / / 

By: 1

Results: 

a Commnnlty OCrenr | On:_ / / By: . 1 

Results: 

• Comnmnity QCrcw | On: / / By: 

Results: 

Omaha Lead SKe 
• • 

- Douglas County Account Jl&inmtion Page 1 of2 

Douglas County, Nebraska Property Record - R2218340000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VieWf OH Ma p Information is valid as of 2009-9-15 Treasurer's Tax Report 

Nev^ Feature ^ ^ - • Auto Sales Search 

Owner 

CAPPELLANO JR LOUIS J 

ETAL 

2905 S 74 ST 

OMAHA NE 68124-0000 

Property Informatio n 

Key Number: 1834 0000 22 

Account Type: Residential 

Parcel Number: 2218340000 

Parcel Address: 1219 S 27 ST 

OMAHA NE 68105-0000 

Legal Description: SHULLS 2ND ADD LOT 11 BLOCK 8 N 40 S 128 W 40 FT LT 12 & N 40 S 128 FT 

40X97 

Value Informatio n 

Land Improvement Total 

2009 

2008 

2007 

2006 

2005 

2004 

$3,900.00 

$3,900.00 

$3,900.00 

$3,900.00 

$3,900.00 

$3,900.00 

$51,800.00 

$51,800.00 

$51,800.00 

$44,100.00 

$44,100.00 

$44,100.00 

$55,700.00 

$55,700.00 

$55,700.00 

$48,000.00 

$48,000.00 

$48,000.00 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.08 3880.0 1.0 97.0 40.0 No 

Improvemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R22... 9/17/2009 
Dbuglas County Account I^i^tio n Page 2 of2 

• # 

Hre> Floor > sse.otait. 

BGinnt 

IMO«q I 

?ir! aaiftwC w ' i 

; t x a VI n \ \ 

2 STORY 

CLICK TO ENLARGE IMAGE CUCK TO ENLARGEJMAGE 

Square Footage: 1122.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 4.0 

Exterior: ^ Frame Vinyl Units: 1.0 

Interior: i Plaster Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: ; 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1902 0 0% 1902 107 

Detail Type Detail Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 656.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Basement Single 1.0 

Porch Slab Roof Ceil 24.0 

Porch Slab Roof Ceil 126.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R22... 9/17/2009 
• • • • 

Page 1 of2 

"> 

Create Another Ticket _ _; ] [iy^i Backtojrth jntarnet \^ | [i. Send Eniai| ] 

• YOUR TICKET NUMBER IS 2382689. 

Original Call Date: 10/08/09 Time: 11:11 am Op: ELIZABETH18790 

Work to Begin Date: 10/13/09 Time: 11:45 am 

State: NE County: DOUGLAS Place: OMAHA 

Address: 1219 Street: S 27TH ST 

Twp: 15N Rng: 13E Sect-Qtr: 28-NE 

Twp: Rng: Sect-Qtr: 

Legal Given: C 


Type of Work: LEAD REMEDIATION 


Location of Work: INCLUDE ALL EASEMENTS LOCATE ENTIRE PROPERTY 


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


UNSURE OF CORNER LOTS 


RESENT Dtra: TO WORK EXTENDING. REFRESH PAINT AND FLAGS 


Company : COASTAL ENVIRONMENTAL SERVICE 


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


Work Being Done For: COASTAL 


Depth of Excavation: 4 FT Comer Lot: N Front: Y Rear: 


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVELS MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Number UtiUty Type 

Day: 4029340469 

CXCATV COX COMMUNICATIONS, INC HEIDI Alt: 4029340469 

Emerg: 4029329757 

Day: 8773668344 

LEVELS LEVELS COMMUNICATIONS, LLC NA Alt: 

Emerg: 8773668344 

Day: 4025047823 

MUD02 METROPOLITAN UTILITIES DISTRICT SANDY Alt: 

Emerg: 4025047970 

Day: 4024447197 

OMAHACOF CITY OF OMAHA-TRAFnC.SEWER RON Alt: 4024445161 

Emerg: 4024445160 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 10/8/2009 
Page 2 of2 

• • • # 

0PPDGPR6 OMAHA PUBLIC POWER DISTRICT NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

QLNNEIF QWEST LOCAL NETWORK NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreationyMessageText.asp?ret=<RESULTS... 10/8/2009 
0 # As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

Owne Omah a Lea d Sit e r Name: LOUIS J CAPPELLANO JR ET 

Sit e Sketc h Address: 1219 S 27 ST 

Phone: H: W: 

Sample Number Lead Sample LAB Concentration Collected 

RYASCPXA-20691 F l ppm D 

RYBSCPXA-20691 F2 tM_ ppm D 

RYCSCPXA-20691 Bl ppm t3^ n 

RYDSCPXA-20691 B2 2 32. ppm n 

RDZSCPXA-20691 DZ 7&>0> ppm a / n 

ROZOCPXA a06»1 GZ ppm n 

-RPZGCPXA-20C91 PZ ppm n n 

Number of Samples = D^ 

OLS#: 20691 

Du Excavated: 10/9/09 e 

20691 

Exteripr Paint North Arrow 

• Poor 

I I Not paint 

Samples Collected 

Firm: PftA- BAlC^ 

Date: ^ n^//i/o 

Time: % rsy 

Samples Analyzed 

XRF Unit: IOl> 7 Book: /I 7 

Date: s'-zsr-os- Time: 7 ^ ^ 

Staff. 

AA. 

lENTEBED 

Omaha Lead Site 46130 

Area

Concrete 

 replaced

Sod 

 with 

7^

Legend 

 Drip Zone Excavated 

Area replaced with 

Roclc/Mulch 

Quadrants Excavated 

Area lef t bar e 

Contrac t #: EP-R7-07-05 Coastal Environmental Group Inc . 
20691 

Omaha Lead Site Owner Name: LOUIS J CAPPELLANO JR ET 

Site Sketch Address: 1219 8 27 ST 

Phone: H: W: 

Sample Number 

RYASCPXA-20691 

RYBSCPXA-20691 

RYCSCPXA-20691 

RYDSCPXA-20691 

EST" 

RDZSCPXA-20691 

Lead Sample 

Concentration Collected 

^ 0>oU ppm a/ i&L. ppm 

\7R ppm 

232 ppm . 

7^<i> ppm 

ppm D 

ppm D 

Number of Samples = K 

178 

V Z32. 

---^^;^»vAl>fc;-

LAB 

D

• 

a 

n 

n 

D 

D 

-?pr 

2 

Exteripr Paint North Arrow 

QJ^ood 

• Poor 4 

[~| Notpaint 

Samples Collected 

Firm: \-BA/c 

Date: lULli 

Time: 120-

Samples Analyzed 

XRF Unit: f 0l> 7 Book: 117 

Date: 5"-2S'-gS ~ 

Time: /'TT) 

Staff: ^: 4 

ENTERED 

MAY? 3 20B5 

tg^TT^ 

Omaha Lead Site 46130 
LL iiy i 

a\o^ 20691  . s ;:)^.cv 

Omaha Exteripr Paint North Arrow Lead Site Owner Name: kOUISJ CAPPELLANO JR ET 

Site Sketch [jj^oo d Address: 1219 827 ST_ • Poor 

W: Q Not paint 

Omaha Lead Site 4(SnO 
I 20691 

Omaha Lead SHe Owner Name: LOUIS J CAPPELLANO JR ET 

Sits Sketch Address: 1219 S 27 ST 

Phone: H: 

w. 

Sampl Lead Sample e Number LAB Concentration Collected 

RYASCPXA-20691 Fl (fiOh ppin D 

RYBSCPXA-2P691 F2 IftI oom D 

RYCSCPXA-20691 Bl 17 ^ ppm Q^ D 

RYDSCPXA-20eS1 82 ggg . ppm D 

RD2SCPXA-20691 DZ Tio to ppm uy a • ROzooDtA-awM—ez ppm D n 

nPgOCPXAFBOOtll PZ .ppm D n 

Number of Samples = | K 

- % • .. ^ < • 

Exteripr PairA Nonh/fniw 

D P«»^ 

Q Not pabit 

Samples Collected 

Firm: Pfi A-Bh let) 

Date: 

Time: 

IP-PCDC . 

Samples Analyzed 

XRF Unit I c m Book: 11 7 

Date: S'-2.^'OS~ 

Time: P7t \ ._ 

Staff. i~ A 

Omaha Lead Site 46130 
D Remote ID! R page of 

< # 

C[>A*T/i l 

r«»ti^ 

Consftillfcrr A<;G<ifi& To t'ropeii+j' 

RIGHT OF ENTRY TO PREMISES 

Grantor (tha property owner) consents to and authorizea the United States 

Environmental Protection Agency (EPA) or its authodzed repreaentatives, collectively 

the Grantee, to enter and perform certain environmental response activtties upon the 

fDllowing descriijed premises;

J : ....

 _ ^ . 

 m\)'' 2cj(Bi 

i Ovmer's Name: 

L-Lo-ols ^. .cappcilam 

Daytime Phone: 

}iOLMl:M^ 

Address of Property 

covered by thit \l\(\ 5 2T 3\t Asreement; 

PURPOSE OF RESPONSE ACTryiTiES 

The EPA is requesting access to collect soil samples and remove soil thet contains 

elevated concentrations of krad end may pose a health hazard. The 8reB(&) wili be 

excavated to remove contaminated soil. The removed ctmtaminated soil will be 

replaced with dean rnatenals and the area will be restored to Its odginal condition. This 

wodt is being performed under the Omaha Lead Superfund Site remediatmn program. 

A representative of Coastal Environmental Group, contracted by USEPA, will contact 

the Grantor in^erson to discuss the work to be performed, the Grantor will have an 

opportunity to review and approve the pienned soil removal, and restoration woric 

before it begins. Once the worit is finished, the Grantor will be asked to review the work 

and conflmn that it is complete and meets with the Grantor's approval. Upon 

completion, the Grsntor will receive vwtlten documentation from EPA that the property 

has been remediated. 

ENVIRONMENTAL RESPONSE ACTIONS 

By signing this Access Agreement, tho Grantor is granting the EPA. its employees, 

contractors and subcontractors the right to enter the property, at all reasonable times 

and with prior notioe, for the sole purpose of performing the wod(. This access shall 

remain in effect until the work has tnen satisfactorily completed. The Grantor also 

agrees to: 

Psge 1 of ? 
D Remote ID: R page of ^ 

C0A* 1 A L 

< Remove obstmctions including boats, trailers, vehicles, plej'scape Items, wo

piles, dog houses, etc; 

od 

f Remove flower bulbs or plants that the Grantor or the Granlcr's tenant may w

to save; 

ish 

< Water and msintain replacement vegetation, Induding fedllizer application,

necessary subsequent to an initial watering period by EPA; 

 as 

< Abide by health and safety guidance provided by EPA; 

< If the property is rented, assist EPA In obtaining tenant approval foi access

the property to perform the woric. 

to 

t Allow vkl«>tap<ng wixUot photographing of the property. 

AGF^EEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the wori( activities, or with any 

of the wori^ done, or with the equipment used on his property, or to undertake any 

actions regarding the use of said praperty 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 (4Q2) 991-t199 

jC WJi ^9 -yd^ S''" s ^ access to my pr«ptrtles Q t do not pnnt leeass te my proparttei 

eisnature / / Date Signsture Dats 

D I would like to be present during any sampling thst is required. 

Paee 2 of 3 
D RsiiOte ID; R page of 

c o * \ '" * *• 

Refitoratscn AgrBsmsnl 

The purpose of this agreemem is to provide • mutual Bgrcemem as TO conditions ofthe property prior lo 

rctnediatioD EctivKies. This -will also serve u documentttion for the purpoiB of tsiuring tiiat reitoiation 

Bcrivitiei are completed lo the Mtisfhction of the propeny owner and ths United Siaies EnviTonmental 

Protection Agency (EPA). 

- 1 

j Property Addnm y i \Q .^ 7*^ g^­

"Q^^'Wii^" rrxpop Ward 

On the eitached di«grBra(B) indicate area(s) to excavate, tttcfvx strueturts uid landscaping features and 

Kcccn incatioa(t) to be \aed fay the ctnmactDrs. Indicate diaiances, depths, itretcrial types, etc. 

Photographically snd VIdeogjapbicaJly document the odttins conditions ofthe property and the bassment if 

necessary. 

items to be Removed by the Owner before Start of Remsdlstlon: 

'.-.; iscioval srojeRii, tritpo^ti, and/or raiL,fn oi iheac Hame m Ihu Ui»/ners 'cspontit'iiiv r •!• III I II lll l I—. I imw ^um i m ""i n~i~^~^nM "•—ii i—irtiima Bun TII M i. ii ^ ^ ^m mw iiftr ^ jptawm •—— — ^wi i % - »ir^wlJ> • • i u -MJ iiB._ _-X^—,_ p^k* ••.• • Rem: / • 

<«K/j« ' .

fuw-f, Vi^^ni r : 

7rvL. _„„.---^i . Rem; ^^^^^^^^"-" ^ ; 

1 

: Item: 1 

! ^ ^ - - - ^ i 

! Item: 

Items to be Removed by the Contractor During Remedlatfon and ^et Replacad 

I Itam 

?^1 fl^tvvoj/^ Ml\u.v, 

I Item: 

Item: 

Kem: 

Page 1 of / 
D Remote ID: R page of 

C « A 1 "T * I 

Items to Be Removed By. Corttrsctor Duriixg Remediation end t^eslaced 

Hem: 

f!>\^ iL_ti 

1 Item: , h ir 1??: 1 • Itetn: 

1 . . . • • » ••— 

Hem: 

Item 

I 

Pre^exiiting propeny area, 

(hat will be enaivatcd. ibsi 

ii eevered with gnm. 

t^umber of trees > 2 Inch 

tnmk diamater 

I Number of trees <" 2 inrh 

trunk dioneter 

Number cf Sprinkler 

Zones. Control Valves. 

Tinen. Heeds, etc. 

'.;!:n.r. .1 sl.i.iri> m i-ie 

• ri'i'lsU-i I;".'.IU. 

Number of sad size of 

each esiden/ flower bed 

../! > i)lid rm;il?'V^-\ 

AgTved npov vejiie of ptam 

materlali not to be 

I repleeeJ by contractor. 

••!?!!• ;; !• . ,.:;i z .\.t - 111 

' .• = i . I. ; ;.-.->r' > 

Easement Area. 10 be 

eKcavatad 

; 

d.^^'t^^.mJf.'fltmf..,.*^... '_ M 

Landscape Inventory 

Quantity Unit Condftion/Type/8peeies 

:j 

Quadranti \Svur ^K^; 

J2I. -r Each 

Eaeh ^ 

xf Each 

'y Esefa 

SquaicFrot j 

I 

i -H.,.-.,. 

r 

E«* I'l's Hi^ t^f^HW'^i ^ 

Paga 2 . - > 
D Remote ID: R page of 

AddHIanal Commvirts / instructions: 

i J Check the box If Owner does not want CEG to documerR Intsrior 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. 

j)^I agree O 1 do not agree 

VJ)ynnr'» Slgnauirt / ' Date Comncter's Sigaai Oatr 

Page 3 of. 

TDTfiL P.07 
BVID 0^9 1 

XRF PROPERTY SAMPLE SHEET 

m^l> T'l-'Trc 

am/pm 

30 sec 

Reading Sample area 

? 3 ^A?^ ^ 2- ^// o £1 

Z- -^12 . Depth 

:t^(i 

?f ^/ / 

Reading Sampie area 

Depth 

Reading Sample area 

Depth 

Reading Sampie area 

Depth 

mst 

Date 

Project. 

XRF1D# 

Shot# 

2 d ^ 

2dJ2SL 

'2^10(^ 

Average

Shot# 

?U^, 

'W(^ 

Average

Shot# 

Average 

Shot# 

Average 

lab sampie # 

\nll(e1 

Omaha lead FP 2nd year opilon 

Reading 

// 3 ^ / 3 

i n TJ^fi­ iOl rklZ­ l((f^(2> 

Sample area 

^^JL 

Depth 

 /z>2'—^// 

Reading 

U

3 ^

X 

 ^ u

'kM. 

^ f i > ^ 

Reading 

Reading 

Lab result 

Sampie area 

D2-

Depth 

Sample area 

Depth 

Address 

Sampie time 

sampie length 

Shot# 

rAn^ 

^ / o Z^(( 

Average 

Shot# 

Average 

Shot# 

Average 

RETEST AREAS 

Sample area Shot* 

Depth 

Average 

Sample area XRF Avg. 

Signature, 

Print FW\)QPJCW (>CP.r^^ 
m t 

/ J/k^ \ Omaha Lead Site—Fixed Price EP-R7-07-05 

I Coastal Environmental Group Inc. vi 

\ _ ' ^ www.coa8talhazmat.com 

^^tpRoT*"^ COASTA L 

(•VltONHIilTAL Clo u r. IN C 

EXECUTIVE SUMMARY: 

BVID #20691-(1219 S 27 ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 
EPA 

EPA Property Close Out Form 

7 . ^ S T 

Property Property AddresstVJ 'i ^ #: 2,C>6> ? / . . 

Date/Time: Ow«r' . Name:. .iL.Cl«-tbj3 'T !'3y ^ ' ^•'" f f^ "'^" ^ 

Quads Excavated: 1^ t Q Zr Contractor Group C»«w<-ht- f e^ r-«»u>.p 

Excavatio Yes No n General 

I. If necessary, were the conect quadrant(s) excavated and restored? 

2. If necessary, were the correct areas ofdrip zone excavated and restored? - ^ ^ 

Gmdlng Sod and Vegetatioa 

I. Doe

from

s

 th

 th

e

e

 house

 gradin

? 

g around the perimeter ofthe house in excavated areas generally slope away T

2. Has sod been laid in all areas that were excavated? ly^ 

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? t / " 

5. Arc the joints between the sod strips generally tight? (Only evaluate if inspected at a 30 day 1 / ' time period) 

6. Was the property graded such that water will nol pool on the propert>'' i;^ 

7. Was danuge to landscaping or plant materials avoided? 'ty ^ 

Gates, Fences and RetataInK Walb VC5 > 0 

I. Do gates open and close freely? (Ifapplicable) 

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

3. Was damage to gates or fences avoided? (I f applicable) y 

4. Was damage to retainmg walls avoided? (Ifapplicable) 

Foundation, SidiBK and GuHers Yes No 

I. Was damage to the siding or trim avoided? IZ. 2. Was damage to the foundation avoided? c X ^ 

3. Was damage to windows avoided? 

4 Was damage to windows or door screens avoided? t y ^ 

5. Was damage to downspouts or downspoul extensions avoided? l y ' 

Sidewalks and Driveways (Concrete) Yes No 

1. Was damage lo driveway surfaces avoided? t ^ 

2. Was damage to walkway surfaces avoided? ly" 
Ovi'ners comments: 

iDSpection notes: 

Removal and restoration aclivales complete ijjcluj^ng the 30-day sod warranty: ju-aay soa warranry: 

EPA Representative Ly^7>\ Date: /d/^/s f 
Property Completion Agreement 

ihis agreemem documenls the compiclion of remedial acliviiies perloimed on my properly My signature 

will designate Ihai I am satisfied with the restoralion of my propeity, and thai no items are in questions, 

now, or al any lime in the future, except those items lisled below, ifany 

Property ID: ^Q^^Q^ ^ 

Property Address: j2_ \ (3 S 7 O SVOwner: o/^v^p^^Y^. CriOpa\rLAn 

Phone: M02 . 551 . f ^^^^^ 

Restoration Items in Question: 

' Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

r^w:\\v\o^ ?/0''s i/'ieb^^v\^ C)-^ prop>eH-y -p< ^ cj-, 

M""^1 Hgrc * c rcstomlion is complcitd, cxccpl as noieri 

[_J i do nol at>rec restoratinn is. eompleled 

( xXU. JVy /%J L lO-CH-D? fcCM^n.i^ ^•7<^\F<:^ 

Owner's Signature / Date Contrarlor's Signature Dale