## TRANSMITTA Lo f OMAH ALEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAID# : 7 Pl'^ PDate : Address : 1^^ ^ s i ^^ ^ ^ f Remediatio nContractor : Coasta l Environmenta l Group

_ Year : _200 i 

# r SOI LREMEDIATIO N PROPERT Y nL EFOLDE RDOCUMENT S ![ / Vide o ofproperty (DVD ) U Executiv e Simimar y \ ZEPA-provide dpropert y sketc h i aSigne dAcces s Agreemen t fo r subjec t propert y -C

TSigne dAcces s Agreement(s ) fo r adjacen t propert y t z Restoratio nAgreemen t &
- Settlemen t docmnent s (i.e. , fo r damag e o r t o replac e plants , etc. ) -B
- Confinnatio ndat a

t

/ Photograph s % ^^" r V k'^^^WAy ffl ^ 6^%ATW v P

^ As-built sketc h [ PSatisfactor y restoratio nsigne db y Propert y Owne r 0 Propert y close-ou t chec k lis t signe db y EP A -& ' Descriptio no f area s no t meetin g RO D cleanu p criteri a 0 Utilit y clearance s y Propert y infonnatio nfro mDougla s Count y Assessor' s Offic e C

J D 

## n Signatur e 3005445 3 Superfun d

# • t

Properl yAcces s Checklis t Property ID : ^^C^ ^ Propert y Addreas : -^O^IK X ^\7 ^ 

# o^^^-^^fVlVV NVlrrv i ^---'b'^'^? ) V 3 T 3 t^A : Phone : Fax : Cell/Page n D Notificatio n Lette r Acces s Agreement Restoratio nAgreemen t D Topsoil Samplin g (i f applicable } D Disposa l Samplhi g Cr f applicable ) D Garde nSamplin g (if applicable ) ; ^ Utilit y Clearanc e 

### Q^ideo/Photo s (Before ) O Video/Pbotos (During) aVideo/Photos (After ) Video/Photo s (30-Day ) ipert y Completio nAgreement Final Report Ai r Monitorin e (a s aoDlicabl e 0 Communit y DCrc w On : / Results : DConunnnit y nCre w On : / RCSDHS : Q Communit y QCrc w On : / Results : nWOR K STARTE D ^ D WORKCOMPELTE D Rente r Phone : Fax : Cell/Page r Additional Information :

Sent : / / By : Signed ; 9_/Q)0/Q: ^ 

### By : Signed:^/2!c./( B 

### By : / / . 

### By ; / / 

### By : / / 

### By : Called:^/2io/Q 9 

# 'y^ ^\3o\nO i

On:£i/_^ ^ By-OCWK/l o On; By : On; / / 

### By : On: / / 

### By : Signed : 

# jlliHii ^ By : Issued : / / 

### By : / 

### By : / By : / By : ON : __/__/ _ ON:__/__/ _

Omah a Lea d SK e 

### 1

## Douglas Count y Accoun t I

[j^sonatio n Pag e 1 o f 1 Dougla s County , Nebrask a Propert yRecor d - R201367000 0 Prin t Repor t NE WFaatur a - ParKfi l Dimfinsion s availabl e O ) scal e 0-5 0 ft wes t o f 52n d S t - ViOW O n Ma p Infonnatio n i s vali d a s o f2009-9-1 5 Treasurer' s Ta xRepor t Ne wFeatur e -»-»- » Aut o Sale s Searc h Owne r WOOD S JAYA 391 8 N 2 3 S T OMAH AN E 68110-000 0 Propert yInformatio n Ke yNumber : 136 7 000 0 2 0 Accoun t Type : Residentia l Parce l Number : 201367000 0 Parce l Address : 392 4 N 2 3 S T OMAH AN E 68110-000 0 Lega l Description : PLAINVIE WLO T4 BLOC K4 5 0 X 12 4 Valu e Informatio n Lan d Improvemen t Tota l 200 9 $300.0 0 $0.0 0 $300.0 0 200 8 $300.0 0 $0.0 0 $300.0 0 200 7 $300.0 0 $0.0 0 $300.0 0 200 6 $300.0 0 $0.0 0 $300.0 0 200 5 $300.0 0 $0.0 0 $300.0 0 200 4 $300.0 0 $0.0 0 $300.0 0 Sale s Informatio n Sale s Date : 2004-07-2 1 Dee d Type : W D Book : 200 4 Page : 09656 9 Price : $0.0 0 Grantor : Jaso n D Wood s Grantee : Ja yAWood s Valid/Invalid : Invali d Exclusio n Reason : Famil ySal e Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 4 6200. 0 0. 0 124. 0 50. 0 Ye s


## http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accoimtno=R20.. . 9/17/2009

### Pag e 1 of 2

" > Creat e Anothe rTicke t Bac k t o Irt h Interne t I [ Sen d Emai l ]



### • YOU RTICKE T NUMBE RI S 2373251 . Origina l Cal l Date : 9/26/0 9 Time : 4:3 7 p m Op : ELIZABETH1879 0 Wor k t o Begi n Date : 9/30/0 9 Time : 7:1 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 392 4 Street : N23R D S T Twp : 15 NRng : 13 E Sect-Qtr : 03-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D REMEDIATIO N Locatio n o f Work : INCLUD E AL L EASEMENT S LOCAT E ENTIR E PROPERT Y Remarks : FAX AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T Cotrrpan 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 Come r Lot : N Front : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N ALT87 2 CXCAT V MAGELLANMUDO l OMAHACO F 0PPDGPR 5 QLNNEI C



### Servic e Are a Contac t Phon e Number UtiUt y Typ e ALT87 2 WINDSTREA M COMMUNICATIO N N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MAGELLA NMAGELLA NMIDSTREA M PARTNER S L PDEBORA H Day : 918574709 8

Alt : Emerg : 918574709 8 MUDO l METROPOLITA NUTILITIES DISTRIC T SAND Y Day : 402504782 3

Alt : Emerg : 402504797 0

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/26/200 9

## Pag e 2 of 2

OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRO N 

## Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 OPPDGPR 5 OMAH APUBLI C POWE RDISTRIC T N A 

## Day : 406728934 3 Alt : 4062071494 Emerg : 888728934 3 QLNNEI C QWES T LOCALNETWOR K 

### N A 

## Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 9/26/2009

# As-Buil t Drawin g COASTA L 

# Omah aLea dSuperfun dSit e 3350 2 Exterio rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : JASO N D vyoOD S • Goo d Sit e Sketc h Address : 392 4 N 2 3 S T |~ 1 Poo r

Phone : H : W : I I No t pain t Sampt e Numbe r Lea d Sampl e L A B Sample s Collecte d Concentratio n Collecte d Firm : RYASCPXA-3350 2 F 1 pp m RYBSCPXA-3350 2 F 2 

## (OS - 

# n Date : pp m 

### U P 

# n Time : 5 ^ • -/ C 

## —HIP . RYCSCPXA-3350 2 8 1 pp m 

### [3 r 

## D Sample s Analyze d RYDSCPXA-3350 2 8 2 pp m 

### \3 r 

# • RDZSCPX A3360 3 B ^ pp m 

### D XR F Unit : 

### / a 3 7 Book : // ? 

# n -RGZSCPX A3360 3 -62 ­ pp m 

# n Date : -7-t'O'S ­ • f^PgOCPXA03002 - -P2 - pp m 

# n D Time : j^yf f Staff : Numbe ro f Sample s = ^ 

# n J,PO L Legend : F l = Fron t Left , F 2 = Fron t Righ t 8 1 = Bac k Left , 8 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewe d fro m th e street , facin g propert y OLS# : 3350 2 Dat e Excavate d :9/30/0 9 : USEP ASigne d Off : 10/23/0 9



### Legen d Concret e Dri p Zon e Excavate d Quadrant s Excavate d Are a replace d wit h So d Are a replace d wit h Rock/Mulc h Are a lef t bar e 

### Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .'j/:jMMi,uiiJii^iiUuS!lsUini/kC&ii^ ^ 

# w m 3350 2 

# l i fM o Exterio rPain t Nort h Arro w 

### Omah a Lea d Sit e Ovyne rName : JASO N D WOOD S • Goo d 

### Sit e Sketc h Address : 392 4 N 2 3 ST • Poo r

Phone : H : W : Q ] Not pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : RYASCPXA-3350 2 F 1 

### fO£ ' pp m D Date : 

### n-L.-0 £ ' RYBSCPXA-3350 2 F 2 

# n Time : 

### 5'::'f 0 RYCSCPXA-3350 2 B l 

### I_fZ^J_Pp m 

# n Sample s Analyze d RYDSCPXA-3350 2 B 2 

### I H ^ ppm 

### D RDZSCPX A3350 3 pp m 

### D D XR F Unit : 10 3 7 Book: //* ? -RGZSCPX A3350 5 QZ ­ pp m 

### D D Date : 7-5'^S " • RPZOCrXA^3350 2 P * pp m 

### D D Time ; 

### ^/ ^ Staff ; 

# L A Numbe ro f Sample s = ^ Legend : F 1 = Fron t Left , F 2 = Fron t Right , B l = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewe d fro m th e street , facin g propett y 

# 'i)(ctyp/^ ^

# ^ \xp m 33502 

# i^jy y Exterio rPain t Nort h Arrow Omah a Lea d Sit e Owne rName : JASO N D vyoOD S 

### • Good Sit e Sketc h Address : 392 4 N 2 3 S T • Poo r Phone : H : W : Q No t pain t Lea d Sampi e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : t='ls AHT/TL ^ RYASCPXA-3350 2 F 1 

# IPS ' pp m 

# y D Dat e 7-L P -O S RYBSGPXA-3350 2 F 2 © 

# M12 ^ pp m 

## D Tim e 5:^-^ 0 RYCSCPXA-3350 2 B 1 pp m 

# JdJd . Q " 

## D Sample s Analyze d RYDSCPXA-3350 2 B 2 

# \ H ^ pp m 

## Q ­ 

# n RDZSCPX A3360 2 B Z pp m 

## D XR F Unit : 

## 10-3 7 Boo k

M ± D -RGZSCPX A3350 5 6Z - pp m 

## D Date : 

## D -f^PZOCPXA'3300 g P ? pp m 

## D Time . ^/ ^ 

## D Staff : 

## JLA . Numbe ro fSample s Legend : F 1 = Fron t Left , F 2 = Fron t Right , B l = Bac k Left. B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z - Pla y Al l quadrant s ar e a s viewe d fro m th e street , facin g propert y 

# ^i)(caep H--J-w'.ir'.''Jtii.T.t^^jaw.ijUfc^ ' 

## 3350 2

NofttiArro w 1 Exterio rPain t Omah a Lea d Sit e Owne rName : JASON D V^rOOD S

- — • Goo d Sit e Sketc h Address : 3S24 N 23 S T • Poor rPhone : H W : Q Notpain t Sampl e Numbe rLead Sampl e ^^ ^ Samptes Collet ^ ' ^

Concentratio n Collecte d ^^ ^ t^h A Firm : l-tT/Tl ^ RYASCPXAr3350 2 F 1 fO ^

Do m R ^ H Date : n~L.~0 £ ' RYBSCPXA-3350 2 F 2 tjjpoD m R ^ f l Time : S'i O RYCSCPXA-3360 2 B 1 i j 2 . I on m H Kn Sample s Analyze d RYDSCPXA^35{ KB 2 

### / V ^

Do m n rn

- Do m n n XR F Unit : ./<? 3 7 Book : //? ,



## - Do m n n Date : l-^'^ ^


### ., "

pp m n n Time : Staff : A 

### L A 1 1nuiiiix a U i aaiiifms s - j " f ; ^ Legend : F 1 = Fron t Left . F 2 = Fron t Righ t B l = Back Left , B 2 = Back Righ t O Z = Dri p Zone . G Z = Garden . P Z = Pla y Al l quadiant s ar e « s viewe d fro m th e stieet , fadng propeit y 

## : Auie Y:

. : ; ;j.... : ..;. . 

## • ENTERE D ; JU L 0 7:208 5 1



# . : [ :i....L . ..L .

. • ;... . ;J . : . : 

## ^L..: i f^..:. . : :: i : • . , . . i , ,,.•......' . •- . . . 

## • .yniu^i-.^s!^...... . : — " 

## Okff^ : Houd e 

# 1" "^ri " 

# i~

. ; i ;].... ; ;. .

- 1 . _ . - f. 1 • 

# fn...u. . . n .i. . .\I0S\ \ qi Z \ f . . , : : : : • -i ^....................... . . ^ \ !......• . .'... ' 

## J l U 

# • h i \

, , , . • 

## n 5 

## ': P : * . : . : . .. ; ;....

_ 3 

### .o n iol—Tf% « 1 . ' Wiik . : 

## :

R«v * i -. . . . 

### ; \hi..2$./yr \ . : i OMM1.0I2 3 • >:• ' —,^,€ 0 6.4, ^

COASTA l INVIROHHIICTA I PBO'** " C R O D P . t N C 

## Consen t fo rAcces s T o Pfopert y RIGH TO F ENTR YT O PREMISE S 

### Granto r(th e propert yowner ) consent s t o an d authorize s th e Unite d State s Environnnenta l Protectio n Agenc y(EPA ) o rit s authorize d representatives , coilectivei y th e Grantee , t o ente ran d perfon n certai n environmenta l respons e activitie s upo n th e followin g describe d premises :

Addres s o fPropert y covere d b ythi s 

# -yv ^ s l y ^ f 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 ) vtnl l b e excavate d t o remov e contaminate d soil . Th e remove d contaminate d soi l wil i b e replace d wit h dea 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 program . Arepresentativ e o fCoasta l Environmenta l Group , contracte d b yUSEPA , wil l contac t 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 wori t 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 

### B ysignin 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 right t o ente rth e property , a t al l reasonabl e times an d wit h prio rnotice , fo rth e sol e purpos e o fperformin g th e worit . Thi s acces s shal l remai n i n effiect unti i th e wor k ha s bee n satisfactoril ycompleted . Th e Granto rals o agree s to :
Pag e 1 o f2

### .*^*""> , COASTA l tlvVlaOitKIKTA l 

# yy C « O 0 P I KC


### « Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; cRemov e flowe rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma ywis h t o save ; ( Wate ran d maintai n replacemen t vegetation , includin g fertilize rapplication , a s necessar ysubsequen t t o a n initia l waterin g perio d b yEPA ; cAbid e b yhealt h an d safet yguidanc e provide d b yEPA ; * I fth e propert yi s rented , assis t EP Ai n obtainin g tenan t approva l fo racces s t o th e propert yt o perfon m th e work . eAllo 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

LS/sren t acces s t o mypropertie s D I d o no t gran t acces s t o mypropertie s 

# too^-c^-ti ^ Signatur e Signature Date Q I woul d lik e t o b e presen t durin g an ysamplin g tha t i s required.

Page 2 of 2

# m

COASTA L 

### Restoratio n Agreemen t Th e puipos e o f thi s agreemen t i s t o provid e amutua l agreeme ma s t o condttion s ofth e propert y prio r t o remediatio nactivities . Thi s wil l als o serv e a s documentatio nfo r th e purpos e o f assurin g tha t restoratio n activitie s ar e complete dt o th e satisfactio no f th e propert y owne r an dth e Unite dState s Environmenta l Protectio nAgenc y (EPA) .

Propert y IP ; 'yp'yb V Propert y Address : "^^^. ^ l 4 'Z^>' ^ ^ Y 

### Q^"" - "T^li M WOO f j Phone : =-_ ! O ndi e sttache ddiagram(s ) indicat e area(s ) t o excavate , surfac e structure s an dlandscapin g feature s an d acces s locatiQn(s ) t o b e use db y th e contractors . Indicat e distances , depths , matena l types , etc . Photographicall y an dVideographicall y documen t th e existin g condition s ofth e propert y an dth e l»semen t i f necessaiy . 

### Itom s t o b e Remove d b yth e Owne rbefor e Start o f Remediation : The lemoval , storafie . disposal , and/o rretur n of thes e Item s i s th e Owner' s responeibility . ftem : 

# ^y\ ^

fuAvi-r V Item : 

# MefM>y i Item : Item :

Item : 

# '\v\ ^ jiMfr - iWfy{f 7 

# Uf f \kHi^i ^ ttem : 

### Itan : Item :
Pag e 1 o f /COASTA L 

### Hem s t o B e Remove dB y Contracto r Durin g Remediatio nan dReplace d Item : 

## lO y

# Y ^ U 

# V \



# yK ttem: Item : 

# 1 I Item : t 

### Landscap e Inventor y Ite m Quantit y Uni t Condition/Type/Specie s Pre-existin g propert y area , Quadrant s tba t wil l b e excavated , tha t 

# h

# -^f- ^ i s covere dwit hgrass .

• Numbe r o f tree s > 2 inc h Eac h trun k diamete r Numbe r o f tree s < = 2 inc h Eac h trun k dinmcte r Numbe r o f Sprinkle r Zones . Contro l Valves , Fari i 

# \\ o Tfano^ . Heads , etc . Aiiat hasktricl i o l tlt e Numbe r o f an dsiz e o f eac hgarden / flowe r be d Eac h 

# kP\^u ^ y/ ^ area . SquareFee t Ali;\t h; i sketc ho l ri-!;ilivi ' <i/i' S an dloc;iiinn s Agree dupo nvalu e o f plan t material s no t t o b e replace db y contractor . 

# fi/va^ ^ \o o " S N'Cl r l!-.i ' ^nl^l c VMI Iti i uso O 1 0 it;u c . 1 ;ilHn ; lOiii-Iu'.
- Ki lli e propcrl x 0 " ner . Easemen t Area , t o b e Eac h excavate d 

### Pag e 2 o f- > 

### cC O A5 1 AL

I Additiona l Comment s / Instructions : ^ 

# ^ - Vl/ , Oil ? f\(^^ < f"^"^ ^

"^^ ^

Q Chec k th e txu ci fOwvne 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 th s txi xCE G i s no t responsibl e fo ran ydamag e don e t o th e interio rt> f house , indudirt g foundatio n crack s o rfissures.

O I d o no t agre e

Owner' s Sinatnr e Dat e Contractor' s Signatnre Dat e Pag e 3 of .Dat e Projec t XRFID #

Shot # 

# T ^

nsz y

Averag e

Shot # 

## J2sa .

i^z ^ J5i Q i>V K Averag e

Shot *

Averag e

Shot #

Averag e la b sampl e # 

### BVID# 33'>^" ^ XR F PROPERTY SAMPL E SHEE T 

# ^mo' i Addres s 

## ^^^ ^

p 2. 3 'SI- . Omah a lea d F P 2nc l yea ropUc n Sampl e tim e am/p m sampl e lengt h 

### 3 0 se c 

## '^-^fe' ? Readin g Sampl e are a Shot # Readin g Sampl e are a 

# Eit . 

# i ±t£3 . 

# ?> t 1 7 Dept h Dept h

spt i 

## Jjb^ i 

# S-5-Z ^ l^ly ^ / / 

# /^ ^ l?w-^ ^ 

# I S *PP ^ "^^lo Averag e f5 0 — ^ 7 Readin c Sampl e are a Shot # Readin g Sampl e are a 

# a E 

# g ^ 

# J M Dept h Dept h * ^ 

## iz<.iH^^ ^ 

# Is x ^ ^ | - ^ I ^ Averag e Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h Dept h Averag e RETES TAREA S Readin g Sampl e are a Shot * Readin g Sampl e are a Dept h Dept h Averag e La b resul t Sampl e are a XR F Avg . Signatur e 

# ^^MlMh . £J J

•yto^j ^ C(Ce(r ^ Prin t r_A \

## Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc . V ^ www.coa8talhazmat.co m ^-"iPBo^*" ^ COASTA L IHVItOHHIHTA l C 1 0 U P , IN C 

# EXECUTIV ESUMMARY : BVID #33502
- (3924 N2 3 ST ) No Issue s o r Concern s [ ^ Issues/Concern s Detai l Explanation : •_• -COASTA LTO ISSU EREIMBURSEMEN T CHEC K FO R$200.00 (COMPLETE D 1/28/10 )

### \ ^ 

# EP A EP APropert y Clos e Ou t For m Property # : X^^rO.. . PropertyAdd^.J>^7 H K.fj^J ^ • - Date/Time : Owner' s Name:..fc.^nS.nn.Myr a. . • • Quad s Excavated : p> ) , jF 2 Contracto r Grou p J^rO.<,\0 i 1 h nVl t rarr\PY\\O i \ Ye s N o Excavatio nGcaeni l I . If necessaiy , were th e correc t quadrant(s ) excavate dandrestored ? 

# U ^ 2 . If necessary , were th e correc t area s ofdri p zone excavate dandrestored ? 

## ly ^ Ye s No Gradin g So dan dVegetatio n 1 .Doe s the gradin g arotmdth e perimeter ofth e hous e i nexcavate darea s generall y slop e awa y 

# ly T fromth e house ? 

# IP ' 2 .Ha s so dbee nlai dinal l area s tha t wer e excavated ? 3 .Doe s th e sodappear to b e generall y health y an dgrowing ? (Only evaluate if inspecte da t a3 0 

# -V­ day time period ) 4 .

Ar e soddedarea s generall y fu man devenly graded ? ^ ' 5 .

Ar c th e joint s twtweenth e so dstrip s generally tight ? (Only evaluate if inspecte da t a3 0 da y 

# T'^ tim e period) 6 .Wa s the propert y grade dsuchtha t wate r will no t poo l o nth e propert>' ? 

# y 7 .

Wa s damag e t o landscapin g o r plan t material s avoided ? Gates . Fence s an dRetainin g Wall s Ye s N o 1 .D o gate s ope nan dclos e freely? (Ifapplicable ) 

# y 2 .Wer e all gate s or fence s takendow ndurin g restoratio nactivitie s reinstalled ? (If applicable ) 

# 1 7 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 ) 

# l y Foundation , Sidin g an dGutter s Ye s N o t ^ 1 .Wa s damag e t o th e sidin g o r tri mavoided ? 2 .Wa s damage t o th e foundationavoided ? 

# y 3 .Wa s damag e to window s avoided ? 

# y ^ 4Wa s damag e t o window s or doo r screen s avoided ? 

## l y ^ 5 .Wa s damag e t o downspout s o r downspoul extension s avoided ? Sidewalk s an dDrKeway s (Concrete ) Ye s N o 1 .Wa s damag e l o driveway surface s avoided ? ^ ' 2 .Wa s damage t o walkwa y surface s avoided ? \ y ^

## Ownen ; comments :

Inspectio nnotes :

Remova l an drestoratio nactivate s complet e includin g th e 30-da y so dwarranty : EP ARepresentativ e LJPyp ) JjP//^j L^ Date : /d/jJM f

### Propert yCompletio n Agreemen t ihi s agreemen t documenl s th e complclio n of remedia l acliviiie s perlbime d on myproperl y Mysignatur e wil l designat e iha l I am salisfie d wit h Ih e restoratio n of myproperly , an d iha l no ilem s ar e in questions , now , or al an ylim e in th e future , excep t ihos e ilem s liste d below , if an y

Propert yIP : 5350^ . Propert y Address : ^Q^^^jJ ^V^ yQ ^ ^ Owner : ^ ^^^fy ^ VSICQT L Phone : Restoratio n Item s in Question :

Item : Kc>tvv\bur^(^wt. M cX><-c4 ^ Item : Item : Item : Item : Item : Additiona l Comments :



### /\Jet 4 k> 4ro p c^'f f ci*jd( l la ^ /^tin^ur-i*-!** ^ ^ ^ -Uux^e s

I nyrc crestoratio n '\% completed , excep t as note d [ I I do no t a|;re crcstoraho nis complete d

Owner' s Swn;)tin rDat e iaclor' s s Signatur

Signatur e e Com i actor' Dat e

## Propert yDamag e Settlemen t

Property ID 33502 Property Addres s 392 4 N2 3 S t Owner Wood s Ja y Phon e (402)408.661 1 

### I have received fix)m the contractor , Coasta l Environmenta l Grou p Inc . (Coastal) , the su mof $200.00 to compensat e fo r plant s an driver rock tha t wer e remove dduring tfie remova l of lea dimpactedsoil from th e property .

Compensatio ntyp e Check 187 9 Valu e o f Chec k $200.00 Check to th e orde r o

f Wood s Ja y Descriptio n o fDamag e 

### While excavating 392 4 N2 3 S t (BVI D 33502) Coasta l damage dsom e plant s beyondsalvage . Propert y owne r receivedachec k

fo r the amoun t of $ 200.00 dollar s fo r th e replacemen t ofth e plants . M ysignatur e belo wacknowledge s th e replacemen t o fm yplants ; 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 rliabilit yrelate d t o thi s property . 

### fM^>r-r^^m^:^^^^^K:^i~i: ^ :-j£i^j,&; , 

### i^s s fef^^ 

## TT^^S^^ M 187 9 COASTA L ENVIRONMENTA L GROU P INC . 27-S/10M>00 3 624737290 4 241 1 MARTH ASTREE T OMAHA . N E 6810 5 

# 42 ^ DAT E i.«S . PAY
- 

# ssiJayJ^esds^^ ORDE RO F_ a*cMi)i r Faalur M 

# jM^^^^^M^^I m Q SS' " Wd>to96tinli,NA .



### OwneVv S Signatur e Date Contractor' s Signatur e Date Pag e 1 o f1