## TRANSMITTA Lof OMAH ALEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R 

# SAlD#:Jiri LDate : ^(f ^ ( M Address : S^l ^ ^tC^ ^ < f Remediatio nContiactor : Coasta l Environmenta l Group

_Year : _2010ARRA _ SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S s/ . Vide o o f propert y (DVD ) [ y E.xecutiv e Summar y EPA-provide dpropeil y sketc h 

# y Signe dAcces s .Agreemen t fo r subjec t propert y -P ^ Signe dAcces s .Agreement(s ) for adjacen t propert y y Restoratio nAgreemen t y Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc: ) _U

_Confinnatio ndat a; . r '. y Photograph s fK ^ t^^Qh/AtWv t •\ho(^''^\\y ^ ­^ ^^ ^ y As-buil t sketc h Ii

r Satisfactor y restoratio nsigne db y Propert y Owne r ; H Propert y close-ou t chec k lis t signe db y EP A­ -B " Descriptio no f area s no t meetin g RO D cleanu p criteri a Utilit y clearance s Propert y iiilprfnaino nfro mDougla s Count y Assessor' s Offic e

3021873 8 Superfun d

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# v\ Propert yAcces s Checklis t Propert y ID : ^L\0^-:^9> ) Propert y Address : t^l^^o ^ 'i>ecc^\^ r ^ . D n WOR K STARTE D WOR K COMPELTE D ON : ON : / / / /

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Acces s Agreemen t Restoratio nAgreemen t Topsoi i Samplin g (i f applicable ) Disposa l Samplin g (i f applicable ) Garde nSamplin g (i f applicable ) UtiUt y Clearanc e Video/Photo s (Before ) Video/Photo s (During ) Video/Photo s (After ) Video/Photo s (30-Day ) Propert y Completio nAgreemen t Fina l Repor t Sent : / / Signed : G ^ /d^' \1 \ 0 Signed : CT ^ /Q." ^ AO / / / / / / 

## caUedDf e / 6M 7 v n OmCTSy^R ^ \ 0 On : / / On : / / On : / / Signed : / / Issued : / / By : By : By : By : By : By : By : By : By : By : By : By : /

Ai r Monitorin g (a s applicable ) 1 1 Conmiunit y C UCre w Results : On : / / 

## By : 1

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### Dougla s County Accoun t Inf i fim^jd^ r Pag e 1 of 2
Dougla s County , Nebrask a Propert yRecor d - R241046000 0 Prin t Repor t NE WFeatur e - Parce l Dimension s avaiiabl e @ scal e 0-5 0 ft wes t o f52n d S t - ViewOf l Ma p Informatio n i s vali d a s o f2009-10-1 5 Treasurer' s Ta xRepor t Ne wFeatur e ->->- > Aut o Sale s Searc h Owne r t-AVOl E JOSEP H C ETA L 541 9 DECATU R S T OMAH AN E 68104-000 0 Propert yInformatio n Ke yNumber : 104 6 000 0 2 4 Accoun t Type : Residentia l Parce l Number : 241046000 0 Parce l Address : 541 9 DECATU R S T OMAH AN E 68104-000 0 Lega l Description : WASHINGTO N HIL L SU B LO T6 BLOC K0 W5 0 E 25 0 F T Valu e Informatio n Lan d Improvemen t Tota l 200 9 $9,600.0 0 $174,700.0 0 $184,300.0 0 200 8 $9,600.0 0 $174,700.0 0 $184,300.0 0 200 7 $9,600.0 0 $174,700.0 0 $184,300.0 0 200 6 $9,600.0 0 $155,600.0 0 $165,200.0 0 200 5 $9,600.0 0 $155,600.0 0 $165,200.0 0 200 4 $9,600.0 0 $155,600.0 0 $165,200.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 4 6350. 0 1. 0 127. 0 50. 0 N o Impro t vemen Informatio n Buildin g 1



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2. . . 10/23/200 9

### Dougla s County Accoun t Inf < 

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### TW O STORY
CLIC KT O ENLARG E IMAG E CLIC KT O ENLARG E IMAG E Squar e Footage : 1908. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Averag e

Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 7. 0 Exterior : Fram e Sidin g Units : 1. 0 Interior : Drywal l Baths : 1. 0 Roo fCover : Compositio n Shingl e Bedrooms : 3. 0

Roo fType : Gabl e Stories : 2. 0 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 195 2 0 % 195 2 5 7 Detai l Typ e Detai l Descriptio n Unit s Ad d O n Bric k Venee r 500. 0 Ad d O n Fenc e Chai n Lin k 1. 0 Applianc e Allowanc e 1. 0 Applianc e Fireplac e Masonr y 1. 0 Basemen t Bsmn t Bloc k 8 ft 1022. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Garag e Attache d 220. 0 Porc h En d Scree n 128. 0 Porc h Sla b RoofCei l 40. 0 Porc h Woo d Dec k 176. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2. . . 10/23/200 9Pag e 1 o f 1

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## ^'^q-^ a Creat e Anothe rTicke t •^ UJ ^ Bac k t o Irt h Interne t -Sen d Emai l L_ :

YOU RTICKE T NUMBE RI S 2609950 . Origina l Cal l Date : 10/06/1 0 Time : 9:2 5 a m Op : ELIZABETH1879 0 Wor k t o Begi n Date : 10/08/1 0 Time : 10:0 0 a m State : N E County : DOUGLA S Place : OMAH A Address : 541 9 Street : DECATU R S T Twp : 15 NRng : 13 E Sect-Qtr : 18-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D REMEDIATIO N Locatio n o f Work : LOCAT E ENTIR E PROPERTY , AL L EASEMENT S AN D T O TH E PEDESTA L Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E I F CORNE R LOT . Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Bein g Don e For : COASTA L 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 0PPDGPR 5 QLNNEI C

Servic e Are a Contac t Phon e Numbe r Utilit y Typ e Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , IN C HEID I Alt : 402934046 9 Emerg : 402932975 7 Day : 402504782 3 MUDO l METROPOLITA NUTILITIES DISTRICT SAND Y Alt : Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCITYOFOMAHA-TRAFFICSEWE RRICH/TRAFFIC Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3 OPPDGPR 5 OMAH APUBLI C POWE RDISTRICT EL M LOCATIN GAlt : 406207149 4 Emerg : 888728934 3 Day : 406728934 3 QLNNEI C QWES T LOCA LNETWOR K EL M LOCATIN GAlt : 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 10/6/201 0

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# Omah aLea dSuperfun dSit e ENVIftOMHiNTA t C I I O U r. IN C OLS# : 8497 8 Dat e Excavated : 10/12/201 0
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_ Date ; IO-l5-a/> , RYBSCPXA-8497 8 F 2 Tim e fn:S o /i/y , RYCSCPXA-8497 8 B l Sample s Analyze d RYDSCPXA-8497 8 8 2 RDZSCPXA-8497 8 D Z XR F Unit : 

### h530Book:22J L RG2SCPXA-8497 8 G Z Dat e n i l QQ RrZOCP)(A-0<97 0 P * Tim e A L Staff : Numbe ro fSample s = | fc | | Q | 

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### Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .

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# 4 - Concenlratio n Collecte d Finn : fPfi t b^'A J RYASCPXA-8497 8 F l 2 . B I pp m D Date ; 10-15-0 ^ RYBSCPXA-8497 8 F 2 T" I R pp m D Time : / n iS d a m RYCSCPXA-8497 8 B l ff2. pp m D Sample s Analyze d RYDSCPXA-8497 8 8 2 " 1 5 pp m D RDZSCPXA-8497 8 D Z ^.^ 1 pp m D XRFUnit : ffl.S'^ O Book : 2ZV
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### \ Sampl e Numbe r RYASCPXA-8497 8 F 1 Lea d Coficentratio n 

## 2.& 1 pp m Sampl e Collecte d LA B 

## D Fimi : Date-. Sample s Collected 

## rZ) 4 ^^-A T I0~l5~0f ^ RYBSCPXA-8497 8 RYCSCPXA-8497 8 RYDSCPXA-8497 8 RDZSCPXA-8497 8 F 2 B 1 8 2 D Z 

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## D D D D Time : //•). ' S O <t m Sample s Analyze d XR F Unit : CiL^H O Book : ?9 ^ RGZSCPXA-8497 8 G Z pp m 

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## Consen t fo fAcces s To Propert y RIGH TO F ENTR YT O PREMISE S 

### Granto r(th e property ' owner) consent s t o an d authorize s th e Unite d State s Environmenta l Protectio n Agency(EPA ) o rit s authorize d representatives , collectivel y th e Grantee , t o ente ran d perfor m certai n environmenta l respons e activitie s upo n th e followin g describe d premises : ^

Owner' s Name : / ^ , , , . - « \ ^ni A Daytim e Phone : 

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Addres s o fPropert y I covere d b ythi s 

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Agreement : PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EP Ai s requestin g acces s t o collec t soi l sample s an d remov e soi l tha t contain s elevate d concentration s o flea d an d ma ypos e a healt h hazard
. Th e area(s ) wil l b e excavate d t o remov e contaminate d soil
. Th e remove d contaminate d soi l wil 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 its 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 program . Arepresentativ e o fCoasta 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 wit h th e Grantor' s approval
. Upo n completion , th e Granto rwil l receiv e writte n documentatio n fro m EP Atha t th e propert y ha s bee n remediated
. ENVIRONMENTA L RESPONS E ACTION S 

### Bysignin g thi s Acces s Agreement , th e Granto ri s grantin g th e EPA , it s employees , contractor s an d subcontractor s th e righ t t o ente rth e property , a t al l reasonabl e time s an d wit h prio rnotice , fo rth e sol e purpos e o fperformin g th e work
. Thi s acces s shal l remai n i n effec t unti l th e wor k ha s bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :

Pag e 1 of2.,*^^°""-^
. COAST AL C K0 U rt KC 

### cRemov e obstruction s includin g boats , trailers , vehicles , playscap e items , wo piles , do g houses , etc ; o d
e Remov e flowe rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma yw t o save ; is h
cWate ran d maintai n replacemen t vegetation , includin g fertilize rapplication , necessary ' subsequen t t o a n initia l waterin g perio d b yEPA ; a s fAbid e b yhealt h an d safet yguidanc e provide d b yEPA ; t I fth e property ' i s rented , assis t EP Ai n obtainin g tenan t approva l fo racces s th e propert yt o perfor m th e work
. t o
cAllo wvideotapin g and/o rphotographin g o fth e property . AGREEMEN TNO TT O INTERFER E 

### Th e Granto ragree s no t t o interfer e o rtampe rwit h an yo fth e wor k activities , o rwit 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 propert ywhic 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

0 ^ c I gran t acces s t o mypropertie s Q I d o no t grzn t acces s t o m ypropertie s 

# 7-c;^7-/ ^ Dst e Signatur e Date

•1 woul d lik e t o b e presen t durin g an ysampling i tha t I s required
.

Paa e 2 o f2COASTA L 

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

Property ID : 

# If^ n Property Addressrj-Y/ ^ , ^p gc ^ "j- UC C~f ' Owner 

## V Phone : O nth e attache ddiagram(s ) indicate area(s ) t o excavate , surfac e structure s andlandscapmg feature s and acces s location(s ) t o b e use db y th e contractors . Indicate distances , depths , material types , etc . Photographicall y andVideographicall y document th e existin g condition s ofth e property andth 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
. Item : 

# A-fl v ^ Ui^^ 3 'T o i f ^ rc K I K^o^ ^ (g _ Item : Item : Item :


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# [pUy ^ 

# h /
. f- h P^ A

# ' 

# fn j Item:.-/ f1 ) Item : Item :

Pag e 1 o f2 ­COASTA L CNVinONMEMTA L CROUP
. INC
. 

### Item s t o B e Remove d B yContracto r Durin g Remediatio n an d Replace d Item : 

# ^ o ) Item : 

# i ^ ^ Item : Item :



### Ite m Pre-existin g property area , tha t wil l b e excavated , tha t i s covere dwit hgrass . Number o f tree s > 2 inc h trunk diamete r Number o f tree s < = 2 inc h trunk diamete r Number o f Sprinkler Zones , Contro l Valves , Timers , Heads , etc . Attac hasketc ho f the sprinkle r layout . Numbe r o f an dsiz e o f eac hgarden/ flower be d area . Attac hasketc ho f relativ e size s an dlocations . Agree dupo nvalu e o f plan t material s no t to b e replace db v contractor . Not e thi s valu e wil l b e use dt o issu e aplan t vouche r t o th e propert y owner . 

# fZ-, P 

# z . F ^

Landscap e Inventor y Quantit y Uni t Condition/Type/Specie s Quadrant s 

# f ^

Eac h Eac h ^
Each

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IAC > /^ ^ Pag e 2 o, ^COASTA L eNVmONHCNTAI
. CROUP , INC
.
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 EP A 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
. r~ l Pleas e chec k thi s bo xi fyo u understan d th e informatio n outline d above
. 

# ( ce ^ A^ 

# ^^,^ e 

# ^If k r

•Chec 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
. 

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## Certificat e o fVerificatio n

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# Thernn o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 1 

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 32 3 Mod e SOI L Tim e 2011-02-0 8 15:5 9 Duratio n 30.1 8 Sequenc e Fina l Flag s BVI D 8497 8 ADDRES S 541 9 DECATU R S T QUADRAN T D Z DEPH T 13 " XR F TEC H C.PADILL A MIS C CONFIRMATIO N NOT E CLEA R
pp m Erro r P b < LC D 14.41 4 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 1 

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 32 4 Mod e SOI L Tim e 2011-02-0 8 15:5 9 Duratio n 30.1 9 Sequenc e Fina l Flag s BVI D 8497 8 ADDRES S 541 9 DECATU R S T QUADRAN T D Z DEPH T 13 " XR F TEC H C.PADILL A MIS C CONFIRMATIO N NOT E CLEA R
pp m Erro r P b < LO D 14.77 1 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 1 

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 32 5 Mod e SOI L Tim e 2011-02-0 8 16:0 0 Duratio n 30.1 5 Sequenc e Fina l Flag s BVI D 8497 8 ADDRES S 541 9 DECATU R S T QUADRAN T D Z DEPH T 13 " XR F TEC H C.PADILL A MIS C CONFIRMATIO N NOT E CLEA R
pp m Erro r P b < LO D 14.72 3 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 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 B y 

## Certificat e o fVerificatio n

32 2 SOI L 2011-02-0 8 15:5 7 90.8 3 Fina l Av g o f319-32 1 541 9 DECATU R S T F2 4 " C.PADILL A CONFIRMATIO N CLEA R

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 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 109.14 6 Supervise d By : 

## Certificat e o fVerificatio n
31 9 SOI L 2011-02-0 8 15:5 6 30.1 8 Fina l 8497 8 541 9 DECATU R S T F2 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 17.03 9

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 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 123.25 0 Supervise d By : 

## Certificat e o fVerificatio n

32 0 SOI L 2011-02-0 8 15:5 7 30.5 5 Fina l 8497 8 541 9 DECATU R S T F2 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 15.77 7• 

# Therm o

SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 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 79.30 5 Supervise d By : 

## Certificat e o fVerificatio n
32 1 SOI L 2011-02-0 8 15:5 7 30.1 0 Fina l 8497 8 541 9 DECATU R S T F2 4 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 15.61 6^*^'-^ * 

# M Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc
. ..o * www.coastalhazmat.co m \ \no^ ^ COASTA L ENVI>ONHENT* L C •O U r . I H C 

# EXECUTIV ESUMMARY : BVI D #8497 8 - (541 9 DECATU RST )

X 

# N o Issue s o r Concern s II Issues/Concern s Detai l Explanation :

# EP A EP APropert y Clos e Ou t Form Propert y Addrws;.-" ^ M S ^ VVr^^WAr,- ^ Propert y tf : ^'-AS S f^ R Date^lme : Owner' s Name : AJTjt^.f.j^V:). . . ' '^\fr>\1 ' Quad s Excavated : Contracto rGrou p , Ye s N o Excavatio nGenera l 1 .I f necessary , were th e correc t quadrant(s ) excavate dan drestored ? 

# y 2 .

If necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? 

# y Gradin g So dan dVegetatio n Ye s N o I Doe s th e gradin g aroun dth e perimete r ofth e hous e inexcavaieri area s generall y slop e away 

### y fromth e house ? 2 .

Ha s so dbeenlai dinall area s that were excavated ? 

## y 3 .Doe s th e sodappea r t

o b e generall y health y andgrowing ? (Onl y evaluat e if inspecte da t a3 0 da y time period ) 

# y 4 .Ar e sodde darea s generall y firmandevenl y graded ? 

# 7 5 .

Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e if inspecte da t a3 0 da y / tim e period ) 6 .Wa s th e property grade dsuc htha t wate r will no t poo l onth e propeny ? 

## y 7 .

Wa s damag e l o landscapin g o r plant material s avoided ? Gates , Fence s an dRetainin g Wall s Ve s N u 

# r 1 .D o gate s openan dclo.s e freely? (I f applicable ) 

# y 2 .

Wer e all gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (If applicable ) 

## y 3 .

Wa s damag e t o gate s or fence s avoided ? (Ifapplicable ) 

# " y 4 . Wa s damag e t o retainin g wall s avoided ? (Ifapplicable ) 

# 7 Foundation , Sidio Kan d Gut(«r « t . Wa s damag e t o th e sidm g o rtri m avoided ? Ye s 

## y N o
2
. Wa s damag e t o th e foundatio n avoided ? ^ ?
. Wa s damag e l o window s avoided ? 4 Wa s damag e t o window s o rdoo rscreen s avoided ? 5 . Wa s damag e t o downspout s o rdownspou l extension s avoided ? 

# y y 

# A Sidewalk s an dDriveway s (Concrete ) 1 . Wa s damag e to drivewa y surface s avoided ? Ve s 

## y N o
2 . Wa s damag e t o walkwa y surface s avoided ?

## OM'ncr s comments :



# ti n .spectio nno<es :

Removal andrestoratio nactivate s cornplel e includin g th e 30-da y sodwarranry : ^Cr - ^ff ^ 

## EP ARcpresentaliv e Date : '•/'«'" >

## Propert yCompletio n Agreemen t Thi s aj^reemen i clocumenls ; Ih e complclio n o \ remedia l acliviiie s perloime d o n m ypioperi yM ysignalur e wil l designat e iha l fa m satisfie d wil h (h e resloralio n o fm yproperty , an d (ha l n o item s ar e m queslion,«,
. now , o ra l an ylim e i n th e fulure , excep i ihos e ilem s liste d below , i fan y

Propert yAddress : ^^^c vDeeo^Vw rt>V
. Owner : 

## -^b^\: ^ V^ e

x^ o-\e
. Phone ; 

## CMf^^^s's\-s9^ a Restoratio n Item s i n Question ;

Item : Item ; Item : Item ; Item ; Item : Additiona l Comments :

I ai;rr crc.^foralfo n i s completed , occp l a s noler i [_ J I rio no l ajjif cresloratio n i s complcle d

ignatiir fDal e Cdnlrailoi' s Sipnaliii t Dat e

## Propert yDamag e Settlemen t

Propert y I D 8497 8 Propert y Addres s 541 9 Decatu r Owne r Josep hLavoi e 

### Ireceive dfromth e contractor , Coastal Environmental Grou p Inc . (Coastal) , th e su mo f $110.0 0 for compensatio nfor plant s removed . Compensatio ntyp e Chec k 225 7 Valu e o f Chec k $110.0 0 Chec k t o th e orde r of Josep hLavoi e
Descriptio n o fDamag e 

### Whil e excavatin g 541 9 Decatu r Stree t (BVI D 84978), Coastal presumabl y remove dplant s fromth e property . Property owne r receive dachec k i

nth e amoun t o f $110.0 0 dollar s fo r th e plants . M ysignatur e belo wacknowledge s th e damage ; further , I acknowledg e tha t thi s wor k wa s complete d satisfactor yan d withi n m yan d releas e Coasta l Environmenta l Group , Inc
. fro m furthe robligation s o r liabilit yrelate d t o thi s property . COASTA L ENVIRONMENTA L GROU P INC
. 

### 225 7 241 1 IVIARTH ASTREE T OMAHA , N E 6810 5 27-5/104 0 00 3 6247372904 

## iP|N)/ o DAT E

PAYT O TH E ORDE R O F 

# Josep hl^vo u .*« » 

# $ 

# DO " 

# ^n ^ ^,jii/r\dA£ dijLyi-ajnd^//ff v

WHI s Farg o Bank , N.A
. Nebrask a weHsfargaco m



### • :iOU00005ai : E>Eii737BqOUii * Oe25 7 

# i-'^^- n 

# ^E ^ M,fZ-qiA / 

# Uid ZOl O Owner' s Signature Date Contractor' s Signature Date

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