TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 7 Pl'^ P Date: 

Address: 1^^ ^ si ^^ ^ ^ f 

Remediation Contractor: Coastal Environmental Group_ Year: _200i r 

SOIL REMEDIATION 

PROPERTY nLE FOLDER DOCUMENTS 

![/ Video ofproperty (DVD) 

U Executive Simimary 

\Z EPA-provided property sketch 

ia Signed Access Agreement for subject property 

-CT Signed Access Agreement(s) for adjacent property 

tz Restoration Agreement 

& - Settlement docmnents (i.e., for damage or to replace plants, etc.) 

-B - Confinnation data 

t / Photographs % ^^" r V k'^^^W A y ffl^ 6^%ATWv 

P^ As-built sketch 

[P Satisfactory restoration signed by Property Owner 

0 Property close-out check list signed by EPA 

-&' Description of areas not meeting ROD cleanup criteria 

0 Utility clearances 

y Property infonnation from Douglas County Assessor's Office 

CJ 

D 

n 

Signature 

30054453 

Superfund 
•t 

Properly Access Checklist 

Property ID: ^^C^ ^ 

Property Addreas: -^O^IKX ^ \ 7 ^

o^^^-^^fVlVVN Vlrrvi 

^---'b'^'^? ) V3 T 3 t^A: 

Phone: 

Fax: 

Cell/Pagen 

D Notification Letter 

Access Agreement 

Restoration Agreement 

D Topsoil Sampling (if applicable} 

D Disposal Samplhig Crf applicable) 

D Garden Sampling (if applicable) 

; ^ Utility Clearance 

Q^ideo/Photos (Before) 

O Video/Pbotos (During) 

a Video/Photos (After) 

Video/Photos (30-Day) 

iperty Completion Agreement 

Final Report 

Air Monitorine (as aoDlicable 

0 Community DCrcw On: /

Results: 

DConunnnity nCre w On: /

RCSDHS: 

Q Community QCrcw On: /

Results: 

n WORK STARTED

 ^ 

D WORKCOMPELTED

Renter 

Phone: 

Fax: 

Cell/Pager 

Additional Information: 

Sent: / / By: 

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

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

/ /. By; 

/ / By: 

/ / By: 

Called:^/2io/Q 9 'y^ ^\3o\nOi 

On:£i/_^ ^ By-OCWK/lo 

On; By: 

On; / / By: 

On: / / By: 

Signed: jlliHii ^ By: 

Issued: / / By: 

/ By:

 / By: 

/ By: 

 ON: __/__/_ 

ON:__/__/_ 

Omaha Lead SKe 

 1 
Douglas County Account I [j^sonation Page 1 of 1 

Douglas County, Nebraska Property Record - R2013670000 

Print Report 

NEW Faatura - ParKfil Dimfinsions available O) scale 0-50 ft west of 52nd St - ViO W O n Ma p Infonnation is valid as of 2009-9-15 Treasurer's Tax Report 

New Feature -»-»- » Auto Sales Search 

Owner 

WOODS JAY A 

3918 N 23 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 1367 0000 20 

Account Type: Residential 

Parcel Number: 2013670000 

Parcel Address: 3924 N 23 ST 

OMAHA NE 68110-0000 

Legal Description: PLAINVIEW LOT 4 BLOCK 4 50 X 124 

Value Informatio n 

Land Improvement Total 

2009 $300.00 $0.00 $300.00 

2008 $300.00 $0.00 $300.00 

2007 $300.00 $0.00 $300.00 

2006 $300.00 $0.00 $300.00 

2005 $300.00 $0.00 $300.00 

2004 $300.00 $0.00 $300.00 

Sales Informatio n 

Sales Date: 2004-07-21 

Deed Type: WD Book: 2004 Page: 096569 

Price: $0.00 

Grantor: Jason D Woods 

Grantee: Jay A Woods 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6200.0 0.0 124.0 50.0 Yes 

http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accoimtno=R20... 9/17/2009 
Page 1 of2 

"> 

Create Another Ticket Back to Irth Internet I [ Send Email ] 

• YOUR TICKET NUMBER IS 2373251. 

Original Call Date: 9/26/09 Time: 4:37 pm Op: ELIZABETH18790 


Work to Begin Date: 9/30/09 Time: 7:15 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 3924 Street: N 23RD ST 


Twp: 15N Rng: 13E Sect-Qtr: 03-SW 


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 LOT 


Cotrrpany : 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: Y 


Involves Tunneling or Horizontal Boring : N Explosives: N 


ALT872 CXCATV MAGELLAN MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number UtiUty Type 

ALT872 WINDSTREAM COMMUNICATION NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

MAGELLAN MAGELLAN MIDSTREAM PARTNERS LP DEBORAH

Day: 9185747098 

 Alt: 

Emerg: 9185747098 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY

Day: 4025047823 

 Alt: 

Emerg: 4025047970 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/26/2009 
Page 2 of2 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RON 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

OPPDGPR5 OMAHA PUBLIC POWER DISTRICT NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

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

COASTA L Omaha Lead Superfund Site 

33502 

Omah Exterior Paint North Arrow Owne a Lead Site r Name : JASON D vyoOD S 

Sit • Good e Sketc h Address : 3924 N 23 ST |~1 Poor Phone : H: W: I I Not paint 

Sampte Number Lead Sample L AB Samples Collected 

Concentration Collected Firm: 

RYASCPXA-33502 F1 

ppm 

RYBSCPXA-33502 F2 

(OS- n Date: 

—HIP ppm UP n Time: 5^ • -/ C . RYCSCPXA-33502 81 ppm [3r 

D Samples Analyzed 

RYDSCPXA-33502 82 ppm \3r •

RDZSCPXA 33603 B ^ ppm D n XRF Unit: / a 3 7 Book: // ? 

-RGZSCPXA 33603 -62 ­ ppm n Date: -7-t'O'S ­ •f^PgOCPXA03002- -P2- ppm n D Time: j^yf f 

Staff: Number of Samples = ^ n J,POL 

Legend: F l = Front Left, F2 = Front Right 81 = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property OLS#: 33502 

Date Excavated :9/30/09 : 

USEPA Signed Off: 10/23/09 

Legend 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with 

Sod 

Area replaced with 

Rock/Mulch Area left bare 

Contract #: EP-R7-07-05 Coastal Environmental Group Inc. 

'j/:jMMi,uiiJii^iiUuS!lsUini/kC&ii^^ 

wm 33502 li fMo 

Exterior Paint North Arrow 

Ovyne Omaha Lead Site r Name: JASON D WOODS 

Sit • Good e Sketch Address: 3924 N 23 ST • Poor 

Phone: H: W: 

Q] Not paint 

Sample Lead Sample Samples Collected Number LAB Concentration Collected Firm: 

RYASCPXA-33502 F1 fO£ ' ppm D Date: n-L.-0£ ' 

RYBSCPXA-33502 F2 

n Time: 5'::'f0 

RYCSCPXA-33502 Bl I_fZ^J_Ppm 

n Samples Analyzed RYDSCPXA-33502 B2 I H ^ ppm D 

RDZSCPXA 33503 ppm D D XRF Unit: 10 3 7 Book: //*? 

-RGZSCPXA 33505 QZ­ ppm D D Date: 7-5'^S " •RPZOCrXA^33502 P * ppm D D Time; ^/ ^ 

Numbe Staff; LA r of Samples = ^ 

Legend: F1 = Front Left, F2 = Front Right, Bl = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing propetty 

'i)(ctyp/^^ 
^ \xpm 33502 i^jyy Omah Exterior Paint North Arrow a Lea d Site Owner Name: JASON D vyoODS • Good Site Sketc h Address: 3924 N 23 ST • Poor 

Phone: H: W: Q Not paint 

Lead Sampie Samples Collected Sample Number LAB 

Concentration Collected 

Firm: t='lsA HT/TL ^ 

RYASCPXA-33502 F1 IPS' ppm y D Date 7-L P -OS 

RYBSGPXA-33502 F2 © M12^ ppm D Time 5:^-^0 

RYCSCPXA-33502 B1 ppm JdJd. Q" D Samples Analyzed RYDSCPXA-33502 B2 \ H ^ ppm Q­ n RDZSCPXA 33602 BZ ppm D XRF Unit: 10-37 Book M ± D -RGZSCPXA 33505 6Z- ppm D Date: D -f^PZOCPXA'3300g P? ppm D Time. ^/ ^ D 

Staff: JLA. Number of Samples 

Legend: F1 = Front Left, F2 = Front Right, Bl = Back Left. B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ - Play 

All quadrants are as viewed from the street, facing property 

^i)(caepH 
--J-w'.ir'.''Jtii.T.t^^jaw.ijUfc^' 

33502 

Omah 1 Exterior Paint NofttiArrow Owne a Lead Site r Name: JASON D V^rOODS -— Sit • Good Address e Sketch : 3S24N 23 ST • Poor 

r Phone: H W : 

Q Notpaint 

Sample Number Lead Sample ^^^ Samptes Collet^ 

' ^ Concentration Collected ^^^ Firm: t^hA l-tT/Tl ^ 

RYASCPXAr33502 F1 fO ^ Dom R ^ H Date: n~L.~0£ ' 

RYBSCPXA-33502 F2 tjjpoD m R ^ f l Time: S'i O 

RYCSCPXA-33602 B1 i j 2. I onm HK n 

Samples Analyzed RYDSCPXA^35{K B2 / V ^ Dom nr n 

- Dom n n XRF Unit: ./<?3 7 Book: //? , 

- Dom n n Date: l-^'^ ^ 

.," ppm n n Time: 

Staff: ALA 1 1

 nuiiiixa Ui aaiiifmss - j " f ; ^ 

Legend: F1 = Front Left. F2 = Front Right Bl = Back Left, B2 = Back Right OZ = Drip Zone. GZ = Garden. PZ = Play 

All quadiants are «s viewed from the stieet, fadng propeity 

: AuieY : 

.: ; ;j.... : ..;. . • ENTERED 

; JUL 0 7:2085 1 .: [ :i....L. ..L. 

.• ;... . ;J . : . : 

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

•.yniu^i-.^s!^....... : — " Okff^ : Houde 1" "^ri" i~ 

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

- 1 . _ . -

fn...u.. . n .i. . f. 1 •

.\I0S\\ qi Z \ f . . , 

: : : : • -i ^....................... . .^ 

\ !......•. .'...' 

J lU • h i \ , , , . • n 5 ': P : * . 

:. : . .. ; ;.... _ 3 .on iol—Tf%« 1 . 

' Wiik . : 

: 

R«v* i -. . . . ; \hi..2$./yr\ . : i OMM1.0I23 • >:•' — 
,^,€0 6.4, ^ 

COASTA l 

INVIROHHIICTAI PBO'**" C R O D P . t N C 

Consent for Access To Pfoperty 

RIGHT OF ENTRY TO PREMISES 

Grantor (the property owner) consents to and authorizes the United States 

Environnnental Protection Agency (EPA) or its authorized representatives, coilectiveiy 

the Grantee, to enter and perfonn certain environmental response activities upon the 

following described premises: 

Address of Property 

covered by this -yv^ sl y ^f 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) vtnll be 

excavated to remove contaminated soil. The removed contaminated soil wili be 

replaced with dean 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 worit 

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 reasonable times 

and with prior notice, for the sole purpose of performing the worit. This access shall 

remain in effiect untii the work has been satisfactorily completed. The Grantor also 

agrees to: 

Page 1 of 2 
.*^*"">, 

COASTA l 

y tlvVlaOitKIKTAl y C « O 0 P I K C 

« Remove obstructions including boats, trailers, vehicles, playscape items, wood 

piles, dog houses, etc; 

c Remove flower bulbs or plants that the Grantor or the Grantor's tenant may wish 

to save; 

( Water and maintain replacement vegetation, including fertilizer application, as 

necessary subsequent to an initial watering period by EPA; 

c Abide by health and safety guidance provided by EPA; 

* If the property is rented, assist EPA in obtaining tenant approval for access to 

the property to perfonm the work. 

e Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

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

LS/srent access to my properties D I do not grant access to my properties 

too^-c^-ti^ 

Signature 

Signature Date 

Q I would like to be present during any sampling that is required. 

Page 2 of2 
m 

COASTA L 

Restoration Agreement 

The puipose of this agreement is to provide a mutual agreemem as to condttions ofthe 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). 

Property IP; 'yp'ybV 

Property Address: "^^^. ^ l4 'Z^>' ^ ^ Y 

Q^""- "T^liM WOOf j 

Phone: 

=-_ ! 

On die sttached diagram(s) indicate area(s) to excavate, surface structures and landscaping features and 

access locatiQn(s) to be used by the contractors. Indicate distances, depths, matenal types, etc. 

Photographically and Videographically document the existing conditions ofthe property and the l»sement if 

necessaiy. 

Itoms to be Removed by the Owner before Start of Remediation: 

The lemoval, storafie. disposal, and/or return of these Items is the Owner's responeibility. 

ftem: 

^y\ ^ fuAvi-rV 

Item: 

MefM>yi 

Item: 

Item: 

Item: 

'\v\^ jiMfr- iWfy{f7 Uff \kHi^i^ 

ttem: 

Itan: 

Item: 

Page 1 of / 
COASTA L 

Hems to Be Removed By Contractor During Remediation and Replaced 

Item: 

lOy Y ^ U V\ y K 

ttem: 

Item: 

1 

I Item: 

t 

Landscape Inventory 

Item Quantity Unit Condition/Type/Species 

Pre-existing property area, Quadrants tbat will be excavated, that h -^f-^ is covered with grass. 

• 

Number of trees > 2 inch Each 

trunk diameter 

Number of trees <= 2 inch Each 

trunk dinmcter 

Number of Sprinkler 

Zones. Control Valves, Farii Tfano^. Heads, etc. \\o 

Aiiath a sktricli ol tlte 

Number of and size of 

each garden/ flower bed Each kP\^u^ y/^ area. SquareFeet 

Ali;\th ;i sketch ol ri-!;ilivi' 

<i/i'S and loc;iiinns 

Agreed upon value of plant 

materials not to be 

replaced by contractor. fi/va^ ^ 

N'Clr l!-.i' ^nl^lc VMII tii 

S \oo " usoO 10 it;uc .1 ;ilHn; 

lOiii-Iu'.- Ki llie propcrlx 

0 " ner. 

Easement Area, to be Each 

excavated 

Page 2 of -> 

c 
C O A 5 1 A L 

I Additional Comments / Instructions: 

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

Q Check the txuc if Owvner does not want CEG to document interior foundation walls and possible 

pre-existing damage. By checking ths txix CEG is not responsible for any damage done to the 

interior t>f house, indudirtg foundation cracks or fissures. 

O I do not agree 

Owner's Sinatnre Date Contractor's Signatnre Date 

Page 3 of. 
Date 

Project 

XRFID# 

Shot# 

T ^ 

nszy 

Average

Shot# 

J2sa. 

i^z ^ 

J5iQ i>VK

Average

Shot* 

Average 

Shot# 

Average 

lab sample # 

BVID# 33'>^" ^ 

XRF PROPERTY SAMPLE SHEET 


^mo'i Address ^^^ ^ p 2.3 'SI-. Omaha lead FP 2ncl year opUcn Sample time am/pm 

'^-^fe'? sample length 30 sec 

Reading Sample area Shot# Reading Sample area 

Eit. i±t£3. ?> t 17 

Depth Depth spti Jjb^ i S-5-Z^ 

l^ly ^ / / /^ ^ l?w-^ ^ IS 

 *PP ^ "^^lo Average f5 0 — ^ 7 

Readinc Sample area Shot# Reading Sample area 

aE 

g^ JM 

Depth Depth * ^ iz<.iH^^^ Isx ^ ^ | - ^ I ^ Average 

Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average 

RETEST AREAS 

Reading Sample area Shot* Reading Sample area 

Depth Depth 

Average 

Lab result Sample area XRF Avg. 

Signature ^^MlMh. 

Prin £JJ •yto^j^ C(Ce(r^ t r_A\ 
Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. V ^ www.coa8talhazmat.com 

^-"iPBo^*"^ COASTA L IHVItOHHIHTAl C 1 0 U P, IN C 

EXECUTIVE SUMMARY: 

BVID #33502- (3924 N 23 ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation •_ : • 

-COASTAL TO ISSUE REIMBURSEMENT CHECK FOR $200.00 (COMPLETED 1/28/10) 
\^ EPA 

EPA Property Close Out Form 

Property #: X^^rO.. . PropertyAdd^.J>^7H K.fj^J ^ • -

Date/Time: Owner's Name:..fc.^nS.nn.Myr a .. •• 

Quads Excavated: p>) , jF2 Contractor Group J^rO.<,\0i 1 h n Vlt rarr\PY\\Oi \ 

Excavatio Yes No n Gcaenil 

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

U^ 

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

ly^ 

Gradin Yes No g Sod and Vegetation 

1. Does the grading arotmd the perimeter ofthe house in excavated areas generally slope away lyT from the house? 

IP' 2.

 Has sod been laid in all areas that were excavated? 

3. Does the sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 -V­ day time period) 

4. Are sodded areas generally fum and evenly graded? ^ ' 

5. Arc the joints twtween the sod strips generally tight? (Only evaluate if inspected at a 30 day T'^ time period) 

6. Was the property graded such that water will not pool on the propert>'? y 

7. Was damage to landscaping or plant materials avoided? 

Gates. Fences and Retaining Walls 

Yes No 

1. Do gates open and close freely? (Ifapplicable) y 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) 17 

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

y 

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

ly 

Foundation, Siding and Gutters 

Yes No 

t ^ 1.

 Was damage to the siding or trim avoided? 

2. Was damage to the foundation avoided? y 

3. Was damage to windows avoided? 

y^ 4

 Was damage to windows or door screens avoided? 

l y ^ 5.

 Was damage to downspouts or downspoul extensions avoided? 

Sidewalks and DrKeways (Concrete) 

Yes No 

1. Was damage lo driveway surfaces avoided? ^ ' 

2. Was damage to walkway surfaces avoided? \ y ^ 
Ownen; comments: 

Inspection notes: 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA Representative L JPyp) JjP//^jL ^ Date: /d/jJMf 
Property Completion Agreement 

ihis agreement documenls the complclion of remedial acliviiies perlbimed on my properly My signature 

will designate ihal I am salisfied with Ihe restoration of my properly, and ihal no ilems are in questions, 

now, or al any lime in the future, except ihose ilems listed below, if any 

Property IP: 5350^ . 

Property Address: ^Q^^^jJ^ V^ yQ^ ^ 

Owner: ^ ^^^fy^ VSICQT L 

Phone: 

Restoration Items in Question: 

Item: 

Kc>tvv\bur^(^wt. M cX><-c4^ 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

/\Jet4 k> 4ro p c^'ff ci*jd(l la ^ /^tin^ur-i*-!** ^ ^ ^ -Uux^e s 

I nyrcc restoration'\%completed, except as noted 

[ I I do not a|;rec rcstorahon is completed 

Owner's Swn;)tinr Date Comiaclor' i actor'ss Signatur Signaturee Date 
Property Damage Settlement 

Property ID 33502 

Property Address 3924 N 23 St 

Owner Woods Jay 

Phone (402)408.6611 

I have receivedfix)m the contractor, Coastal Environmental Group Inc. (Coastal), the sum of $200.00 to 

compensate for plants and river rock that were removed during tfie removal of lead impacted soil from 

the property. 

Compensation type Check 1879 

Value of Check $200.00 

Check to the order of Woods Jay 

Description of Damage 

While excavating 3924 N 23 St (BVID 33502) Coastal damaged some plants beyond salvage. Property 

owner received a check for the amount of $ 200.00 dollars for the replacement ofthe plants. 

My signature below acknowledges the replacement of my plants; further, I acknowledge that this 

work was completed satisfactory and within my and release Coastal Environmental Group, inc. from 

further obligations or liability related to this property. 

fM^>r-r^^m^:^^^^^K:^i~i:^ 

:-j£i^j,&;, i^ss fef^^ TT^^S^^M 1879 

COASTAL ENVIRONMENTAL GROUP INC. 27-S/10M>003 

2411 6247372904 MARTHA STREET 

OMAHA. NE 68105 42 ^ DATE 

i.«S. 

PAY ssiJayJ^esds^ - ^ ORDER OF _ a*cMi)ir 

FaalurM jM^^^^^M^^Im Q SS'" 

Wd>to96tinli,NA. 

OwneVvS Signature Date Contractor's Signature Date 

Page 1 of 1