TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: ^//^ f Date: J^jll/c^ 

Address: ^3 / PdcJ^C ^ 

Remediation Contractor: _Coastal Environmental Group_ Year: _2007_ 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

EPA-provided property sketch 

Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adjacent property 

5/ Restoration Agreement 

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

!¥ Confiimationjdata 

m Photographs • 

E^ As-built sketch 

B^ Satisfactory restoration signed by Property Owner 

^ Property close-out check list signed by EPA 

D Description ofareas not meeting ROD cleanup criteria 

D Utility clearances 

D Property information from Douglas County Assessor's Office 

D 

D , 

D 

rP£L/^^^^^^ft<:^J^i:^^ iignatur( 

Supe rfund 
Final Report Property Check List (piease place with each tiie) ^^L 

Hard Copy Information J^^ l fAll/\'^ 

-<^ropert y Check List ^ ^ ^ J) 

,y^S!^S'\te Working Drawing Map 

-rr ^ EPA originals Map 

4. Douglas County Assessor's Map 

^• ^ Property Contact Sheet 

Agreement 

.(^^d'T^^ccss Agreement 

'^Restoration Agreement 

Misceilaneous Documents 

J„-Firnal Map from the Field 

^ 2. Change Orders 

V ^'^RFDat a 

V \ ^ 4. Any ernails or PO correspondences 

Property Completion 

1. Executive Summary 

2. AS BUILT 

...^Property Completion Agreement i 

>^>\^4. Any buyout info or reimbursement info i 

^Cx^S. Check or money order copies 

^ -^^x^EPA Property Close Out Form 

/f. Attached Begin Video 

Electroni c Documentatio n 

Drawings 

^ . EPA original 

X,^^ Working Drawing 

3. AS Built.vso 

K

I 

4. AS Built.jpg 

Photos 

Begin Photos 

During/Excavation Photos 

Sod Photos 

30-Day Sod Photos 

Scanned Documents 

Final Documents 

2. Executive Suinmary 

Videos 

Begin Video 

2 My Movie 
m 

Property Access Checklist 

Property ID: .2J I

Propertv Address:

 8 *? 

2-45 1 Po^O('-fl' C

n

 D

 WORK STARTED 

WORK COMPELTED

ON: 

ON:

: / 

_/

/

 /_ 

/ 

Owner: RobeLCJ" {^CcxJ e

.Address: 9

Phone: 7l4--f,{2 % 

Fav: 

Cell/Pa"cr: 

Renter: 

Phone: 

Fax: 

Cell/Pajicr: 

.Additional Information: 

CH

I s

j S ^

n

CH

CD

B

I S

n

n

i D

cn

n

 Notification Letter 

.Access .Agreement 

Restoraficm .Agreement 

Topsoil Samplini: (if applic Jble) 

Disposal Samplinj; (If applicahle) 

Garden Samplin" (if applicable) 

Utility Clearance 

Video/Photos (Before) 

Video/Photos (During) 

Video/Photos (After) 

Video/Photos (30-Da>) 

Property Completion Agreement 

Final Report 

.Sent: / / 

Sisned: Y / S 1 / 0 7 

Siiined: 7_/3J/0 7 

/ ,' 

/ / 

/ / 

Called: & / \ ;0 7 

On: / / 

On: / / 

On: / / 

On: / / 

Signed: / / 

Issued: / / 

Bv: 

By: 

By: 

By: 

By: 

By: 

By. 

By 

By 

By 

By: 

By 

By 

1 

1 

1 

1 

-Air Monitorin<;(as applicable) 

CH Comnuinity CH Crew 

Results: 

On: / / ! Bv: 1 • 1 

CH Community

Results:

 O Cre» On: / / By: 

li 

CH Community

Results: 

CH Crew On: / / By: 

Omaha Lead Site 
1 

1.0 % 5^^70 

^ ^ [ N W ^ 0 r ^ A"^^ Total Quj^Bt Square Footage to be Excavated = 2056 

Property Classification: £ 00 ^^ r ^ Total^ff Zone Linear Footaqe to be Excavated = 0 

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Legend 

NorthArrow Omaha Lead Site 

OmafTa, Nebraslo gO ^ Concrete 

\/ A Excavated Area 

Property Number N OLS-21189 m m Existing Structure Scale 

• • • Fence Property Address 

Inch = 20 feet or 1 grid = 5 x 5 ft 

^^• ^ Permanent Landscaping 

2431 PACIFIC ST 

Uuaarant Bounaary Post Excavation Concentrations (ppm) 

- Street Boundary ; O V HG L F1 B2 Play Are a M7')rr)(M-:.UK;ir |r> /X

 1 1 i ^ i z_ F2 DZ Easemer It 1 ree/C3 \-r < * • ^'^Prri ^ 

B1 Gar den_ Ottie r 

Description of post excavation areas Fl, front yard left-hand quadrant; F2, front yard ri(^t-hand quadrant; Bl, backyard left-hand quadrant; B2. backyard right-h^d quadrant, 

DZ, dnp zone (1 -3 foot area of soil around ttie foundation of the house). 
LD+ 21.189 . 

Omaha Lead Site Exterior Painl North Arrow Owner Name: ROBERT L KARGLE 

Address: 2431 PACIFIC ST 

Phone: H: 402-714-0466

Sample Number 

RYASCPXA-21189 Fl 

-P^DCCrXA-21109 F2 

RYCSCPXA-21189 B1 

RYDSCPXA-21189 B2 

WBZsepy^ 21180—B Z 

Lab RYDSCPLA-21189 

Result 902 ppm 

Site Sketch 

 W: 

Lead Sample 

Concentration Collected 

ppm 

ppm u 

ppm Q^ 

ppm D 

ppm D 

ppm D 

ppm D 

Number of Samples = j Z 

^ .^ ^ ^

trlC^r> 

[ 

2^31 

- ^ 

.ei. 

wo^ \K 

?^ Ol ft. 

LAB 

D 

D 

n, 

ET 

n 

n 

n 

 ^!­

;t 

-ziB 

rt. 

• Good 

• Poor 

Q Not paint I

Samples Collected 

Firm: rC>^Pf>/J-& 

Date: 07-6fe ~Q ^ 

Time: 2-i W 

Samples Analyzed 

XRF Unit: ^ ^ Book: S o 

Date: iJ/^lo^ 

Time: f M 

Staff: PAJ 

ENTERED 

JUL 1$ii««4 

 '—/ V • • • X 

•>: 

57/ 

> : 

^ —^ \ 

Omaha Lead Site 46130 
1 

CONTACT FORM 

Property ID # 

Property 

Address: 

Initial Contact: 

Second Contact: 

Final Contact: 

Final Action: 

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

:Z1I^1 

2431 

Date: 

Date: 

Date: 

Transmit to 

p^ct-Pi'o 

Time: 

Time: 

Time: 

EPAD 

Action: 

Action: 

Action: 

Other Action: D 
.'<^'^°"''^. . - » 

COASTA L ENVIRONMENTA L 

GROUP . INC . 

Consent For Access To Property 

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: 

Owner's Name: ^^^ 4 YMMU C Daytime Phone: ^ / ^/ ' ^ I 2 S 

Address of Property 

covered by this z-^Z} T^Pto 

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 
- » 

COASTA L • V . -^' ^ [NVmONHENTAL 

C R 0 U r . INC . 

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

piles, dog houses, etc; 

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; 

Abide by health and safety guidance provided by EPA; 

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

property to perform the work. 

Allow videotaping and/or photographing ofthe 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 (877) 234-6270. 

[3lgI gran r t access to my properties D i do not grant access to my properties 

Signature Date 

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

Page 2 of 2 
COASTA L ENVIRONMENTA L 

GROUP , INC . 

Consent For Access To Property 

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: 

Owner's Name: iJ ^ tCjil\QC Daytime Phone: 

\iSi7l7^1 ^ 

^^5^ ^ Ti£^iLX^ -r- -^ ^ T-^ 2l3/PA64no 

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 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 
iM. COASTA L ENVIRONMENTA L 

GROUP . INC . 

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

piles, dog houses, etc; 

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; 

Abide by health and safety guidance provided by EPA; 

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

property to perform the work. 

Allow videotaping and/or photographing ofthe 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 (877) 234-6270. 

Efl grant access to my properties D I do not grant access to my properties 

0U^J2. Qinnotiir a ^ • Signature TBat^ Signature Date 

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

Page 2 of 2 
m 

Restoration Agreement 

The purpose of this agreement is to pro\ ide a mutual agreement as to conditions of property' prior to 

remediation activities. This will also serve as decontamination 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 ID: '^^7 

Property Address: ^^5 / f^c/fY ^ ^T ^ 

Owner: ^o^^jr r ^^A<j^/j ^ 

Phone: 

y/4/- // ^ 

On the attached diagram(s) indicate area(s) to excavated and depth of excavation, location of all known 

utilities, subsurface features, surface structures and landscaping features, access location(s) to be used by 

contractor, and the direction of North. Indicate distances, depths, material tvpes, etc. Indicate digital photos 

by referencing the photo-log number with an arrow indicating direction of view. 

Items TO Be Removed By Owner Before Start Of Remediation: 

(Use additional sheets as necessary) 

The removal, storage, disposal, and/or return of these items Is the Owner's responsibility. 

Item: , . 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 
•..(0> 

Item s To Be Remove d By Contractor During Remediation An d Net Replaced 

(Use additional sheets as necessary) 

Item: 

f ^ ^J^ 'Cfoe 

Item: 

Item: 

Item: 

Item: 

Iten: 

I'o — • 

I*- . 

IteT.: 

Item: 

Item: 

Item; 

Item: 

Item: 

Item: 

Page 2 of. 
Items To Be Removed By Contracto r Durin g Remediation An d Replaced 

(Use additional sheets as necessary) 

Item: 5^^ 

Item: 

Item: ^ _ 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 of 
& > 

Item 

Landscape Inventory 

(Use additional sheets as necessary) 

Quantity Unit Condition/Type/Species 

Pre-e\isting propeny area 

llu: is co\ered wiih sirass. 5( SqLiare feet 

N,.r:ber ;.'. :rec5 • 

:-:-k .:::i:::c:c' 

N_:'-.r=r 

Nur!iber ct" Sprinkler 

Zones. Coniro' \'alves. 

Tin-.ers. H^aJs. e:j. 

Anach a skeich ct" ;he 

sprinkler layout. 

1 

NLRiber of and size of 

each garden fics^er bed 

area. 

.Attach a sketch cf relative 

sizes and locations. 

Each 

Square Feet 

Page 4 of 
Item Quantity Unit Condition/Type/Species 

Agreed upon value of plant 

materials not to be 

replaced bv contractor. 

Note this value will be 

used to issue a plant 

voucher to the property 

owner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. Each 

Include a sketch of were 

each plant will be placed 

bv the contractor. 

.Agreed upon area cf 

propeny to be replaced 

uith grass sod. tO>S^ SF 

Include a sketch of the 

area(s) to be replaced \\ith 

srass sod. 

Area of Cit\ or County 

properry to be landscaped 

per their requirements. SF 

Include a sketch of the 

area (s) 

Page 5 of. 
Additional Comments / Instructions: 

I I 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. 

[ / l I agree Q I do not agree I I I agree I I 1 do not agree 

-y^^^^-iU^^^ y^^jc^c^.-^ 7-^/'6 y 

^ /^ Date P*gc 6 of ctor's Signature Dale ^ 
PROPERTY CLEARANCE WORKSHEET 

^?i=5 

Date Property ID "61^10^ JTH?^ 

Property Project Omaha Lead — Fixed Price §^&l Address ^ 

l^easurement XRF ID 0107-51 

Count/Time 

Field Shots 

Sample Area S^ot # Reading Sample Area Shot # Reading 

ao? M:.i Ai q^'Lf 

Sample Area /:^i <i-0'' 

I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Anaiytical 

Readinq Average (Dried & Spilt Sent Number Results (Bag) Sieved) -> (Bag) 

i / J - 13? 

XRF Corrected Value —> 

(use calibration chart or add 

20% to value) 

n^ 

Sample Area Pass/Fai l ? 

In Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical 

Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Baq) Sieved) 7 

2 

3 

4 

XRF Corrected Value - > 

5 (use calibration chart or add 

20% to ualue) 

Sample Area Pass/Fai l ? 

I n Situ Composite Composite Analytical 

Aliquot Composite Readings Lab Analytical Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Baq) Sieved) 7 

2 

3 

4 

XRF Corrected Value - > 

5 (use calibration chart or add 

20% to value) 

Sample Area Pass/Fai l ? 

I n Situ Composite Composite Analytical Aliquot Composite Readings Lab Analytical Readinq Average (Dried & Spilt Sent (Bag) Number Results 1 (Baq) Sieved) 7 

2 

3 

4 

XRF Corrected Value —> 

5 (use calibration chart or add 

20% to value) 

Sample Area Pass/Fail ? 

Aliquo I n Situ Composite Composite Analytical t Readinq Composite Readings Lab Analytical Average (Dried & Spilt Sent (Bag) 

(Baq) Sieved) ? 

2 

3 

4 

XRF Corrected Value —> 

1 Number Results 

5 (use calibration chart or add 

20% to value) 

llSf AlfOttlONAl iHH/ V // 

XRF Technician's Siq "iture _^^Z^ij2 ^ ns^_ HfFDH) 
i:* l?)5^^7p 

Total Qi^^B t Square Footage to be Excavated = 205i 

Property Classification: 800 Tota^TO Zone Linear Footaqe to be Excavated = 0 

t .• ! 

I \ ! ! 

11 KZ"? -: 3;T 

-, ^ < ^ ^ ?Pc<iTL/.Ai 

"TSr-/^/ 6 

^ ' 

.6^^ 

^^^"^ 

K-h- : 

Pacific Street 

^r^ 5 ; , i 

Leo|end Omaha Lead Site P^-i j Concrete Omaha, Nebraska 

(/ ^ Excavated Area Property Number N 1^ 1 Existing Structure OLS- 21189 Scale •—•— • Fence Property Address 1 Inch = 20 feet or 1 grid = 5 x 5 ft 

^^[ ^ Permanent Landscaping 2431 PACIFIC ST 

— — — Cjuadrant Boundary Post Excavation Concentrations (ppm) 

Street Boundary A > HGL 82 PlayArea 

DZ Easement Vp,.y Garden Other (Q ) Tree'Shrub 

Oesaouon ol poa a«c»aion areas F1 front yard leOJiand quadrant; F2. »onl yard ni^t-hwid quadrant. Bl, bsayard IsH-hand quadrant. B2. backyard nghihsna quaarant DZ. dtp zone it ] (DO area of sol around Ihe foundation of lha house) 

.4 
/\X|^ \ Omaha Lead Site—Fixed Price EP-R7-07-05 

I ^^^7° Coastal Environmental Group Inc. 

XT^^TP * www.coastalhazmat.com 

%PBoi* ^ COASTA L ENVIRONMENTAL 

C R O U f . INC . 

EXECUTIVE SUMMARY: 

21189—2431 PACIFIC ST 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 
As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

1t)(al Quadrant Stfiar? Foobge In be Enavaled - 2056 

Piqierty OMgHiealKin: aoo TMal DUp Zone unear Fcolaiie to tie Eiccayalea - 0 

All access point grade and sod. 

Take down hump backfill but 

do not re-sod. Leave rose bush I 

Pacific Stneet 

NorthArrow ^ ^ c«:Ql^#: 21189 

r~i Date-Excavated: 8/29/07 

lite USEPA Signed Off: 9/6/07 

sca» 

• •—• 11nch - 2D Teet or 19 H - 5 X 5 tt 

P^ ^ Peimonent LjBntfscvtqi 

— — — Quadrsnt SowwMry 

S*velS<»id«y vb; T HG L 

wrj C- j •=• iiii.-^vrt.--i.- I.--­ ltce<3>ifiib o I, •• 1 - - — : = 

»«r|ii«iiira m i im i Pl.MntiMl i «!»«—*P3.mniHW<»tliaim CO. « p MM <«.t laaana c«<l*MDwM'M«u<M 

Legen d 

Oinalia Lead Site 

Omalia, NeDra&ta 

Property Nur*er 

OLS-21189 

F¥Gpefty Adck«ss 

2*31 PAaRC ST 

Ptist Excavatnn Concentrations (ppm) 

Fl B2 PlayArea 

F2 DZ Easenterrt 

Bl Gamefi OSter 

Area not Excavated j Dripzone Excavated Quadrants Excavated 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group Inc , 
^P A Property Close Out F^r a 

Property #; -.^zm. Property Address: ^ Y V T^/f/ C 

Datc/Tlmc: Owner's Name: ^e^^i^ f 7^4*:^^t i 

Quads Excavated: Contractor Croup 

Eicavatioa Genenl Yes No 

1. If necessary, were the correct quadrant(s) excavated and restored? l ^ 

2. If necessify, were the correct areas of drip zone excavated and restored? t ^ 

Grading Sod and VcccUtioB Yes No 

1. Does the pading around the perimeter ofthe house in cxca\ ated areas generally slope away 

from the house? • " 

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

3. Does the sod appear to be generally healthy and grow ing? (Onlv evaluate if inspected at a 30 

day time period) 

4. .\re sodded areas gcnerallv firm and evenly graded? ^ / 

5. Are the joints between the sod strips generally tight? (Only ev aloate if inspected at 12-0 day 

time period) 

6. Was the property graded such that w ater v» ill not pool on the propeT) ? 1 ^

". Was damage to landscaping or pta.nt -aterials a\ oided'? t ^ 

Gmcv Fences aoc ReUiniDf naiis \es No 

'.. Do gates open and close freely':' ('.f applicable) 

^ 

2. Were all gates or fences taken down during restoration activ ities reinsialled? ^ If applicable) ^ / 

3. Was damage to gates or fences avoided? 'Ifapplicable) t ^ 

1 i -..

 Was damage tc retaining »• alls avoided? (Ifapplicable) 1 i ^ 

Foundation, Sidiof and Gutters Ves Nc 

1. Was damage tc the siding or trim avoided? 

L ^ 1 

2. wi s damagi to the foundation avoided? t^ ' 

3. Was damage to v^ indows avoided'' A 1 

4 Aas damage to windows or door screens avoided? t^^ 

1 

5, Was damage to downspouts or downspout extensions Evoided? 

4 ^ i 

Sidewalks and Driveways (Concrete) 

Yes No 

1. Was damage to drivcv^ay surfaces avoided'^ iJA; 

2. Was daraage to waDcv.ay surfaces avoided? j^J/^ 
Ic?pect!cn Ectes 

(jJcU-c^ i^liras^Jor Sd<L ^ -^^ 4 acces s -j^rui^^L AG^^U^/A, J 

Remc\al and restoration acti\ates comr'ete includine the 30-da\' sod '>^•arran^ 

EP.A Representativ Date ^ - t^ -( 0 7 
Property Completion Agreement 

This agreement documents the completion of remedial activities performed on my property. My signature 

will designate that 1 am satisfied with the restoration of my property, and that no items are in questions, 

now, or at any time in the future, except those items listed below, if any. 

Property ID: 7///-^ 

Property Addresi: 2^^ / ^C/F/ 2 

Owner: /^py^f^ r 7^4/e^6 e 

Phone: 7/ ^ tJ^9 ^ 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

[Zfi^[ agre . e restoration is completed, except as noted 

I I do not agree restoration is completed 

Mt?(u^70 C7^^^^^ ^ '=}'^-0 7 ^^^> ^ ^/~^.:^S>^ T7<7O ^ 

Ovvner' Dat Date Contractor's Signature 'Dafe s Signature / (y t 

I