TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: *57tn Date: 

^ U \] 

^11 1^ ^<^ ^^ Address: 

Reinediation Contractor: Coastal Environmental Group_ Year: _2010ARRA_ 

7 

1 

/ 

si 

7 

^ 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

EPA-provided properly sketch 

Signed Access Agreement for subjecl property 

Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

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

Confirmation data 

Photographsffir Oc<^R1[l^ T t^^^Ht ^ A 4 ^ 

As-buill sketch 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Description ofareas not meeting ROD cleanup criteria 

Utility clearances 

Property information from Douglas County Assessor's Office 

A 

^ IJ 

Date ' 

Superfund 
Property Access Checklist 

Property ID: 

Property Address;

W ^ 

 C j J- ^ jf\J ^-f^^'^^l ^ 

n

D

 WORK STARTED 

 WORK COMPELTED 

ON: 

ON: 

_/

I

 l_ 

I 

Owner 

toarcss:

Phone; 

\ \ Q 

Renter 

Phone: 

Fta: 

Cell/Pager 

Additional Infonnation: 

Cell/Pager 

D Notification Letter 

IjqJ Access Agrecmetit 

t ^ Restoration Agreement 

D Topsoil Sampling (if applicable) 

D Diaposal Samplhig (if applicable) 

1 D Garden Sampling (if applicable) 

^ Utlli^ Clearance 

1 ^ Video/Photos (Before) 

a Video/Photoa (During) 

D Video/Photos (After) 

D Video^hotos (30-Day) 

D Property Completion Agreement 

D Final Report 

Sent: / / 

Signed: j£3//t^//4 ^ 

Sigfttd: UP//Jil IQ. 

1 1 

1 1 

1 1 

Called; u l \ 1 \o 

On: v^ / v^/ vo 

On: / / 

On: / / 

On: / / 

Signed: / / 

Issued: / / 

By: 

By: V*.t.\c 

By: ,..>cVc 

By: 

By: 

By: 

"y= vv/a/i o

By: .,., . 

By: 

By: 

By: 

By: 

By: 

 lA^evNcL. 

Air Monitorine (as applicable] 

n Community D Crew 

Results: 

On:_ / / By: 

D Community

Results: 

Q Crew On: _ / / By: 

• Community

Results: 

D Crew On: / / By: 

Omaha L«ad Site 
Douglas County Account I lion Page 1 of 1 

Dougias County, Nebraska Property Record - R0527580002 

Print Reoort 

View Interactive GIS Mao Information is valid as of 2010-8-30 Treasurer's Tax Reoort 

New Feature -•-•• • Subdivision Sales Search 

Owner 

CITY OF OMAHA 

1819 FARNAM ST #910 

OMAHA NE 68183-0000 

Property Informatio n 

Key Numlier: 2758 0002 05 

Account Type: Ex Government 

Parcel Numlier: 0527580002 

Parcel Address: 971 N 25 ST 

OMAHA NE 68131-0000 

Legal Description: ARMSTRONGS 1ST ADD LOT 27 BLOCK 1 LT 26 & S 20 FT LT 27 80 X 127 

Value Informatio n 

Land Improvement Total 

2010 $0.00 $0.00 $0.00 

2009 $0.00 $0.00 $0.00 

2008 $0.00 $0.00 $0.00 

2007 $0.00 $0.00 $0.00 

2006 $3,500.00 $0.00 $3,500.00 

2005 $3,500.00 $0.00 $3,500.00 

Show All Transactions 

Land Informatio n 

Acres SF Units DepOi Width Vacant 

0.23 10160.0 1.0 127.0 80.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R052... 9/2/2010 
Page 1 of2 

"> 

[ Create Another Tipket J Back to Irth Intemet Send Email 

YOUR TICKET NUMBER IS 2630925. 

Original Call Date: 11/01/10 Time: 10:59 am Op: ELIZABETH18790 

Work to Begin Date: 11/03/10 Time: 11:30 am 

State: NE County: DOUGLAS Place: OMAHA 

Address: 971 Street: N 25TH ST 

Twp: 15N Rng: 13E Sect-Qtr: 15-SW,16-NE-SE 

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: (877)662-4211 


: UNSURE IF CORNER LOT. 


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 Tvmneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUDOl OMAHACOF OPPDGPRS QLNNEIC 


Service Area Contact Phone Number Utility Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVELS LEVELS COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC.SEWER RICH/TRAFFIC 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

http://vmvkr.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/1/2010 
Page 2 of2 

OPPDGPRS OMAHA PUBLIC POWER DISTRICT Alt: 4062071494 ELM LOCATING 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK

Day:

 ELM LOCATING Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

http://vvww.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 11/1/2010 
25067 

As-Built Drawing 

COASTA L Omaha Lead Superfund Site ENVIftONHCNTAL C « O U P. IN C 

OLS#: 25067 

Date Excavated: 11/4/2010 

Date USEPA Siqned Off: 12/2/20 

Area Sodden: 2715 sa ft 

Omaha Lead Site 

Site Sketch 

Sampling Address: 971 N 25 ST 

Sample Lead Sample Samples Collected Number LAB Concentration Collecf Hectee d Fimn ? r TM C PfrT A 

RYASCPXA-25067 F1 S02 - PPmM D Date Rll7ln q 

RYBSCPXA-25067 F2 •^5 ppm D Time fiiii£i_Jyt \ 

RYCSCPXA-25067 Bl ~IS S ppm Samples Analyzed RYDSCPXA-25067 B2 M o ppm 

nOZSOPXA 26067 BZ ppm a XRF Unit: lOftti? Book: ZMZ C 

RGZSCPXA-25067 GZ 2. 0 ppm n Date g • 2i> Qg^ 

ppm D Time RYDSCPLA-25067 .Lab _B=_ Staff •Result 37.8 ppm Number of Samples = j J ^ \ \ / \ m i u 

Legend: Fl = Front Lefl, F2 = Front Right, Bl = Back Left, 82 = Back Rigfit DZ = Drip Zone, GZ = Garden, PZ = Play 

ENTERED xx^ - ­

:AU6 i 2 2009 

M. 255r . 

Legend 

Concre'te Drip Zone Excavated Quadrants Excavated 

Area replaced with Area replaced with 

So Area lef t bare d Rock/Mulch '- ^ 

Contrac t #: EP-R7-07-05 Coastal Environmental Group Inc . 
25067 C\p^ Lv \\l ^ 

Exterior Paint North Arrortf Omaha Lead Site 

• Good Site Sketc h 

• Poor 

Sampling Address: 971 N 25 ST P^ Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collect lecteed Firm: ? F TM C P&T A 

RYASCPXA-25067 Fl SO 2. . PPmM D Date: R/lZlp q 

RYBSCPXA-25067 F2 -^ 5 ppm Time: B^^ H AhA 

RYCSCPXA-25067 B1 1^ 5 ppm 

n Samples Analyzed RYDSCPXA-25067 B2 H£> ppm 

RDZSCPXA 25067 BZ ppm XRF Unit: IbRL? Book: IMI P 

RGZSCPXA-25067 GZ LO ppm Date: g-2/?OC i 

ppm Time

.La b RYDSCPLA-25067

n Jfe^ 

D Staff ; Result 37.8 ppm Number of Samples = [ ^ \ msu L

D 

Legend: F1 = Front Left, F2 = Front Right, 81 = Back Left, B2 = Back Right DZ = Drl|D -gZ ^ Garden, PZ = Play 

AAl Iti faclnopropei l quadrant quadrantss ar aree aass viewe viewedd fro fromm Inee street street,, facinaproperty 

'M p ^ -fef gf o&^ e

ENTERED 

:AU6 i 2 2009 

^^ ^YyYYy^^ 
25067 

Omah Exterior Paint Nortti Arrow a Lead Site 

Sit • Good e Sketch 

• Poor 

Sampling Address: 971 N 25 ST ^ f Not paint 

Sample Number Lead Sample LAB Concentration Collected 

RYASCPXA-25067 Fl ^02 - PPmM 0 D 

RYBSCPXA-25067 F2 ^ ^ ppm D 

RYCSCPXA-25067 81 IS S ppm [27 

RYDSCPXA-25067 82 HC> ppm \3y RDZCOnXA 25067 BE ppm D 

RGZSCPXA-25D67 GZ Z O ppm a 

ppm n RYDSCPLA-25067 

I Result 

.Lab 

37.8 ppm Number of Samples = [ ^ \ ± 

Legend: F1 = Front Left, F2 = Front Right, Bl = Back Left, B2 = Back Right 

Al quadrants are as viewed from the street, facii 

^iT-A '>^.) ' i*^ ' r,9^A /^ ^ 7J, 

Samples Collected 

Firm: ? F TM C VpT \ 

Date: R/lZlo' ? 

Time: fi-^H ^^A 

Samples Analyzed 

XRF Unit: IbRUl Book: 2ML > 

Date g -22? QCt 

Time Jn. Staff msw 

DZ = DripZQpe^gZ = Garden, PZ = Play 

^yy^tk. 
25067 

Omaha Lead Site 

Site Sketch 

Sampling Address: 971 N 25 ST 

Sample Numt)er Lead Sample 

Concentration Collected "-^^ 

RYASCPXA-25067 Fl ppmM H • 

RYBSCPXA-25067 F2 i5- ppm 

RYCSCPXA-25067 81 ppm \3/ U 1g? RYDSCPXA-25067 82 J±k. ppm u7 ^ 

r^DZCGPXA 26067 BZ ppm •/ n

RGZSCPXA-25067 GZ ppm [Z D 

ppm D n RYDSCPLA-25067 

; Result 

.Lab 

37.8 ppm Number of Samples = | ^ \ \ \ \ 

Exterior Paint North Airow 

• Good 

• Poor 

[^Not paint 

Samples Collected 

Fimn: ?F TM C P^T A 

Date: R/lgJQ? 

Time: fi:Mn AtA 

Samples Analyzed 

XRF Unit: Jiifi^iZ^ Book: Zfii ^ 

Date: __ 2^o q 

Time: fe 

Staff: mZA^ 

Legend: Fl = Front Left, F2 = Front Right, Bl = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

Al quadrants are as viewed from tha street, facing propeity ^ LUC f 

N. 253r. 
\'7y 7 \ 

'', . <P' C G ^ ! 1 A I 

' ' pft t ^ ^^*•IP^0^'«1' i/.i 

c t c u I »• c 

C;oiiKc-^ii\ fi)r Ac:c;o.«;i- "i o rio|XHi(y 

RIGHT OF ENTRY TO PREMISES 

Granlot (the property' ownef) consenls. to and authorizes the i.inited Slales 

Environmental Protection Agency (PPA) oi its authorized representatives, collectively 

the Grantee, to enter snd perform certain environmental lesponse activities upori the 

following described premises- -j <y~}'^/ ^ ^ 

Ovi'nei's Name: Daytime Phone: 

Address of Property 

covered by this 

Agreement: /-/..., 

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 leasonable 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 
I

C C A S 1 A I 

I k V|^o»«^^ ^ tt i 

c n 0 u » ^ *• i 

' Remove obstructions incluf^ing boats, iraileis, vehicles, pl£ysca[)e he.m?-, wood 

piles, doo houses, etc; 

' [Remove flov/ei bLilbs oi plants tfist the Grantoi or the Grantoi's tenant may wish 

to save; 

Water and maintain leplacernenl vegetation, including fertilizer applicption, as 

necessary' subsequent tc an initial watering period by EP/\; 

< Abide by health and safety guidance provided by EPA; 

< If the property is rented, assist EPA in obtaining tenant appioval foi access lo 

the property to perform the work 

 Allow videotaping and/or photographing of the properly. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tampei with any of the Vi'ork activities, oi 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 

0^9I gran 1 t access to my properties D I do nof grant access to my properties 

.LOMQ 

ignature Date Signature Date 

G f would likt io bt. ptesent duritig any samplino that is lequiied. 

Paae 2 of 2 
C O A.S T A.U 

Restoration Agreement 

Ttie 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). 

PropertylD: 0^7715% OOOZ ^ 1y-n^C7 

PropertyAddress: <^-Jj ^ ^i < ^ 

Owner: / W ST" fi/yiAUa 

Phone: 

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 return of these items is the Owner's responsibility 

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

Page 1 of. 
COASTA L 

C R O U * . ) N C 

Items to Be Removed By Contractor During Remediation and Replaced 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

.Attach a sketch of the 

sprinkler lavout. 

Number of and size of 

each garden/ flower bed 

area. 

Aiiach a skeich of i-eiati\f 

sizes and locaiion.s. 

Agreed upon value of plant 

materials not to be 

replaced bv contiactor. 

N'otr this \jiliio nill he 

used (0 i'istie a plant 

louclicr 1(1 tht propcrl> 

OWIKT. 

Easement Area, to be 

excavated 

Quantity 

•>$/ 

y 

y 

y 

H/i^ ^ 

Landscape Inventory 

Unit 

Quadrants 

Each 

Each 

Each 

Each 

Square Feet 

$ 

Each y O

7^i^,:y ^ /^Z£y^.^yyQ^ 

Condition/Type/Species 

7 . ^ // 

Page 2 of. 
C O A S T A, L CMVinONHtNTA L 

CROUP . IN C 

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. 

Q Please check this box if you understand the information outlined above. 

n 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. 

^ I agree n I do not agree 

10-I'i'(0 

Date 9ntractor's Signature Date 

Page 3 of. 
BVID# ZSO^l : 

XRF PROPERTY SAMPLE SHEET 


Date /- ZI ­ z^ou Address 

Project Omaha Lead ARRA Sample time am/pm 

XRF ID# .^^niL-L. sample length 30 sec 

Shot# 

Z£8 

L^^ 

'iy\o 

Average 

Reading 

ZL^^ i ZS 

Z.S(^ i -LS 

3(5 i Z6 

Sample area 

8] 

Depth 

•f' 

7?iG i Z^ 7 

Shot# 

Average 

Reading Sample area 

Depth 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading 

RETEST AREAS 

Sample area Shot# Reading Sample area 

Average 

Y

^-n 

/ 

Depth 

Average 

Depth 

Signature_ 

Print wiy H^rO^ 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By: 

Certificate of Verification 

291 

SOIL 

2011-01-21 16:33 

90.70 

Final 

Avg of 288-290 

971 N 25 ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Blllerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 286.572 

Supervised By: 

Certificate of Verification 

288 

SOIL 

2011-01-21 16:31 

30.21 

Final 

25067 

971 N 25 ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± • 25.636 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 286.314 

Supervised By: 

Certificate of Verification 

289 

SOIL 

2011-01-21 16:32 

30.30 

Final 

25067 

971 N 25 ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 25.972 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Blllerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 315.266 

Supervised By: 

Certificate of Verification 

290 

SOIL 

2011-01-21 16:33 

30.19 

Final 

25067 

971 N 25 ST 

Bl 

4" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 26.908 
I vA ^ '^ Omaha Lead Site—Fixed Price EP-R7-07-05 

3 J^^^ L I Coastal Environmental Group Inc. 

\y^y^ www.coastalhazmat.com 

^PRoit** COASTA L INVIIONHINTAl 

6 DO U P, IN C 

EXECUTIVE SUMMARY: 

BVID # 25067 - (971 N 25 ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 

-DAN GARVEY WALKED THE PROPERTY ON 12/2/2010 
« 

EPA Property Close Out Form 

Proptrty ff: ^SOCeTh 

Datc/Time: Owner's f^ame:fame! /: . fu..} \7-^S y ^ ^ nj^i V^/^^*^^*'^^

Quads Eicavaltd: |V1 Contractor Group. 

Excavation General 

1. If necessaiy, were the correct quadrant(s) excavated and restored? 

Yes

/ 

No 

2. If necessary, were the correct areas ofdrip zone excavaled and restored? / 

Grading Sod and VitetetloB 

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

from the house? 

Yes

/ 

No 

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

J. Does the sod appear to be generally healthy and growing? (Only evaluate ifinspected at a 30 

day time period) y 

4. Are sodded areas generally (inn and evenly graded? y 

S. Are the joints between the sod strips generally tight? (Only evaluate iflnspected at a 30 day y time period)

 __. . _. 

6. Was the property graded such that water wili not pool on the property? / 

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

Gates. Fences and Remalng Walb 

Ves No 

1. Oo gates open and clo.se freely? (Ifapplicable) 

/ 

2. Were all gates or fences taken down during restoration activities reinsulled? (If applicable) / 

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

4. Was damage lo retaining walls avoided? (Ifapplicable) 7 

Foundation, SidlBR and Ga(ler« Yes No 

I. Was damage to the siding oririm avoided? / 

2. Was damage to Ihe foundation avoided? J 

.". Was damage io windows avoided? 7 

^ Was damage to windows or door screens avoided? / 

S. Was damage to downspouts or downspoui extensions avoided? 7 

Sidewalks and Driveways (Concrete) f No 

1. Was damage to driveway surfaces avoided? 

2. Wiffl damage to walkway surfaces avoided? r 
% 

Ort'ners comraents: 

jlin.'! pection no<es: 

Removal and resloration activates complete including lhe 30-day sod warranry: 

EPA Representative ^ ^ Date: vl\L^"*_ 
Property Completion Agreement 

ri)i» ygrecmem doculTlenl^ Ihe coinplchon ol reinediKl aclivmes perlonned on my pioperly My signaiuitr 

will designate ihai I sm satisfied with ihe rcsioialion of my properly, nnd ihal no uems are m questions 

now. or 81 any lime in ihe future, except ihose Hems listed below, ifany 

Property Addrm: ^ f / " 7 J ^ ^ " 7 X 

Owne,^£J^__^ ^ ^QAnQy^Ct . 

'y!Z--Sd,oL^y.yH-.Aydl/dlx. ..J 

Restoration Items In Question: 

Item: 

Horn: 

lism: 

Item: 

ttem: 

• ^ wi»ug7»r»i-i3 

Item: 

Additional Comments: 

L-,-

I tfirtt tntornllon it eomplcttd, rrccpl M naftd 

[_| I rfo not tj.'i'tc rritomiion in conipjeicri 

Ownf I'J signariirf Dnte imii arini't %n«lin'« Ofl If