# TRANSMITTA Lo f

OMAH ALEA D SITE SOI LREMEDIATIONFILEFOLDE R SAID#:_Mii__ Date : 

# T/V l 7 Address : M<Ul^htlTC ^ ^1 ^ Remediatio nContractor : _Coasta l Environmenta l Group _ Year ; _20^ ^ SOI LREMEDIATIO N PROPERT YnLEFOLDE RDOCUMENT S Vide o o f propert y (DVD ) Executiv e Summar y EPA-provide dpropert y sketc h Signe dAcces s Agreemen t fo r subjec t propert y Signe dAcces s Agreement(s ) for adjacen t propert y Restoratio nAgreemen t



# - a Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) Confirmatio ndat a Photograph s li ^ V(^ft1W ^ \\rfMvfir(]Q ^ As-buil t sketc h Satisfactory restoratio nsigne db y Propert y Owne r Propert y close-ou t chec k lis t signe db y EP A Descriptio no f area s no t meetin g RO D cleanu p criteri a Utilit y clearance s Propert y informatio nfro mDougla s Count y Assessor' s OfTice D 

# ..-:2 D D Signatur e 

# / r V Dat e 

## / ?
3021776 8 Superfun d

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## Propert yAcces s Checklis t Prcpcrt^LD : 5^ 3 3 Propert y Addre. : ^c^/ ^ p^uA^^t^St D DWOR K STARTED WOR K COMPELTE D ON . ON : / / 

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# 52)3 6 s 9 y 5 f Rente r Phone : FiLv : 

### Phone : qC)t'^^-2lpn7L Fa v Cell/Pager . Cell/Pager : Additiona l Inlormittion' .

Q Notiricatio n Lette r D Acce u Agreemen l 1 1 Restontio D Agreemen t d Topsoi l Samplin g (i fapplicubic ) D OisposaJ Samplin g (i fapplicable ) G Gnrdc n Snmplio g (i fapplicable ) I S Utilit yClearanc e [l|-''"^eo/Photo s (Before )

•Video/Photo s (During )
•Video/Pholo j (After ) D Video/Photo s (30-Day ) p . Propert yCompletio n Agreemen l

•Fina l Repor t Sent : / / Signed ; / / l 3 id ^ 

### S;enc6:_U_/3./6 ^ 1 1 1 1 1 1 

## Cu\\tii:JllM.lO ^

On : l l l< 5 1 ^ On : / / On : / / On : / / 

## Signed : J_//I/0 5 Issued : / / By : 

### ^y(TA6Vi O ^r-{0C-kX\^i 6 By : By : By : 

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= ///^/n ^ By : A^ ^ By : / By : By ­ . 

## By:^k^J ^ 0 By : Ai rMonitorint ! ( « U|)plicabl e

D Communit yD Cre w 

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### On ; / / By :
D ComrounJtA ' Results : Q Cre w On : / / By :

•Communir i Results : D Crc> v On : 

### / / J By :

Omah a Lea d Srt e

### ^ugla s Coimt y Accoim t In^UjiM^o n Pag e 1 of 2 nujiM^ c Dougla s County , Nebrask a Propert yRecor d - R053355000 0 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 - ViewO n Ma p 

### Informatio n i s vali d a s o f2009-9-2 9 Treasurer' s Ta xRepor t Ne wFeatur e ••^ ^ Aut o Saie s Searci i Owne r ALSTATTEDWAR D D ETA L 503 6 S 9 4 S T OMAH AN E 68127-000 0 Propert yInformatio n Ke yNumber : 335 5 000 0 0 5 Accoun t Type : Residentia l Parce l Number : 053355000 0 Parce l Address : 4513BURDETTES T OMAH AN E 68104-000 0 Lega l Description : BAKE R PI^C E LO T4 BLOC K8 4 4 X 12 8 Valu e Informatio n Lan d Improvemen t Tota l 200 9 200 8 200 7 200 6 200 5 200 4 $6,000.0 0 $6,000.0 0 $6,000.0 0 $6,000.0 0 $6,000.0 0 $6,000.0 0 $40,400.0 0 $40,400.0 0 $40,400.0 0 $40,400.0 0 $25,600.0 0 $25,600.0 0 $46,400.0 0 $46,400.0 0 $46,400.0 0 $46,400.0 0 $31,600.0 0 $31,600.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 2 5632. 0 1. 0 128. 0 44. 0 N o Improvemen t Informatio n Buiidin g 1

http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accotmtno=RO. . . 10/13/200 9

## - , Siougla s County Accoun t In &m|B^o n 

## Pag e 2 of 2

"P^iir i

•—-*£•,- 1

Aw«C n CLIC KT O ENLARG E IMAG E Squar e Footage : 720. 0 Percen t Complete : 

### 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Averag e

Buil t As : Ranc h Cond o Squar e Footage : 0. 0

HVAC : Force d Ai r Rooms : 5. 0 Exterior : Fram e Aluminu m Units : 

### 1. 0 

## interior : Drywal l Batiis : 

### 1. 0 Roo fCover : Compositio n Shingl e Bedrooms : 2. 0

Roo fType : Hi p Stories : 

### 1. 0 Floorcover : Allov»/anc e Foundation : Bloc k Sprinlde 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 192 5 0 % 192 5 8 5 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 720. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Garag e Detache d 216. 0 Porc h En d Scree n 96. 0 Porc h Sla b Roo fCei l 128. 0



## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RO. . . 10/13/200 9

# 0 Pag e 1 o f 1

" > | i • • Oreate^A ^ ., j Sen d Emai l 

## YOU R TICKE T NUMBE R I S 2400116 . Origina l Cal l Date : 11/04/0 9 Time : 11:5 2 a m Op : ELIZABETH1879 0 Worlc t o Begi n Date : 11/06/0 9 Time : 12:3 0 pm State : N E County : DOUGLA S Place : OMAH A Address : 451 3 Street : BURDETT E S T Twp : 15 NRng : 13 E Sect-Qtr : 08-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D REMEDIATION Locatio n o f Work : INCLUD E AL L EASEMENT S LOCAT E ENTIR E PROPERTY Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T Compan y: COASTAL ENVIRONMENTA L SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Being Don e For : COASTAL Dept ho f Excavation : 4 F T Corne r Lot : N Front : Y Rear : Involve s Tunneling o r Horizonta l Boring : N Explosives : N CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Plion e Numbe r Utilit y Typ e CXCAT V CO XCOMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7
MUDO l METROPOLITA NUTILITIE S DISTRIC TSAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0
OMAHACO FCITYO FOMAHA-TRAFFIC,SEWE R 

### RICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1

Emerg : 402444516 0
0PPDGPR 5 OMAH APUBLI C POWE RDISTRIC TN A 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES TLOCA LNETWOR K NA 

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

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 11/4/200 9OLS# : 5803 3 

# As-Buil t Drawin g Dat e Excavated : 11/9/0 9 Dat e USEP ASigne d Off : 12/3/0 9 COASTA L Are a Sodden : 63 9 s o f t 

# Omah aLea dSuperfun dSit e

5803 3 Exterio rPain t Omah a Lea d Sit e •Good Sit e Sketc h •Poo r Samplin g Address : 451 3 BURDETT E S T l^'^No t pain t Samp)l e Numbe r Lea d Sampl e Sample s Collecte d 

# I LA B Concentratio n Collecte d Fir m RYASCPXA-5803 3 F 1 _i9jy_pp m 

### D Dat e 

### i/oyb i RYBSCPXA-5803 3 F 2 .?ff2 - pp m 

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### D Sample s Analyze d RYDSCPXA-5803 3 B 2 pp m 

### D 

# _ai ^ RDZSCPXA-5803 3 D Z 

## 3^ 1 pp m 

### D XR F Unit : W^ h Book : ZZ" ? nCZCCPX A6803 3 62 - 

### D Date : pp m 

### D IJ^-O'S I RPZSCPy, A580 M i2Z - pp m 

### D Tim e 

# n ICEx . Staf f 

### pnrsL > Numbe ro fSample s = | 3 | [ Q | Legend : F 1 = Fron t Left , F 2 = Fron t Right , B 1 = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla ; Al l quadrant s ar e a s viewe d fiw n th e street , facin g propert y Alley.
. 

# ENTERED

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## Legen d Concret e Dri p Zon e Excavate d Quadrant s Excavate d 

### Are areplace d So d wit h Are a replace d wit h Rock/Mulc h Are a lef t bar e 

### Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .

### 5803 3 

# l/ l ll/Di ,

Exterio rPain t Omah a Lea d Sit e •Goo d Sit e Sketc h •Poo r Samplin g Address : 451 3 BURDETT E S T 12'^^'o t pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : FV A
. RYASCPM-5803 3 F t pp m 

### D Date: l/Of/O f RYBSCPXA-5803 3 F 2 pp m Time : / '^ 5 t>/ n 

# n RYCSCPXA-5803 3 B 1 

# 22 5 pp m 

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### D Date : /•/.•^-/O ^ 

### D RPZSCPX A6B03 3 Pi - " pp m 

### D Tim e 

## B r Staff : Numbe ro fSample s = | 3 | | ( ^ 

# n | 

## pnrsL L Legend ; F 1 = Fron t Left
. F 2 = Fron t Right
. B 1 = Bac k Left , 8 2 = Bac k Righ t D Z = Dri p Zone
. G Z = Garden
. P Z ' Pla ; A d quadrant s ar e a s views d fro m tt> e strpet . facin g propert y 

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# ENTERE D



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## 5803 3 

# H Wh i

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# n Date :

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### 2 2 5 pp m D Sample s Analyze d RYDSCPXA-5803 3 8 2 pp m 

### D 

# 3± ^ RDZSCPXA-5803 3 D Z 

# i 3 H 1 pp m 

### D XR F Unit : (rf^ O Book ; 2Z 1 • RCZSCPX A6803 3 62 ­ pp m 

### D Date : hlfj'Q ^ RPZSISPXA6803 3 fO - 

### D 

# • pp m Time : ftn-i 

### D Staff : mSL ^ Numbe ro fSample s = | 3 \ \ O I Legend : F l = Fron t Left
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### \ Q^No t pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r 

# I I LA B Concentratio n Collecte d Firm : 

## FP 4 RYASCPXA-5803 3 F l pp m D Date : 

# J M M RYBSCPXA-S803 3 F 2 

## .?^2
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### D 

# 3 r Staff : Numbe ro fSample s = | 3 I | (*) ] 

# iraL L Legend : F l = Fron t Left , F 2 • Fron t Right
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# 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 Nam e 

### Daytim e Phon^^ ^ ^

7 ^ 7 ^ 21 ^ 07
_ 

# td^or d AUK-H Addres s o fPropert y covere d b ythi s 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 and-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 vtnl 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 . ArepreserYtativ 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 perfonned , 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 wor k 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 fro m EP Atha t th e propert y ha s bee n remediated
. ENVIRONMENTA LRESPONS 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 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 effec t unti l th e wor k ha s bee n satisfactoril ycompleted
. Th e Granto rals o agree s to :
Pag e 1 o f2\'^i-^r vCOASTA L *V ^

^ tNTtROHHIKTA L ^ t PRO"* * C t O U » » KC


### « 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 ; e 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
. « t 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 ©fgr a D i d o no t gran t access t o mypropertie s gran t acces s t o mypropertie s

^^^/.^ ^ -' ' 

# 3/o X

SignatureD6t e ^ Signature Date
G 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

## ^C£ L :-% ^ C O A» T__ At 

# Restorataor t Agreemen t The purpos e of thi s agreemen t i s to provide amutua l agreemen t a s to condition s ofth e propert y prior t

o remediatio nactivities . Thi s will als o serv e a s documentationfo r the purpos e of assuring tha t restoration activitie s ar e completedt o th e satisfactionof th e propert y owne r andthe UnitedState s Environmenta l Protectio nAgenc y (EPA) . Propert y ID : ^5 0 / 3 Propert y Add;«s:T-/5"/ 3 ^^Q^dU^ ^ SfT 

# o^«"-f3rvo(xr dP^^t). ^ Phone : 

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nth e attacheddiagram(s ) indicat e area(s ) to excavate , surface structure s an dlandscaping feature s an d acces s location(s ) to b e use dby the contractors . Indicat e distances , depths , materia l types , etc . Photographically an dVideographicall y documen t th e existing condition s ofthe propert y an dthe basemen t if necessary . 

## Item s t o b e Remove db y th e Owner before Start o

f

Remediation : Th e lenoval . storage , disposal , and/or retur no f thes e item s i s the Owner' s responsibility . Item : 

# ^—-/ ZrL ^ item : 

# 7 " Item : Item :

Item s t o b e Remove d b yth e Contracto rDurin g Remediatio n an d l^o t Replace d item : 

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# $ O^ U 

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## Ite m Pre-existin g piopen y area , that wil l b e excavated , tha t i s covere dwithgrass . Numbe r o f tree s > 2 inc h trunlc diamete r Numbe r o f tree s < = 2 inc h trun k diamete r Numbe r o f Sprinkle r Zones , Contro l Valves , Timers , Heads , etc . Aiiat h; i sketcl i o l ili c >-ri'rklc i l;>\;)ii i Numbe r o f an dsiz e o f eac hgarden / flowe r be d area . AlUic h. 1 slvi-'icl i o l rt-!;iliv f <\'/t: s nn dloc;iii('M i Agree dupo nvalu eo f plan t material s no t t o b e replace db v contractor . Voi r ll'.i ' VHIII C «fl l n i i;si' C 1 0 b;ui . : iilaii ; \nin.;ii.' ; I d(li e ijriipcrl s iM

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### Pag e 2 of.C O AS 1 AL O k

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### ! Additiona l Comment s / Instructions :

[Chec k th e bo xi fOwne rdoe s no t wan t CE G t o documen t interio rfoundatio n walls 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
.

0^ 1 agre e C II«* o no * sg** *

Owner' s Signatur e Date < Contractor' s Signature Date Pag e 3 o f

### BVI D 

# , g-goS ^ XR F PROPERT YSAI^PL E SHEE T Date Projec t XR F ID #

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

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 7 4 Mod e SOI L Tim e 2010-02-0 3 19:0 3 Duratio n 90.5 6 Sequenc e Fina l Flag s AVERAG E i;;A^jf)f71-7 3 \ ADDRES S 451 3 Burdett e St
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. BARAJA S 1 1

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

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 7 3 Mod e SOI L Tim e 2010-02-0 3 19:0 3 Duratio n 30.1 7 Sequenc e Fina l Flag s BVI D 5803 3 ADDRES S 451 3 Burdett e St . QUADRAN T F l DEPH T 6 XR F TEC H O
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## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 15 2 Mod e SOI L Tim e 2009-11-0 9 13:4 0 Duratio n 91.5 5 Sequenc e Fina l Flag s AVERAG E 

### (3.vgo f14<9-I5 p ADDRES S 451 3 burdett e QUADRAN T e m DEPH T 1 " XR F TEC H R
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# BV : F^A/^m A

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

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pp m P b 101.35 4 Supervise d By : 

## Certificat e o fVerificatio n

14 9 SOI L 

### 2009-11-0 9 13:3 9 30.5 4 Fina l 5800 3 451 3 burdett e e m 

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

## Certificat e o fVerificatio n XL3t-3902 2 Readin g N o 

### 15 0 Mod e SOI L Tim e 

### 2009-11-0 9 13:3 9 Duratio n 30.4 8 Sequenc e Fina l Flag s BVI D 5800 3 ADDRES S 451 3 burdett e 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 98.67 8 ±13.18 3 Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Biilerica , 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 92.92 4 Supervise d By : 

## Certificat e o fVerificatio n

15 1 SOI L 

### 2009-11-0 9 13:4 0 30.5 3 Fina l 5800 3 451 3 burdett e e m 

### 1 " R
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### 12.91 2

## fyjQL i Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 I ^^^ ^

I Coasta l Environmenta l Grou p Inc
. V"^^ ^

www.coastalhazmat.co m Xp„o^«< ^ 

# EXECUTIV ESUMMARY : BVID #58033-(451 3 BURDETTEST ) No Issue s o r Concern s Q Issues/Concern s Detail Explanation : ^^s^ ^ "^^^ COASTA L ENVIROHHCHTA L G t O U P , IM C4 

# EPAProperty Clos e Ou t Form Propert y# : 

# ^63 3 Propert y Address : Datc/Tlroe : Owner' s Nam e Quad s Excavated : Contracto r Grou p Excavatio nGenera l I .I f necessaiy , wer e th e correc t quadrant(s ) excavate dan drestored ? 2 .I f necessary , wer e th ecorrec t area s o f dri p zon e excavate dan drestored ? Gradin g So dan dVegetatio n I .Doc s th e gradin g aroun dth e perimete r ofth e hous e inexcavate darea s generall y slop e away fromth e house ? 2 .Ha s so dbee nlai di nai l area s tha 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 tim e period ) 4 .Ar e sodde darea s generall y Tir man devenl y graded ? 5 .

Ar eth e joint s ijetwee nth eso dstrip s generall y tight ? (Onl y evaluat e i f inspecte da t a3 0 day tim e period ) ; 6 .Wa s th e propert y grade dsuc hthat wate r wil l no t poo l o nth e property ? 7 .

Wa s damag e t o landscapin g o r plan t material s avoided ? Gates , Fence s an dRetotnin g Wall s I .D o gate s ope nan dclo.s e fteely? (Ifappiicable ) 2 .Wer e al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (Ifappiicable ) 3 .

Wa s damag et o gate s o r fence s avoided ? (Ifappiicable ) 4 .Wa s damag e t o retainin g wall s avoided ? (Ifappiicable ) Foundation , Sidio Kan d Culler s 1
.

Wa s damag e t o th e sidin g o rtri m avoided ? 2
.Wa s damag e t o th e foundatio n avoided ? 3
.Wa s damag e t o window s avoided ? Wa s damag e t o window s o rdoo rscreen s avoided ? 5 .Wa s damag e l o downspout s o rdownspou l extension s avoided ? Sidewalk s an dDrivtway s (Concrete ) I .Wa s damag e l o drivewa y surface s avoided ? 2 .Wa s damag e t o walkwa y surface s avoided ? Ye s No 

### / 

## y Ye s N o 

# y 

# y L y y y / Yes N o 

### / 

## y y y Yes N o 

## y y y 

# y y • Yes N o -y ­I 

## owner s comments :



# Inspectio nnotes :

Remova l an dreslorationactivate s complet e including th e 30-da y sodwarranty : EP ARepresentaliv e Q^J ^ Date : »*}' '

## Properl yCompletio n Agreemen t riii s agreemen l document s th e completio no f remedial acliviiie s perloime do nm y properl y M y signalur e will designat e ihal Ia msatisfie dwit hIhe restoralio no f m y properly , andIha l n o ilem s ar ei nquestions , now , o r at an y lime i nthe fiilure , excep l ihos e ilem s liste dbelow , if an y Propert y ID : 

# 2 ^ Propert y Address : -L^^e^ ^ 3 ftivd fcU Owner : EduOai^ dAI-SHTU T 

### Phone : {MOVJ-^nTX
- 1 UC^ l • X 

### Restoratio nItem s \x \Question : Item : 

### Item : Item : Item : Item : 

### Item : Additiona l Comments : 

## lf\/nj- ^


# [y rHjjrc cI t

rcstortilio ni. s completed , rxccp i a s note d l_ JIrto no l jjjre c restoratio nis complele d 

# kji4^ ^ nil ) 10 ^ 

# Ink Owner' s Signatnr r 'ontrartnr' s Signatur e Dat ePropert yOwne rSatisfactio n Surve y Omali a Lea d Superfun d Si t 

## 200 8 

# m ^^ 

# * Remediatio n Contractor : Coasta l Environmenta l Grou p rviv/lCin M Prnpert vIdentifie rNumber : .^ft O Pj' ^ OllPFRFUN D UW\o\VJi v Propert yAddr.« : U.-S \ ^

iftny-^^^l P -^^k,, ^ SUrtnrU l Propert yOwner' s Name : ^r U tY^r AJX ) Trrrt h (abov e informatio n l o be fille d ou t byremediatio n contracto rprio rt o deliver yoffor 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 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 , 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 worl ( 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 wor k performe d o n you rproperty . Pleas e indicat e you rleve l o fsatisfactio n wit h th e contractor' s wor k 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 fth e propert yowner. ) C^9 ^

"excellent " 7- 8 "ver ygood " 5- 6 "acceptable " 3- 4 "poor " 1-2 "ver ypoor " Propert yOwner' s Satisfactio n Ratin e Regardin g Contractor' s Wori t 

### 1 0 5 9 4 8 3 7 2 6 1 Additiona l Comment s fro m Propert yOwne rtoptionat : continu e t o baci t o fpag e I fneeded l



### Propert yOwner' s Signature : ^^Uyfl^JgL yDate : / / '/Z/^Q ^ 

# . 

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