# TRANSMITTALo f

OMAHALEAD SIT E SOI LREMEDIATIO NFIL EFOLDER 

# i ^ 

# u Date : SAID 

# *iu H Address : ^"I^ifi I ^ f Remediatio nContractor : Coasta l Environmenta l Group
_ Year : 2 0 

# tft SOI LREMEDIATIO N PROPERT Y nLEFOLDE RDOCUMENT S Vide o ofpropert y (DVD ) Executiv e Summary EPA-provide dpropert y sketc h Signe dAcces s Agreemen t fo r subjec t property Signe dAcces s Agreement(s ) for adjacent property Restoratio nAgreemen t Settlement document s (i.e. , fo r damag e o r t o replac e plants , etc. ) -G - 

### Confinnatio ndat a Photograph s J U^f{1\( ^ \^CPo/ftTW n

-y ^ ^ f |^<»' > / As-buil t sketc h 3021757 1 

# x i Satisfactor y restoratio nsigne db y Property Owne r 

# i Wi n Property close-ou t chec k lis t signe db y EPA Superfun d 

### Descriptio nofarea s no t meetin g RO D cleanu p criteri L Utility clearance s Property informatio nfro mDougla s County Assessor' s Offic e C

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# Propert y Acces s Checklis t Property ID : D WOR K STARTE D ON : __/__ / 

# um= L D WORKCOMPELTE D ON ; / / Propert yAddress ; 7 7 ^ ^ / ^-j r Rente n Owne rM/^iA^LUCA S OttTl ^ Address : Phone : Fax : Cell/Page n Additit»a l Information : 

# Phone : SoLj'-qd^q s Fax : Cell/Page n
D NodficationLette r Sent : / / By : ^ Acces s Agreement Signed : i^/13/Q Q By : J ^ Restoratio nAgreement 

## Signed : id/13-/(2 3 By : D Topsoil Samplin g (if applicable ) / / By : D Disposa l Samplhi g (if applicable ) / / By : D Garde nSamplin g (if applicable ) / / By : |H 1 Utilit y Qcaranc e Called : ^/^A22
. 

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^ Video/Photo s (Before ) 

# On:Jl/ 3/J2i ^ 

# By : /4iUD X 0 Viileo/Pboto s (Dnring ) On : / / By : D Video/Photo s (After) On : / / By : D Video/Photo s (30-Day ) On : / / By : ' ^ Property Completio nAgreement Siened : I I J\l-IO ^ By : t ] FinalRepor t Issued : / / By : Ai r Monitorin e (a s aoDlicable ) nCommunit y OCrc w ] On : / / By : Results : D Commnnit y QCre w On : / / By : Resohs : D Communit y QCrc w On : / /
. By : Results :
Omah a Lea d Sit e

## Dpuglas Count y Accoun t InfoisM|ion Pag e 1 of3 i^Hg c Dougla s County , Nebrask a Propert yRecor d - R041790000 1 Prin t Repor t NE WFeatur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t o f52n d S t - VlO WO H Ma p 

### Infonmatio 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 ORTI Z LUCA S 220 6 1 S T OMAH AN E 68107-000 0 Propert yInformatio n Ke yNumber : 179 0 000 1 0 4 Accoun t Type : Residentia l Parce l Number : 041790000 1 Parce l Address : Lega l Description : 220 6 1 S T OMAH AN E 68107-000 0 SOUT H OMAH ACIT YLOT S LOT8 BLOC K13 4 W6 0 F T Valu e Informatio n
200 9 200 8 200 7 200 6 200 5 200 4 Lan d $4,500.0 0 $4,500.0 0 $4,500.0 0 $4,500.0 0 $4,500.0 0 $4,500.0 0 /mprovemen f $75,500.0 0 $75,500.0 0 $75,500.0 0 $75,500.0 0 $43,200.0 0 $43,200.0 0 Tota l $80,000.0 0 $80,000.0 0 $80,000.0 0 $80,000.0 0 $47,700.0 0 $47,700.0 0 Sale s Informatio n Sale s Date : 2004-06-1 1 Dee d Type : W D Book : 200 4 Page : 07803 7 Price : $85,950.0 0 Grantor : NEBRASKA-IOWAPRO P LC Grantee : LUCA S ORTI Z Valid/lnvalid : Vali d Exclusio n Reason : Sale s Date : 2004-03-0 4 Dee d Type : TR D Book : 200 4 Page : 03691 8 Price : $45,001.0 0 Grantor : Eri cLindquis t 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO..
. 10/17/2009,r|^1 ( 

### Dpugla s County Accoun t Inforj^io n Pag e 2 o f 3

Grantee : ; N E- 1 APropertie s Valid/Invalid : Vali d Exclusio n Reason : 

### _L Sale s Date : 1991-10-1 4 Dee d Type : Book : 191 2 Page : 52 8 Price : $37,750.0 0 Grantor : Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.0 6 3000. 0 

### 1. 0 50. 0 60. 0 N o Improvement Informatio n Buildin g 1 1 1,- 2 StoryFi n 220 6 I S t
EttiSlMfW M

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8snnB«>! » TIHIICQ): , CLIC KT O ENLARG E IMAG E Squar e Footage : 

### 1152. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : ; Averag e Uni t Type : Condition : Ver yGoo d

Buil t As : 1 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r 

### Rooms : 6. 0 Exterior : Fram e Viny l Units : 1. 0 Interior : Drywal l Baths : 

### 1. 0 Roo fCover : Compositio n Shingl e Bedrooms : 3. 0

Roo fType : Gabl e Stories : 

### 1. 5 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0


### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO.
. . 10/17/200 9

### Dougla s Cotmty Accoun t Infori^o n Pag e 3 of 3 rji^i c

Yea rBuil t 190 8 Detai l Typ e Ad d O n Applianc e Basemen t Fixtur e Fixtur e Garag e Porc h Porc h Use r Yea r Remodele d 0 Percen t Remodele d 0 % Detai l Descriptio n Fenc e Woo d Allowanc e Bsmn t Bloc k 8 ft Bas e Fixture s Bat h Ful l Detache d En d Soli d Wal l Sla b RoofCei l Se e Note s Adjuste d Yea r Physica l Ag e Buil t 190 8 10 1 Unit s 1. 0 1. 0 704. 0 1. 0 1. 0 180. 0 132. 0 120. 0 1. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO.
. . 10/17/200 9

### Pag e 1 of 2

" > 

### Great e Anothe r Ticket , Bac k t o Irt h Interne t ^ ^

Sen d Ernair. J



## • YOU R TICKE T NUMBE R I S 2402260 . Origina l Cal l Date : 11/07/0 9 Wor k t o Begi n Date : 11/12/0 9 Time : 12:1 2 p m Time : 7:1 5 a m Op : ELIZABETH1879 0
State : N E Address : 220 6 County : DOUGLA S Street : I S T Place : OMAH A Twp : Twp : 14 NRng : 13 E Rng : Sect-Qtr : 03-NW 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 : FAX AL L CLEAR S TO : (877)662-421 1

: UNSUR E O F CORNE R PROPERT Y Compan y: COASTA L ENVIRONMENTA L SERVIC E Contact 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 : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N ALTS7 2 QLNNEI F ATTNEBR l CXCAT V LEVEL S MUD0 2 OMAHACO F 0PPDGPR 6

Servic e Are a Contac t Phon e Numbe r Utilit y Typ e
ALT87 2 WINDSTREA M COMMUNICATIO NN A 

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

ATTNEBR l ATT/T 

### Day : 8002413624 9 Alt : Emerg : 8002413624 9

CXCAT V CO X COMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 AU : 402934046 9 Emerg : 402932975 7

LEVEL S LEVEL 3 COMMUNICATIONS , LL C N A 

### Day : 877366834 4 Alt : Emerg : 877366834 4
http://vmw.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.
. . 11/7/200 9

### Pag e 2 of 2

MUD0 2 METROPOLITA NUTILITIES DISTRIC T SAND Y 

### Day : 402504782 3 AU : Emerg : 402504797 0
OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C 

### Day : 402444719 7

AU : 402444516 1 Emerg : 402444516 0
OPPDGPR 6 OMAH APUBLI C POWE RDISTRIC T N A 

### Day : 406728934 3 AU : 406207149 4 Emerg : 888728934 3 QLNNEI FQWES T LOCA LNETWOR K N A 

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

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.
. . 11/7/200 9OLS# : 1113 4 

# As-Buil t Drawin g Dat e Excavated : 11/10/0 9 Dat e USEP ASinne d Off : 11/30/0 9 COASTA L 

# Omah aLea dSuperfun dSit e Are a Sodden : 13 5 s o f t INvmONNIMTA L CROUP , IN C 

## 1113 4 Exterio rPain t Nort h Am> w Omah a Lea d Sit e Q Good Sit e Sketc h •Poo r Samplin g Address : 220 6 I S T Q TNo t pain t \ Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : fO AF'Syp Q RYASCPXA-1113 4 F 1 2 3 H pp m D Date : TX^'O l RYBSCPXA-1113 4 F 2 HHAppm M Time : ^•.OOp.Or^ , 

# n RYCSCPXA-1113 4 B l CaJp ppm D Samples Analyzed RYDOOrX A1113 4 B » ~ pp m D RDZSCPXA-1113 4 D Z ) 5fl H po m XR F Unit : GSH O Book : 2/ 3 D RGZSCPXA-1113 4 G Z IM 2 pp m Date : fi -/ ^ -b t RTZSOPXA1113 4 9 A pp m D Time : D 

## ja r 

# n Staff : Numtie ro f Sample s = | ^ | | Q | 

## JDik L Legend : F l = 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 , fadn g properl y

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 * ^ 

# w- Are a lef t bar e Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .

### 1113 4 

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### D Time : H"-OC > p. m• RYCSCPXA-1113 4 B l pp m 

### D Sample s Analyze d RYDCiCPK A1113 4 -S & pp m 

# n RDZ^CPXA-1113 4 b z 

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## 1113 4 

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## fi-/^-os Time : _ 

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s viewed fro m th e street , facin g propert y

Re v200 8 Created : O.^-May-O K

## 1113 4 Exterio rPaint Nort h Arro w 

### Omah a Lea d Sit e •Goo d 

### Sit e Sketc h •Poo r Samplin g Addrass : 2206 1 S T 

# 1 QfNo t paint Sampl e Numbe r Lea d Concentratio n Sampl e Coiiecte d LA B Firm : Sample s Collecte d RYASCPXA-11134 F l pp m 

# s f D Date : RYBSCPXA-11134 F2 ppm M 

## D Time : RYCSCPXA-11134 RVDOOPXAIIig M 8 1 B » pp m pp m 

## D D D Sample s Analyze d RDZSCPXA-11134 RGZSCPXA-11134 nPgCOPW V 1110 4 D Z

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COASTA t IHytRONn fKTA I r . •o u p IN C '•» < fHO - 

### Consen t fo rAxces s T o Propert y RIGH TO F EISITR YT O PREMISE S 

### Granto r(th e propertyowner) consent s t o an d authorize s th e Unite d State s Environmenta l Protectio n Agenc y(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 : Daytime Phone :

Addres s o fPropert y covere d b ythi s >-r . 

# • >7^ ^



# y Agreement : PURPOS E O F RESPOJMS E ACTIVITIE S 

### Th e EPAi s requestin g acces s t o collect soi l sample s an d remove soi l that contain s elevate d concentration s o flea d an d maypos 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 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 Environnienta 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 opportunityt 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 Ki 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 EPAtha t th e property 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 , contractors an d subcontractors 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 effect unti l th e wor k has bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :

Pag e 1 of2

# <,^- y
8 COASTA L tHVIKONH^KTA l CROU P IH C



### « 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 perfor m th e work
. «> Allo 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
I gran t acces s t o mypropertie s D i d o no t grsn t acces s t o mypropertie s



### z ' 'Signatur e Date ^ \ ' 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 o f2

# a

1 

# RESTORATIO NCHANG EORDE R OMAH ALEA D Propert y I D #l\\^ ^ Propert y Addres s l-SlJc>lj 2 " p 1^4"

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# Owne r Signature//// 6 P/A0/?^.yP
. Contracto r Signatiire jCOASTA L C • O U r• »• C 

## Restoratiio n Agreemen t Th e purpos e ofthi s agreemen t i s t o provid e amutua l agreemen t a s t o condition 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 property owne r an dth e Unite dState s Environmenta l Protectio nAgenc y (EPA)
. 

# 7r/3 ^ Propert y Address : -TO^CX P - C ST.:
. 

## o^"- ' .y„^4r - - UAC ^

Pi^r? ^ Phooe : 

# 6^f^f r O nth e attache ddiagram(s ) indicat e area(s ) t o excavate , surfac e structure s andlandscapin g feature s and acces s location(s ) t o b e use db y th e contractors . Indicat e distances , depths , material types , etc . Photographicall y an dVideographicall y documen t th e existin g condition s ofth e property an dth e basemen t i f necessary . 

### Item s t o b e Remove d b yth e Owne rbefor e Start o f Remediation : Th e cenoval
. stora.qe , disposal , and/o rretur n o f thes e itom s i s th e Owner' s responeibiiity
. ftem : 

# A ^ < , Item : /
Item : Item :



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## Item s t o B e Remove dB y Conti^ctp r During Remediatio nand^Replaced^ Item : 

# S^i L "f^ ^ 

# , 07 ^ Item : 

# "y^ ^ ' 

# ^^J ^ Item : Item :

Landscap e Inventor y 

## Ite m Quantity Unit Condition/Type/Specie s Pre-existing propert y area , 

# pz - Quadrants tha t wil t b e excavated , tha t i s coveredwit hgrass . Numbe r o f tree s > 2 inc h Eac h 

# 7_ trunl c diamete r Numbe r o f tree s < = 2 inc h Eac h 

# n ^ triml c diamete r Numbe r o f Sprinlde r Zones
. Control Valves , Eac h 

## M / 

# V Timers , Heads , etc . Aii.it h i l sl>i'tcl i o l ilit f '•pr'rklc i l;;y'.iLi i 

### Numbe r o f andsiz e of eachgarden / flowe r lied Each area . Squar e Feet Alliic hi l skclr ho l rcliilivi.

­ <i/c s mi dlociiiioii s 

### Agreeduponvalue of plan t material s no t to b e replace db v contractor . Voi rl!i r^Hl^i cwil l n i liSi' C I U it;u ( .1 piBli i XOIKSU'. - 1( 1 lh e i;rci))crl \ in t ner . 

### Easemen t Area , to b e Eac h excavated
Pag e 2 of
.

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### ! Additiona l Comment s / Instructions :

Chec k th e bo xifOwne rdoe s no t wan t CE G to documen t interio rfoundatio n walls an d possibl e pre-existin g damage
. Bycheckin g thi s bo xCE G is no t responsibl e fo ran ydamag e don e to th e interio r ofhouse , includin g foundatio n crack s orfissures
.

•I do no t agre e

' Owner' s Signatur e I Contractor' s Sienatur ifat e Dat e t ( , Contractor'sSignatur e 

### Pag e 3 of
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### 2010-02-1 6 18:1 0 Duratio n 

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

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. QUADRAN T D Z DEPH T 1 3 XR F TEC H O
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pp m Erro r P b 327.70 4 ± 28.19 5 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpiic e Billerica , M A0182 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 348.12 2 Supervise d By : 

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o f Verificatio n XL3t-3902 2 Readin g N o 6 8 Mod e SOI L Tim e 2010-02-1 6 18:2 5 Duratio n 90.7 8 Sequenc e Fina l Flag s AVERAG E V.Ayg_of65^67 J ADDRES S 220 6 I St
. QUADRAN T E M DEPH T 1 XR F TEC H 0
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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 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 274.69 1 Supervise d By : 

## Certificat e o fVerificatio n

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### 2010-02-1 6 18:2 4 30.2 9 Fina l 

### 1113 4 220 6 I St
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### 1 O
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### 1 1

± Erro r ± 26.06 1

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 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 276.52 9 Supervise d By : 

## Certificat e o fVerificatio n

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 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 282.99 6 Supervise d By : 

## Certificat e o fVerificatio n

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

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### 2009-11-1 0 12:0 1 Duratio n 

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pp m P b 248.02 6 Supervise d By : 

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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 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 215.03 2 Supervise d By : 

## Certificat e o fVerificatio n

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# Therm o

SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

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pp m P b 231.54 7 Supervise d By : 

## Certificat e o f Verificatio n

23 3 SOI L 2009-11-1 0 12:0 1 30.9 3 Fina l 1113 4 220 6 I s t F 2 6 " R
. VENTR Y clearenc e ngn c

± Erro r ± 19.77 4

## /lA. \ Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 I ^^^ ^

I Coasta l Environmenta l Grou p Inc
. V"^^j ? www.coastalhazmat.co m XPROT* ^ COASTA L INVIIONNINTA I S lO U r , IN C 

# EXECUTIV ESUMMARY : BVID #11134-(2206 1 ST ) No Issue s o r Concern s | ^ Issues/Concern s Detail Explanation : -COASTA LTO REPLAC ETH EGRAS S O NFRON T YAR D WHER EFLOWER S WER EBEFORE
. (COMPLETE D 11/20/09 )^ ^ 

# EP A # 

### laa l r ^ 

# EP APropert y Clos e Ou t For m Propen y # : \ ^ ) 3.^ „ Propert y Address : Datc/Tlroc : 

### Owner' s Name:
. ^ Quad s Excavattd ; f ^ Z- , f ) fP ^ Contracto r Grou p Eicavatio nGenera l 1
.I f necessary , were th e correc t quadrant(s ) excavate dandrestored ? 2
.If necessary , were th e correc t area s ofdri p zone excavate dandrestored ? Gradin g So dan dVegetatio n I
.t>oe s the gnulin g aroun dthe perimeter ofth e hous e i nexcavate darea s generally slop e awa y fromth e Iiouse ? 2
.Ha s so dbee nlai dinall area s tha t wer e excavated ? 3
.Doe s the sodappear to b e generally healthy an dgrowing ? (Only evaluate i f inspecteda t a3 0 day time period ) 4
.Ar e soddedarea s generally Tir man devenl y graded ? S
.Ar e th e joint s betwee nth e so dstrip s generally tight ? (Only evaluate if inspecte da t a3 0 da y tim e period) 6
.Wa s the propert y grade dsuchtha t wate r wil l no t poo l o nthe propert>' ' 7
.

Wa s damage t o landscapin g o r plan t material s avoided ? Gates , Fence s an dReuinin g Wall s 1
.D o gate s ope nan dclos e freely? (Ifapplicable ) 2
.Were all gate s or fence s takendow ndurin g restoratio nactiviiie s reinstalled ? (If applicable ) 3
.Wa s damag e t o gate s o r fence s avoided ? (Ifapplicable ) 4
.Wa s damage t o relainin g wall s avoided ? (Ifapplicable ) Foundation , Sidin g an dGnller s I
.Wa s damage t o th e sidin g o r tri mavoided ? 2
.Wa s damag e l o th e foundationavoided ? 3
.Wa s damage to window s avoided ? 4
.Wa s damage to window s o r doo r screen s avoided ? 5
.Wa s damage t o downspout s or downspou t extension s avoided ? Sidewalk s an d Drh'cway s (Concrete ) 1
.

Wa s damag e t o drivewa ysurface s avoided ? 2
.Wa s damag e t o walkwa ysurface s avoided ? Ye s N o



### ,y

Ye s N o 

## y y _
y
y y Ve s N o • 

# y y

1 ^ 

### Ye s N o 

## y y 

## y y y Yes N o 

## y i ^

# 4^_

_

# ^ Ort'ner s comments :

Inspectio nnotes :

Remova l an drestorationactivate s complete including the 30-da y sodwarranty : EP ARepresentaiiv e B ^ JL ^ Date : /yfe ^

## Propert yCompletio n Agreemen t
I hi s agreemen l document s lh e completio n o fremedia l acliviue s perloime d o n m ypioperl yIVI ysignatur e wil l designal e iha i 1 a m satisfie d wit h (h e restoraiio n o fm yproperly , an d tha t n o item s ar e i n queslions
. now , o ra l an ylim e i n th e future , excep t thos e ilem s liste d below , i fan y

P I opert yfD : \{ \ 2^L J Propert yAddress : 12JOU > JX TSV L 

### Phone : [HQZ ^ C^^^ ^ ^^^C ^ Restoratio n item s i n Question :

Item : Item : ^

I •• •I ••L L Item : item : Item : Item :
Additiona l Comments :

r^ l I iiurc cI tstoralio n i. t complcled , cxccp l a s note d [_ J I rto no l »\iTt crestomtio n j j complete d

Owner' s Sicnutm rDat e ^^^GtrtTtiactor' s Signatur e Dal e

# © •

Propert vOwne rSatisfactio n Surve y Omah a Lea d Superfun d Si t NO V 2 3 200 9 200 8 Humediatio n Contractor: Coasta l Environmenta l Grou p ^IIPFRFUN D DlVlSIOt ^ Propert yIdentifie rNumber : \tt^ M Q U TL11 1 u Propert yAddress : ?^QU/ C "S W Propert yOwner' s Name : ' M Qr i A/ Lor^fJ ^ Or-V-)! ^ (abov e Informaiio n t o b e fille d ou t b yremediatio n contracto rprio rt o deliver yof for m l o PropertyOwner )
instruction s t o Propert yOwner : Thi s for m i s provide d t o yo u a s a mean s o f tryin g t o captur e you rleve l o f satisfactio n wit h th e wor k o f th e above-identifie d reniediatio n contractor , as applicabl e t o th e soi l cleanu p actio n a t you r property
. Th e U.S
. Environmenta l Protectio n Agenc y(EPA) i s ver yintereste d i n you ropinio n regardin g th e wori t performe d b yit s contractors
. Thi s for m i s intende d t o provid e a n eas ymean s fo ryo u t o expres s you ropinio n abou t th e wori cperforme d o n you rproperty
. Pleas e indicat e you rleve l o f satisfactio n wit h th e contractor' s worl < b yselectin g a numerica l ratin g (rangin g fro m 1 t o 10 ) usin g th e followin g ratin g scale , the n pleas e sig n an d dat e th e for m an d retur n i t t o th e USEP Ai n th e attache d self-addresse d & stampe d envelope , (additiona l comment s ma y als o b e provide d i n th e spac e below , a t th e optio n o f th e propert yowner. ) 9-1 0 "excellent " 7- 8 "ver ygood " 5- 6 "acceptable " 3- 4 "poor " 1- 2 "ver ypoor " Propert yOwner' s Satisfactio n Ratin g Regardin g Contractor' s Wor k 1 0 5 

# (J ) ^

fi 3 7 2 6 1 Additiona l Comment s fro m Propert yOwne r(optional : continu e t o bac k of pae e i f needed l

Propert yOwner' s Signature : > A ^ J^/ ? //9 - f ) /rV^JZ
. Date : U/l^/rJ \