## TRANSMITTA Lof OMAH ALEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R 

# (n^ ^ SAI D # : 

## Date : ^ / ^ / ^< ^ U Address : /. t H ^M^!>U ^ )>U ^ Remediatio nContractor : Coasta l Environmenta l Group
_ Year ; 200 1 • ^ 

### SOI LREMEDIATIO N PROPERT YnLEFOLDE RDOCUMENT S Vide o o f property (DVD ) Executiv e Summar y EPA-providedproperty sketch 

## i / SignedAcces s Agreement fo r subject propert y SignedAcces s Agreement(s ) fo r adjacen t propert y Restoratio nAgreement Settlemen t document s (i.e. , fo r damag e o r t

o replac e plants , etc. ) Confinnatio ndata. 

## Photograph s b<CfiwAi\<f M r mhccto/fii'do^ As-built sketch Satisfactor y restoratio nsignedby Propert y Owner Propert y close-out check lis t signedby EP A -& - 

### Descriptio nofarea s not meetin g RO D cleanup criteri a 

# y Utilit y clearance s Propert y infojmflTia nfro mDougla s Couniy Assessor " s Office ^



### 3021787 5 Superfun d

# ^ v Propert y Acces s Checklis t Property ID : . -^ ^ ^ p ^ Property Address : 2 Zj ql^fiA-yn/y ^ t^wT n n WORK STARTE D WORKCOMPELTE D ON : __/__ / ON : __/__/
_ 

## O^-'^'-'^Oy^f>>k
. py^.r/iW^^A- h Address : '• '
Phone^llQ^ ) ^U^iS^^-lQ] ^ 

## 1 Fax :



## ''^'^•-(U!V^'SOM^l\\ , Renter : Phone : Fax : Cell/Pager : Additional Information :

D NotificationLette r ^ Acces s Agreement I s Restoratio nAgreement 1 D Topsoil Samplin g (if applicable ) D Disposa l Samplin g (if applicable ) D Garde nSamplin g (if applicable ) \y[ ^ utilit y Clearanc e

D Video/Photo s (Before) D Video/Photo s Paring ) D Video/Photo s (After) nVideo/Photo s (30-Day ) 1 nf ^ Property Completio nAgreement D FinalRepor t Sent : / / Siened : / / Siened : / / / / / / 

### \J_IILI(2L CaUed : / / On : / / On : / / On : / / On : / / Sienedl2

- il l lO ^ Issued : / / 

## By : By : By : By : By : 

## ^y-nj/^lr ^ By : By : By : By : By : By : By : 

## iiVL'izI z 1

Ai r Monitorin g (a s applicable ) nCommunit y Q Cre w Results : On : / / 

## By : 1
1 IZ ICommunit y Results : JZ i Cre w On : / / By :

• Communit y Results : Q Cre w On : / / By :

Omah a Lea d Sit e

## Douglas Count y Accoun t Infya|^o n Page 1 of 2 aaa^ c Dougla s County , Nebrask a Propert yRecor d - R240308000 0 Prin t Repor t NE WFeatur e - Parce l Dimension s availabl e ( ^ scal e 0-5 0 ft wes t o f52n d S t - VlOWO n Ma p Informatio 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 BURGHARD TANNETT E M ETA L 221 4 HANSCOI ^ BLV D OI^AH AN E 68105-000 0 Propert yInformatio n Ke yNumber : 030 8 OOO O 2 4 Accoun t Type : Residentia l Parce l Number : 240308000 0 Parce l Address : 2214HANSCOI^B D OI^AHAN E 68105-000 0 Lega l Description : VIRGINI APLAC E LO T4 BLOC K2 S 6 F TL T3 & AL L5 6 X12 7 Valu e Informatio n Lan d /mprovemen f Tota l 200 9 $6,700.0 0 $137,600.0 0 $144,300.0 0 200 8 $6,700.0 0 $137,600.0 0 $144,300.0 0 200 7 $6,700.0 0 $137,600.0 0 $144,300.0 0 200 6 $6,700.0 0 $102,500.0 0 $109,200.0 0 200 5 $6,700.0 0 $102,500.0 0 $109,200.0 0 200 4 $6,700.0 0 $102,500.0 0 $109,200.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 6 7112. 0 1. 0 127. 0 56. 0 N o Impro t vemen Informatio n Buildin g 1



## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2..
. 10/17/2009^X^l l 

### Dougla s County Accoun t InfcgiMtio n Pag e 2 of 2

2 1/ 2 Stor yFi n Blrt*r t 8t«i < 8 f l

Firs t Ftoo r Secon d Floo r .j:-, ; 96 8 0sq.ft
. " " ThMFl«« f 4: s r> o T

TiT r=|l :

CLIC KT O ENLARG E IMAG E CLIC KT O ENLARG E IMAG E Squar e Footage : 2323. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Fai r

Buil t As : 2 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 7. 0 Exterior : Fram e Aluminu m Units : 1. 0 Interior : Drywal l Baths : 1. 5 Roo fCover : Slat e Bedrooms : 4. 0

Roo fType : Gabl e Stories : 2. 5 Floorcover : Allowanc e Foundation : ; Biocl < Sprinkle rSquar e Footage : 0. 0 Yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 191 5 196 0 0 % 191 5 9 4 Detai l Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 f t 962. 0 Fixtur e Additiona l Fixture s 1. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Fixtur e Bat h Hal f 1. 0 Garag e Detache d 320. 0 Porc h En d Scree n 128. 0 Porc h Sla b Roo fCei l 24. 0 Porc h Sla b Roo fCei l 74. 0 Use r Atti cFul l Finis h 360. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2..
. 10/17/200 9" > 

### Pag e 1 of 2

Creat e Anothe rTicke t Bac k t o Irti i Interne t SendEmai j i ] 

# ] E _ J
YOU RTICKE T NUMBE RI S 2413595
. Origina l Cal l Date : 11/26/0 9 Time : 2:5 2 pm Op : ELIZABETH1879 0 Wor k t o Begi n Date : 12/02/0 9 Time : 7:1 5 a m State : N E County : DOUGLAS Place : OMAH A Address : 221 4 Street : HANSCOM BLV D Twp : 15 NRng : 13 E Sect-Qtr : 28-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : lead remediatio n Locatio n o f Work : LOCAT E ENTIR E PROPERTY , AL L EASEMENT S AND T O TH E PEDESTA L Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABETH Phone : (877)662-421 0 Wor k Being Don e For : coasta l Dept ho f Excavation : 4 f t Come r Lot : N Front : Y Rear : Involve s Turmeling o r Horizonta l Boring : N Explosives : N CXCAT V LEVEL 3 MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F
Servic e Are a Contac t UtiUty Typ e 

### Phon e Numbe r Day : 402934046 9 CXCAT V CO XCOMMUNICATIONS , IN C HEID I 

### Alt : 402934046 9 Emerg : 402932975 7 Day : 877366834 4 LEVEL S LEVEL S COMMUNICATIONS , LL C 

### N A Alt : Emerg : 877366834 4 Day : 402504782 3 MUD0 2 METROPOLITA NUTILFTIE S DISTRIC TSAND Y 

### Alt : Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCIT YO FOMAHA-TRAFFICSEWE RRICH/TRAFFI C Alt : 402444516 1 

### Emerg : 402444516 0

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT.
. . 11/26/200 9

## Page 2 of 2

0PPDGPR 6 OMAH APUBLI C POWE RDISTRIC TN A 

## Day : 406728934 3 Alt : 4062071494 Emerg : 888728934 3
QLNNEI FQWES TLOCALNETWOR K 

### N A 

## Day : 406728934 3 Alt : 4062071494 Emerg : 888728934 3

http://vmw.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT..
. 11/26/2009OLS# : 1789 8 

# As-Buil t Drawin g Dat e Excavated:11/30/0 9 Dat e USEP ASione d Off : 12/22/0 9 C OASTA L 

# Omah aLea dSuperfun dSit e Are a Sodden : 266 4 s o f t

Name : ?>.-^^K;.^l,,4 ' Address ; -PCll ^ 14-.^^^ ^ Phone : R'^tr - Oo-) < $/,,-. ( Omah a Lea d Sit e Sit e Sketc h Date : Time : 5?/f/c ^ 3 ]'^''3 0 Nort h Arro w

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—/7g^ ^ ) ^g"f< r Lea d Concentratio n ppm ppm ppm pp m pp m ppm pp m XR F Code "5^0 1 Confinnatio n Sampl e < Yes ° ^;Ye s • ^ xYes 1 ^ '^- > Yes C D T5zYe s D < $ Ye s • Ye s • N o ^ N o [2 1 N o p ; N o P ; N o C 3 N o ca N o • 

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# m Quadrant s Excavate d Are areplace d So d wit h Are areplace dwit h Rock/Mulc h Are alef t bar e Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc
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. COASTA l IHVIXONKIHIA l CROUP

. IH C 

## Consen t fo rAcces s T o Propert 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 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 :

Owner' s Name : Daytim e Phone :

Addres s o fPropert y covere d b ythi s 

## Z^\^ ( M<>ti05coi ^ Ppi^\/9 ^ 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 ) 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 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 < 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 from 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 time s 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 effec t unti l th e wori t ha s bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :

Pag e 1 of2\^^0^' f COASTA L •/ ; . ^ tItVINOHHIKTA t ^ < «10< * C •D U > I KC 

### ( Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; G Remov 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 ; t 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 ; c

Abid 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
. < tAllo 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 wort< 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

Qlkgran t acces s t o mypropertie s D I d o no t gran t access t o mypropertie s 

# ^... ^ /rrvlf^if^^// ' ///r9/ ^ 9 SignatureDate Signatur e ( J Date ~

D I woul d lik e t o b e presen t durin g an ysamplin g tha t i s required
.

Page 2 of 2COASTA L c« e u r-M r 

## Restoratio n Agreemert t Th e purpos e ofthi s agreemen t i s t o provid e B mutua 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 nofth e property owne r an dth e Unite dState s Environmenta l Protectio nAgenc y (EPA)
.

PropertylD : |~fg^ ^ • Propert y Address : £j2>t ^ /^..^-g^^icv nl^Ll/ Q Owner : ;^'iiJF-7T C ( ^ Ur^ 6 W/t^^D T 

### Phone : [^[Qr^^^Lli ^
. ^^jC^ H {.Hp ? ) V^ O • H^ \t( G C O nth e attache ddiagram(s ) indicat e area(s ) t o excavate , surfac e structure s an dlandscapin g feature s and acces s Iocation(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 db y th e Owner before Star t o

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. ttem: 

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

# Pl, M i s covere dwh hgrass . Numbe r o f tree s > 2 inc h Eac h trun k diamete r 

# I
Numbe r o f tree s < = 2 inc h Eac h trun k diamete r ^ Numbe r o f Sprinkle r Zones , Contro l Valves , Eac h Timers , Heads , etc . Aiiat h ! i sktfic h o l tlitf ­ '•pripklo i linini i Numbe r o f an dsiz e o f eac hgarden / flowe r be d Eac h area . Squar e Fee t Aili\t h ; i skcic h 1) 1 rclativi. ' >i/i' S nn d loc;Mi('iis
. Agree dupo nvalu e o f plan t material s no t t o b e replace db v contractor . N'OK - IM ' \HIII C «II I n t usi' C U) isiu i
. 1 filaii i ^o^K•>ll.• : I d lh e |irii))Ci"l \ 0 " ner . Easemen t Area , t o b e 

# Ve 4 Eac h excavate d 

### hei^Nuipy^ f\g3c.^(H > ^ / Pag e 2 of
.f f C O AS 1 AL O ft O U ' , •N C
fAdditiona l Comment s / Instructions : 

# c^kL^ u ?< D 2- 3 Dc^ ^ lMtJuAiA}Cj: ^

^Chec k th e bo xi fOwne 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 thi s bo xCE G I s no t responsibl e fo ran ydamag e don e t o th e Interio ro fhouse , includin g foundatio n crack s o rfissures
.

I agre e r~j l d o no t agre e

Dat e Contractor' s Signatur rDat e Pag e 3 o f7

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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 123.00 8 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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# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1 

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 14 6 Mod e SOI L Tim e 2009-12-0 4 09:3 7 Duratio n 30.8 7 Sequenc e Fina l Flag s BVI D 1789 8 ADDRES S 221 4 hansco m blv d QUADRAN T e m DEPH T 1 " XR F TEC H R
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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 fVerificatio n XL3t-3902 2 Readin g N o 14 7 Mod e SOI L Tim e 2009-12-0 4 09:3 8 Duratio n 30.5 5 Sequenc e Fina l Flag s BVI D 1789 8 ADDRES S 221 4 hansco m blv d QUADRAN T e m DEPH T 1 " XR F TEC H R
. VENTR Y MIS C clearenc e NOT E ngn c

pp m Erro r P b < LO D 11.85 7 Supervise d By :

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

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 14 8 Mod e SOI L Tim e 2009-12-0 4 09:3 8 Duratio n 30.5 5 Sequenc e Fina l Flag s BVI D 1789 8 ADDRES S 221 4 hansco m blv d QUADRAN T e m DEPH T 1 " XR F TEC H R
. VENTR Y MIS C clearenc e NOT E ngn c

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## iysA^ \ Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 I ^^^ Z ° Coasta l Environmenta l Grou p Inc
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wvvw.coastelhazmat.co m ^^tPHoxt* ^ 

# EXECUTIV ESUMMARY : BVID #17898-(221 4 HANSCO M BLVD )
No Issue s o r Concern s [ ^ Issues/Concern s Detail Explanation : ^'>^g^ ^ -"^ ^ COASTA L • NYIIOHHINTA I SIOUP , IN C$ ^ 

## EP APropert y Clos e Ou t For m Propert y If
. Propert y Address : 

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# i-^f e Date/Time : Owner' s Name ; Quad s Excavated ; if^i
. fel" Contracto r Gron p /l^ ^
Excavatio nGenera l 1
.

I f necessaiy , wer e th e correc t quadiantfs ) excavate dan drestored ? 2
.I f necessary , wer e th e correc t area s ofdri p zon e excavaie dao drestored ? Gradin s So dan dVcRelatio n I
. Doe s th e gradin g aroun ddi e perimete r ofth e hous e i nexcavaie darea s generall y slop e away fromIh e Iiouse ? 2
. Ha s so dbeenlai db i al l area s Ou t wer e excavated ? 3
. Doe s th e so dappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t a3 0 da y tun e period ) 4
. Ar e sodde darea s genei«Uy firman devenl y graded ? 5
. Ar e di e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte da t a3 0 da y tim e period ) 6
. Wa s tb e properl y grade dsuc hthat wate r wil l not poo l o nlh e prnperty* ) r 7
. Wa s damag e t o landscapin g o r plan t material s avoided ? Gates , Fence s an d Retainin s Wail s 1
.

D o gate s ope n an d clos e freely? (I fapplicable ) 2
.Wer e al l gate s o rfence s take n dow n durin g restoratio n aelivilie s reinsuiied ? (I fapplicable ) 3
.Wa s damag e t o gate s o rfence s avoided ? (Ifapplicable ) 4
.Wa s damag e t o reiauiin g wall s avoided ? (Ifapplicable ) Foundation , Sidiasan dGntter s 1
.Wa s damag e t o di e sidui g o r tri mavoided ? 2
.Wa s damag e t o th e foundatio navoided ? 3
.Wa s damag e t o window s avoided ?
< lWa s damag e t o vrindow s o r doo r screen s avoided ? Wa s damag e i o downspout s o r downspou l extension s avoided ? Sidewalk s an dDriveway s (Concrete ) I
.Wa s damag e t o drivewa y surface s avoided ? 2
.Wa s damag e t o walkwa y surface s avoided ? Ye s N o 

## y y Ye s N o 

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## Ort'Dcr ^ comments :

[Inspectio nnotes :

Remova l an dreslorationactivate s complet e includin g th e 30-da y so dwarranry : EP ARepresentative '^y\Date : >^ ^

## Propert yCompletio n Agreemen t This agreement documents lhe complcliono f remedia l aclivitie s perloime do nm y pioperl y M y signalur e wil l designat e liia t I a msalisfiedwil hlh e restoraiio no f m y properly , andIha l n o items ar e mqueslions
. now , or a

t any lim e i nthe futuie , except thos e ilem s lisledbelow , i f any Propert yfP : p ( ^ p ^ 

### Propert y Addrcs : ^ ^/ ^ |^,O.S-rW \, fi^lW. Owner : /^y^y^^j^p ^ faomkaiX 

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Phone : ^^ y^ ^j^.^A ^ Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item :
Additiona l Comments :

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1 ii|;rc ciKtoralio n i % completed , except a s nntec t [_

J I ri o not iit;re cresloratio n i s complete d 

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# y^.y-j^ ^ Owner' s Signatn^^^ ^ Dat e ontrarlor' s Signatur e Dal ePropert vOwne rSctisfartio n Survey i Omah a Lea d Superfun d Si t 200 8 Remediatio n Contractor : Coasta l Environmenta l Grou p



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# 2 4 2(10 9 Propert yIdentifie rNumber : 

# s 2 m Propert yAddress : 2Z) a ' lA/Jt^fi r.Cyrf i ^ i tc l Propert yOwner' s Name ; JV^ne-H? > \n\)r<^(:ih ^ (abov e informatio n t o be fille d ou t b yremediation'conlracto rprio rt o deliver yo ffor m t o Propert yOwner )
Instruction s t o Propert yOwner : Thi s for m i s provide d t o yo u as a mean s o ftryin g t o captur e you rleve l o fsatisfactio n wit h th e wor k o fth e above-identifie d remediatio n contractor , a s 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 veryintereste d i n you ropinio n regardin g th e wor k performe d byit s contractors
. Thi s for m i s intende d t o provid e an eas ymean s fo ryo u t o expres s you ropinio n abou t th e wor k performe d o n you rproperty
. Pleas e indicat e you rleve l o fsatisfactio n wit h th e contractor' s worl < byselectin 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 may als o b e provide d i n th e space below , a t th e optio n ofth 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 Ratlri e Regardin g Contractor' s Wor k 

### 1 0 5 A 3 * 2 1 Additiona l Comment s fro m Propert yOwne r(optional : continu e t o bac k o fpag e i fneeded l

Propert yOwner' s Signature : 

# D,,e
. 

# y/70 ^