TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: A^C a Date: SJlfp/ZpiO 

Address: QXPN U ?S - ?)Mr T^A 

Remediation Contractor: Coastal Environmental Group_ Year; 2008 

SOIL REMEDIATION 

PROPERTY HLE FOLDER DOCUMENTS 

^ Video of property (DVD) 

^ Executive Summary 

y EPA-provided property sketch 

p f Signed Access Agreement for subject property 

Kil^ Signed Access Agreement(s) for adjacent property 

y Restoration Agreement 

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

^ Confirmation data 

D Photographs piTe -^ t -» PymMdVlOri ?)M3 y 

>a As-built sketch 

7 ^ Satisfactory restoration signed by Property Owner 

40333869 

j 7 Property close-out check list signed by EPA 

,..__.„1 

WP Description of areas not meeting ROD cleanup criteria Superfund 

^ Utility clearances 

^ Property infonnation from Douglas County Assessor's Office 

[J 

D 

n 

^ Signature Date 
^v 

Property Access Checklist 

Property ID; ]^2jf ^ 

Property Address; 2}0 ^ ^ i3 M S T 

D

D

 WORK STARTED

 WORKCOMPELTED

 ON: / / 

 ON: __/__/_ 

Owner: (2,)Q Q J Ro-Vo \ ^ 

Address: 

Phone(qQ2} 3qi^g;, q 

Fax; " 

Cell/Pager: 

Renter: 

Phone: 

Fax: 

Cell/Pager: 

Additional Information: 

<^ 

7 

D Notification Letter 

J ^ Access Agreement 

^^Restoration Agreement 

D Topsoil Sampling (if applicable) 

D Disposal Sampling (if applicable) 

D Garden Sampling (if applicable) 

D Utility Clearance 

• ^ Video/Photos (Before) 

n Video/Photos (During) 

D Video/Photos (After) 

D Video/Photos (30-Day) 

0 Property Completion Agreement 

D Final Report 

Sent: / / 

Signed; 9_/1^/Q 9 

Signed;^ ll^lCf\ 

1 1 

1 1 

1 1 

CaUed: / / 

On;4./ %ld\ 

On; / / 

On; / / 

On; / / 

Slened; / / 

Issued: / / 

By: 

Byr^ 

By:^/-

By: 

By: 

By; 

By: 

By= ftlO^)*h'^v^v 

By: 

By: 

By: 

By; 

By: 

Air Monitoring (as applicable) 

IZl Community • Crew 

Results: 

On: / / By: 1 

D Community

Results; 

Q Crew On: / / By: 1 

CD Community

Results: 

Q Crew On: / / By: 

Omaha L.ead Site 
Douglas Coimty Accovmt Iv*%w,^tion Page 1 of2 

Douglas County, Nebraska Property Record - R2541190000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJe W O n Ma p Information is valid as of 2009-9-15 Treasurer's Tax Report 

New Feature -¥ ^ •* Auto Sales Search 

Owner 

ROTOLA CHAD 

ETAL 

2104 S 34 ST 

OMAHA NE 68105-0000 

Property Informatio n 

Key Number: 4119 0000 25 

Account Type: Residential 

Parcel Number: 2541190000 

Parcel Address: 2104 3 34 ST 

OMAHA NE 68105-0000 

Legal Description: WINDSOR PLACE LOT 68 BLOCK 0 N 10 FT LT 67 & ALL 60 X 133 

Value Informatio n 

Land Improvement Total 

2009 $7,100.00 $122,500.00 $129,600.00 

2008 $7,100.00 $122,500.00 $129,600.00 

2007 $7,100.00 $122,500.00 $129,600.00 

2006 $7,100.00 $112,200.00 $119,300.00 

2005 $7,100.00 $112,200.00 $119,300.00 

2004 $7,100.00 $112,200.00 $119,300.00 

Sales Informatio n 

Sales Date: 2002-02-26 

Deed Type: WD Book: 2210 Page: 35 

Price: $128,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.18 7980.0 1.0 133.0 60.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.coin/DouglasCoNe/static/accoimtinfo.jsp?accoiintno=R25... 9/17/2009 

imp.// w w w.uiiuii.uig/11 uiiiiiciiici/x-TivyiNi-^ou^icv/icaiiuii/ivicssagic i CAi.asp j 1 ci—^Kiioc u i o... - 10/\}l^\j\jy 
Douglas County Account ^^sTji^tion Page 2 of2 

Building 1 

-nn. J'""' 

miT 

TWO STORY 

7617 ; • • • 

ff4 Fbt»' , Sacood Floor 

9040SF 

y r ^ • 

CUCK T0^Et4LARGE IMA(3E 

CLICK TO tNl^KU t IMAGE 

Square Footage: 1972.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 8.0 

Exterior: Frame Shingle Units: 1.0 

Interior: Dryw/all Baths: ! 1.0 

Roof Cover: ' Composition Shingle Bedrooms: 4.0 

Roof Type: Gable Stories: 2.0 

Floorcover: Allowance Foundation: Block 

Sprinlder Square Footage: 0.0 

Year Built year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1895 0% 1895 114 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 1068.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 480.0 

Porch Open Slab 288.0 

Porch Slab w/Steps 35.0 

Porch Slab w/Steps 134.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R25... 9/17/2009 
Property ID #

Property 

Address:

Initial Contact:

Second Contact:

Final Contact:

Final Action:

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

CONTACT FORM 

 IftZ^' ? 

 ZI P M S 3 ^ S T 

 Date: Time: Action: 

 Date: Time: Action: 

 Date: Time: Action: 

 Transmit to EPA D Other Action: D 
Page 1 of2 

"> 

Create Another Ticket Back to Irth Internet I [, Send Email | 

• YOUR TICKET NUMBER IS 2380545. 

Original Call Date: 10/06/09 Time: 10:53 am Op: ELIZABETH18790 


Work to Begin Date: 10/08/09 Time: 11:30 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 2104 Street: S 34TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 28-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 


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 Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Number UtiUty Type 

Day: 4029340469 


CXCATV COX COMMUNICATIONS, INC HEIDI Alt: 4029340469 


Emerg: 4029329757 


Day: 8773668344 


LEVEL3 LEVEL3 COMMUNICATIONS, LLC NA Alt: 


Emerg: 8773668344 


Day: 4025047823 


MUD02 METROPOLITAN UTILrnES DISTRICT SANDY Alt: 


Emerg: 4025047970 


Day: 4024447197 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RON Alt: 4024445161 

Emerg: 4024445160 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 10/6/2009 
Page 2 of2 

0PPDGPR6 OMAHA PUBLIC POWER DISTRICT NA

Day:

 Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

QLNNEIF QWEST LOCAL NETWORK NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dlioii.org/irthiiiteniet/DHONNoticeCreatioii/Message'llxt.asp?ret=<RESULTS... 10/6/2009 
Page 1 of2 

Create Another Ticket Back to Irth Intemet • Send Eniail J 

YOUR TICKET NUMBER IS 2369051. 

Original Call Date: 9/21/09 Time: 3:42 pm Op: ELIZABETH18790 

Work to Begin Date: 9/23/09 Time: 4:15 pm 

State: NE County: DOUGLAS Place: OMAHA 

Address: 2104 Street: S 34TH ST 

Twp: 15N Rng: 13E Sect-Qtr: 28-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 


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 Tunneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Number Utility Type 

Day: 4029340469 

CXCATV COX COMMUNICATIONS, INC HEIDI Alt: 4029340469 

Emerg: 4029329757 

Day: 8773668344 

LEVEL3 LEVEL3 COMMUNICATIONS, LLC NA Alt: 

Emerg: 8773668344 

Day: 4025047823 

MUD02 METROPOLITAN UTILITIES DISTRICT SANDY Alt: 

Emerg: 4025047970 

Day: 4024447197 

OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RON Alt: 4024445161 

Emerg: 4024445160 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/21/2009 
Page 2 of2 

0PPDGPR6 OMAHA PUBLIC POWER DISTRICT NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

QLNNEIF QWEST LOCAL NETWORK NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/21/2009 
leroote ID: R page of 

s e : e776e2423. 0 r«k.x : 6776624213 . 

s^^^^^^ ^ 

£.e-fe. : 236905 X 

r^js s : 23.0 4 S 34fF H S.KP 

1X<3 : B. .n f ^afxnak.bi<»x% j^ae-^^rd-^l o dl l»a r blrx ^ ^x% ^ qtl X «s^r&b«Ka r bd-cilc^ b . 

r«>x» hM.ir«> at.xi3r ^n^^^'^'^^o*^ ^ r IpX^ai.^ ^ 4s^n'ts.eK.<3b X<«i-w«iX 3 • ^ Jlk.^^e» b >4eLrk«k9^Mmaixkb. ^P^ « 

> 0 —44 X —0223 . 
Lemote ID: R page of 

s« : 677662423.0 ITmL X z 87766242X X 

t i ^ ekx» Xsngp^arba^nb k4«k^^aiL9^ farcMnck XJO^T ^ X 3 Ci<jMUKta»,xa.S.<xsL'b.A.^x%^ < g^^anftuarXy lcrk^*#x» 4Bk^ 

L d^isaapd.3»4»<a. ^ n •fc.lik^ On.« C;M.XX C^xa,-feear •fc.d.olcei-b . 

£.»«:;: 2380S4 S 

k-fcy : ^^TJCmWS ^XaL<s^ : 

r«ks s i2X 0 4^ S- 3j|5P|HL^S^ 

SXJ3 : 

j^'V^ X 3 C^i«nKn.tax«.d.a«k-fcd.a»n.^ l^ak.^ rit^te.^armJ.x*^ dl ^-viar f flk.o*d.Xd.is.dL«»as CM-ar^ aX«»CM.aE' c»f -bl^ct 

lus^qarrt >>CBdl l»3r ar^'*^'^ ^xk ^ C;«LXX Cr^n'tecbar 'ted.^lc^-fe . XICJ-V^X 3 cr^MToncnan.dLcteL'fcd.^xk^ «#d.XX it 

ftCL-w^ 'bo Xc»c»aL-b.^ mLTxjf VLXXA^ as^az^VLTx^L xabiXiisd.^ ^ «L'fc -felid.^ d.ig ' ^d.-b.^ . X f jf^v i txeL-xn 

I«a^^ted.^x«is , ^X^«L^« i «»«»rk-feak«s'ts. Ti-rt-n—r>1 3 CTewnaxnaz^d.cteft.'fa.d.^x^^ etfc X — 80 0 — 4 4 X — 0 2 2 3 . 

>0—44X—022S. 

ai^^B:^^B^B ^ 
OLS#: 18207 1^ ^As-Built Drawing ^ Date Excavated: 10/7/09 

Date USEPA Signed Off: 3/4/10 

COASTA L Omaha Lead Superfund Site Area Sodden: 1080 sa ft 

< • * 1 • 

Name: Omaha Lead Site Date: North Arrow 

Address: _ 7^10^ Site Sketch Time: V.l ^ f.m, ^' m ^r- Phone: 

Team aii.i>/J.h)m//^^, BVID # Ig'?^' 7 XRF Code ^^02- . 

Sample Number Lead Concentration Confirmation Sample 

RVASCPJCA-l'^2Dl I'jYes a 

5, 7^ 7 

Legen d 

Concret Drip Zone Excavated e Quadrants Excavated 

Area replaced with Area replaced with 

Sod ' ' Rock/Mulch Area left bar e 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc . 
i 'Wi"^ 

^JfL. 

Name: _ Omaha Lead Site Date: lllf h North Arrow •— i 

Address: -JTggsjL^r-jyS ' Site Sketch Time: I. Z f f, ^ 

Phone: 

Team XRF Code ^"^Z-, 

Sample Number Lead Concentration Confirmation Sample 

/^I'^^' g ppm fives • No £3^'^ 

ftces n No O^ ' 

^ dlYes • No ra^ 

~—C*!.— ^-'^ ppm No ^^ ^ 

175^? ^ oom No O ^ 

6 % s • No n 

Yes n No • 

5, 7vjr 
• • 

U "1 l"1 

Name: •• • _ • ­ - - ­ - : -

Omaha Lead Site Date: North Arrow 

Address: _ ^/«7 f .^l 314 ^r - Site Sketch Time: 

Phone: i_. . ^ 

Team V^.ri.l>/Jjhj/H/ fi(^, BVID# \^zo i XRF Code ^'^Z­ , 

Sample Number Lead Concentration Confirmation Sample 

2 ky/6V>x 

^-/^•2£)7 

 ;ev^<z^x>^—/;?:zo^ -^M^JA pp;: 

PjYes a 

i. /vjr 
. . • 

» ' 

•'•'• ' •-•--- •

Name: Omaha Lead Site Date: nl^fld S North Arrow 

Address: _ Stte Sketch Time: \',Z^>1f,ih. ^lO f .?. :3i/Sr' 

Phone: 

Team ^/^);tlC>/^Ji-^J/H/ ^ BVID# \^Zo l XRF Code 'T'^yZ- , 

Sample Number Lead Concentration Confimiation Sample 

v-l^l0J_ 

~^i9:zin 

ftves

l^ s

 n

 n

 No Q ^ 

 No C3--" - 1%TD 

I'^TJi 

A.ll^'^J^/>m-l<K7n-l 

J(Yes

rt/Yes

iS-es

 Cl

 tn

 n

 No 13^ 

 No El ^ 

 No O ^ 

ppm ''S^es O No CD 

: ppm Yes • No • 

5. 7v 7 
\ 

COASTA I INVtRONH I HTAI 

' I »qo " C R O tl P IN C 

Consent for Accciss To Properly 

RIGHT OF ENTRY TO PREMISES 

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

Environmental Protection Agency (EPA) or its authorized representatives, collectively 

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

following described premises: 

DaytJme Phone: (l/C^y{/''^// ^ fftA 

Address of Property 

covered by this ^ / ^ :5 5/^^ 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 reasonable 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 
OW>«»4f 

COASTA L tNVfROHHfKTA l 

C R O U » IH C 

c Remove obstructions including boats, trailers, vehicles, playscape items, wo

piles, dog houses, etc; 

od 

< Remove flower bulbs or plants that the Grantor or the Grantor's tenant may w

to save; 

ish 

i Water and maintain replacement vegetation, including fertilizer application,

necessary' subsequent to an initial watering period by EPA; 

 as 

f Abide by health and safety guidance provided by EPA; 

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

the property to perform the work. 

to 

< Allow videotaping and/or photographing of the property. 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees nol 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 

11 grant access to my properties Q I do not grant access to my properties 

^-V.^-O' ^ 

Signature Date Signature Date 

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

Page 2 of2 
' -v ».,• 

COASTA L 

Restoratiicn Agreement 

The purpose ofthis agreemeni is to provide a mutual agreemem as to conditions ofthe propeny 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). 

i Property Address: Z//] ^ '5 3^5 T ~_\ 

I Owner 

Phoae: 

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 Videographic^ly document the existing conditions ofthe property and the basement if 

necessary. 

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

The lanoval. storacje, dispobal, and/or relym of these items is the Owner's responEibility ^_ 

- Item: 

3/)i4// jfiJ/iA^r^ 

i item: 

\ Item: 

Item: 

Items to be Removed by the Contractor During Remediation and Wot Replaced 

fltem: 

I Item: r- y 

\ Item: ' 

Item: 

Pagel of. 
^ r * » I 

COASTA L 

Items to Be Removed By Contractor Durinp Remediation and RgQJaced 

Item: ^ y y t 

^^U. ^ //^l^U ^ Af^ly/J^k /> ^ 

fltem: ^ ^ t 

\ 

• Kem: 

i t 

> . 1 -

Item: 

Landscape Inventory 

Item Quantity Unit Condition/Type/Species 

Pre-existing property area, Quadrants that will be excavated, that 

is covered with grass. m

­ Number of trees > 2 inch Each 

trunk diameter 0 ^ 

Number of trees <= 2 inch F.ar,ii 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Each Timers. Heads, etc. ^ 

>.ri'i>kiL' i li;\'.tii . 

Number of and size of b^ 

each garden/ flower bed Each 

area. Square Feet 

Ail;'.tl' •' -kticl i ui ri.':i;i\ c 

M^i-s iii'd loc;iiii>iiN 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

S ">i;l ( ill ' *«iii r »iil l I H 

>;.ic i ii : 1?'. U'. .- •;liii' ; 

. (Hn.;K - '<• • III :;• i"-;): ' ' s 

Easement Area, to be 

excavated Each 1

Page 2 of. 
r '4 » i 

C O A S 1 A I. 

Additional Comments / Instructions: ^ _. ^ , . 1 

\ je^^pfci tu/t/^jfn^ ^ fJ ^fJca^ (''^^^ '^^"^ 

y /U77Y PO Prfc>. T^ 0y^^ ^ 7)'^^ ' I 

Q Check the t)ox tf 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. 

1^ I agree Q I do not agree 

Owner's Signature Date Contractor's Signature 'Date 

Page 3 of 
# 

BVID # ^90l -

XRF PROPERTY SAMPLE SHEET 


Date io-'4-o'^ Address /^tfoH 5 ^(fSf " 

Proiect Omaha lead FP 2nd year option Sample time am/pm 

XRFID# l?rM>H^ sample length 30 sec 

Shot# Reading 

i;^^iH 

m R^ 4-\a< ^ IS^ -L 1^ 

^"^ -^in 

Average )t)^ ± / 3 

Shot# Readini 

A ^ ^ 

/V^ i /.? if /f?gf /

.i^32 /??Vi / 

Average }HB ^I S 

Shot# Reading 

Average 

Shot# Reading 

Average 

lab sample # Lab result 

Sample area Shot# Reading Sample area 

Bl ml I^ / ^ ^ ^ l>e 

_Depth Depth JRH3. Ma:f q-C^ /^^v ^k^J^ Tib I3L!L 

Average &^aL J Bs" 

Sample area Shot# Reading Sample area 

.^A 

Depth Depth 

i l l 

Average 

Sample area Shot# Reading Sample area 

Depth Depth 

Average 

RETEST AREAS 

Sample area Shot# Reading Sample area 

Depth Depth 

Average 

Sample area XRF Avg. 

Slaoatur^/>/!eJte< l 
m 

I'wA^ \ Omaha Lead Site—Fixed Price EP-R7-07-05 

I ^^^^ ^ o Coastal Environmental Group inc. 

\7^^c P www.coa8taihazmat.com 

'"t-ntT^ COASTA L 

INVIiONHIIITAl G • 0 U r, IH C 

EXECUTIVE SUMMARY: 

BVID #18207-(2104 S 34 ST) 

No Issues or Concerns ]~\ Issues/Concerns 

Detail Explanation: 

-DAN BAHNKE WALKED THE PROPERTY AND SIGNED OFF ON 3/4/10 
# 

EPA Property Close Out Form 

Proptrty #: \^0 ^ .r 

Property Addrcsai-j^.•' • • > ^ i 

Datc/Tlme Owner's Name: .^^^y^r.bUL K: ^ ^ 

Quads Excavattd; ^ \ p? . Contractor Croap^OQIj^n 

Yes No Excavation General 

1. If necessaiy, were the correct quadrantCs) excavated and restored? o­ 2. If necessary, were the correct areas oFdrip zone excavaied aod restored? 

[7 ^ 

Grsdin Yes No g Sod and VmetettoB 

I. Does (he grading around the perimner ofthe house in excavaied areas generally slope away U ^ fix>m tbe house? 

^^ 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 (imt and evenly graded? { 7 

5. Are the joints between the sod strips generally tight? (Only evaluate if inspected at a 30 day 

time period) 

6. Was the property graded such that water will not pool on the property^ L y 

r ?. Was dBRiige to landscaping or plant materials avoided? 

Gates. Fences and Rematng Walls Yes No 

I 1. Do gates open and cloiie fteely? (Ifapplicable) y 

2. Were all gates or fences taken down during restoration activities reinsulled? (If applicable) K 7 

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

4. Was damage to reiabiing walls avoided? (If applicable) ( ^ ' 

Foundatiott, Sidtng and GaMers 

Yes No 

t. Was damage to the siding or trim avoided? l y ' 

2. Was damage to Ihe foundation avoided? K 7 

Was damage to windows avoided? t x ' 

4 Was damage to windows or door screens avoided? y 

5. Was damage to downspouts or downspout extensions avoided? 

Sidewalks and DrKeways (Concrete) 

Vcs No 

1. Was damage to driveway surfaces avoided? y 

2, Wai damage to walkway surfaces avoided? -z.' 
I 

Ort'Ders comments: 

ninspection notes: 

Removal and restoration activates complele including the 30-day sod warrmiry: 

EPA Representative Li^Tn jj/yXxA ^ Duleij^A^Oj/ ^ 
} 

Property Completion Agreement 

I Ins agreemem documenls the completion ot remedial activities perloimed on my properly My signature 

will designate that I am satisfied with the restoralion of my propeily, and thai no Hems are in questions 

now, or al any lime m the future, except ihose ilems listed below, ifany 

Property rP: |^2.Q l 

Property Addrcv?: j-lQ U S ) ^S M '^ . 

o-"'^' V>rY) ^ V-drA\C \ 

Phone • {^aQ m\-fs\\^ 

Restoration Items in Question: 

item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Cornmcnts: 

[_l I i^rct K I c.ttorjilion t.< comptcltd, except as noteri 

[ I I rio nol »\^rt.e restoration is compleled 

hAuf^^Ji^ 7^Ui ^^CftT^ /Wy ^ 

0>vnr>'!t Sic'"»ti»ie Dntc i ( C.wtn acTor's Signsilurc Dnfc