TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#:_Lil3B_ Date: ^//^/2/3^6 

Address: 3~] ^ \ S Z^ Sn-egjT 

Remediation Contractor: Coastal Environmental Group_ Year: 2007 

SOIL REMEDIATIO N 

PROPERT Y FILE FOLDER DOCUMENTS 

M Video of property (DVD) 

SZ Executive Summary 

M EPA-provided property sketch 

M Signed Access Agreement for subject property 

E' Signed Access Agreement(s) for adjacent property 

S/ Restoration Agreement 

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

M Confirmation data 

E^ Photographs b^6j IA ^ Qxejud ^ cjan n^ y SOdu As-built sketch 

M Satisfactory restoration signed by Property Owner 

U Property close-out check list signed by EPA IA.ht/2AX)7 

D Descriptionof areas not meeting ROD cleanup criteria 

D Utility clearances . 

M Property information from Douglas County Assessor's Office 

^ Om.\r/lc^ r^rf\ 

D 

Signature ignature / Date 

40312844 

Superfund 
Final Report Property Check List (piease place with each file) 

Hard Copy Information 

\ Property Check List 

X. Site Working Drawing Map 

V 

3. EPA originals Map 

^. Douglas County Assessor's Map 

Property Contact Sheet 

Agreement 

X Access Agreement 

S^ Restoration Agreement 

Miscellaneous Documents 

1. Final Map from the Field 

2>Change Orders ^\*( 

• ^^R F Data . v 

4>Any emails or PO correspondences ^^ ^ 

V Property Completion 

KJExecutive Summary 

VA S BUILT 

\J*roperty Completion Agreement ^^ ^ oy 

X^n y buyout info or reimbursement info *^\ 

SN^I'heck or money order copies y\to<. 

'"t^ EPA Property Close Out Form 

Tss^ttached Begin Video 

Electronic Documentation 

Drawings 

EPA original 

/S,.^ Working Drawing 

\ s AS Built.vso 

Ns^AS Built.jpg 

Photos 

y Begin Photos 

\S^ During/Excavation Photos 

k Sod Photos 

30-Day Sod Photos 

Scanned Documents 

' Final Documents 

2. Executive Summary 

Videos 

Begin Video 

My Movie 

4
Property Access Checklist 

n WORK STARTED ON: / /_ 

Property Address: ^:^P [ g ^ ^ j ^

D WORK COIMPKLTKD ON: / /_ 

0>>IK' '^LIUI £XK1_^L_ E Renter: 

Phone: 

Fax: 

Ceil/PaL'cr: 

Plionc Additional Information: 

Fax: 

Cell/Pajjei 

1 ^ Notification Letter Scnt:/d l^f l tf^ 

13' Access Ajjrccnicnt Sis?ned:/^/^/Z ^ 

Restoration Agreement signcd/iL iQk & «•>•• Ql^j^s 

I I Topsoil Sampliii"; (if applicahle) By: 

D Disposal Sampiin" (if applicahle) Bv: 

Garden Sampling (if applicable) Bv: 

Utility Clearance Called: jbl^blA ^ '^y-fchv ////@ Ji^ ]^\ 

J ^ Video/Photos (Before) On:/i/2^/i^ Bv: S 

1 ^ Video/Photos (Durinj,') On:illjZ.I_0 y 

Video/Photos (After) Oiy.W_l(^ l CL J 

D Video/Phofos (3(>-Day) On: Bv: 

JST Property Completion Ajirecmenf Signed: ^^3_/A 7 Bv: Ch n 5 

n Filial Re|)ort Issued: / / Bv: 

Air IVlonitoriiig (as ap|)lical)lc 

1 L J Community CH Crew 

) 

1 Results: 

On: / / By: 1 

I n Community

Results: 

O Crew On: / / Bv: 

1 n Community

Resuhs: 

Q Crew On: / / 1 

Omaha Lead Site 
12788 

Exterio North Arrow Omaha r Paint Lead Site Owner Name: 

Site • Good Address Sketch : 3721^4 ST ^^^^ J ^ • Poor Phone: H:" 2^<5g'5 7 w: 

l^^o t paint 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

Firm:

Samples Collected 

 (VASS S.iW, Ky n 

RYASCPXA-12788

RYBSCPXA-12788

 F1 

 F2 

3£>Z

"Z-"^8

 ppm 

 ppm 

y n 

n 

Date;

Time:

 T^'Oi ^ 

 "^'^^prv ^ 

RYCSCPXA-12788

RYDSCPXA-12788

 Bl 

 82 

13$^ 9

?6> 6

 ppm 

 ppm 

n 

D Samples Analyzed 

RDZSCPXA-12788 DZ .9f^?S " ppm n XRF Unit inr n Book: 1£ ± 

rtOZOCDCA-12700 8* -

RPZoo^Xj^ 12700—pz 

(^ycscpKA *t:Arer 

ppm 

ppm 

Number of Samples 

D 

D 

= 5 

n 

n 

Date:

Time:

Staff:

 _ ^ 

 Pog 

 M'Cu:) 

\ -o( p 

Legend: Fl = Front Left, F2 = Front Right, Bl - Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

I I , AU quaelr^>8 are as viewed from the street, facing property 
Douglas County Account Information Page 1 of 3 

Dougla s County , Nebrask a Propert y Recor d ­ R231684000 0 

Infonnation is valid as of 2007-10-10 

Values not finalized until after Board of Equalization 

Print Report 

View on Map 

Treasurer's Tax Report 

Owne r 

KOCHV,CTOR,AT ^ ^ ^ . ^ ^ ^ ^ 

3721 S 24 ST 

OMAHA NE 68107-0000 

Propert y Informatio n 

Key Number: 

Account Type: 

Parcel Number: 

Parcel Address: 

Legal Description: 

1684 0000 23 

Residential 

2316840000 

3721 S 24 ST 

OMAHA NE 68107-0000 

SWETNAMS SUB DIV LOT 15 BLOCK 0 40 X 150 

Valu e Informatio n 

2007 

2006 

2005 

2004 

2003 

2002 

Land 

$4,600.00 

$4,600.00 

$4,600.00 

$4,600.00 

$4,600.00 

$0.00 

Improvement 

$40,400.00 

$40,400.00 

$16,800.00 

$15,300.00 

$15,300.00 

$0.00 

Total 

$45,000.00 

$45,000.00 

$21,400.00 

$19,900.00 

$19,900.00 

$0.00 

Sales Informatio n 

Sales Date: 2006-07-21 

Deed Type: WD Book: 2006 Page: 084955 

Price: $68,749.00 

Grantor: SEMIN DOLORES M TR 

Grantee: KOCH VICTORIA T 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 2005-11-29 

Deed Type: WD Book: 2005 Page: 159664 

Price: $25,500.00 

Grantor: Adair Holdings 

Grantee: Dolores M Semin Trustee 

http://douglasne.mapping-onIine.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2... 10/25/2007 

•!.•• ••; K\'." '^\ ••^^iu':*,::,^:t:-'.^.:i,fi,'i \/-.y^'a': : 
Douglas County Account Information Page 2 of 3 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 2003-10-28 

Deed Type: SHD Book: 2004 Page: 044099 

Price: $11,385.00 

Grantor: Douglas County Sheriff 

Grantee: Adair Holdings, LLC 

Valid/Invalid: Invalid 

Exclusion Reason: Sale by Govt Agency 

Land Informatio n 

Acres SF FF Units Depth Widtii Vacant 

0.13 6000.0 40.0 1.0 150.0 40.0 No 

Improvemen t Informatio n 

Building 1 

2 1/2 Story Unfin 3721 S 24 St 

•J I 

ax.. . 

(ntfmmt 

ni«« « ri 

I t 191 p« n 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 1563.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

Owner Occupied: No Condo Square Footage: 0.0 

Built As: 2 1/2 Story Unfin Rooms: 8.0 

HVAC: Forced Air Units: 1.0 

Exterior: Frame Siding Baths: 1.0 

Interior: Drywall Bedrooms: 4.0 

Roof Cover: Composition Shingle Stories: 2.5 

Roof Type: Gable Foundation: Block 

Floorcover: Allowance Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2... 10/25/2007 
Douglas County Account Information Page 3 of3 

1900 0 0% 1900 

Deta/7 Type Deta/7 Description 

Appliance Allowance 

Basement Bsmnt Block 8 ft 

Basement Walkout 

Fixture Base Fixtures 

Fixture Bath Full 

Garage Detached 

Porch Cvrd Wood Deck 

Porch End Solid Wall 

Porch Slab Roof Ceil 

User Busy Street 

106 

Units 

1.0 

881.0 

1.0 

1.0 

1.0 

240.0 

239.0 

144.0 

239.0 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2... 10/25/2007 
Property ID # 

Property 

Address: 

Initial Contact:

Second Contact:

Final Contact: 

Final Action: 

1 Comment: 

Owner 

Comment (s): 

Site 

1 Coordinator 

1 Comment (s): 

CONTACT FORM 

f^7^9 

^171^ 2^sr 

 Date: A4 ^ Time: /// 5 Action: /Afi^ f/y^K­

 Date: AaA/C Time: ^fAA^ Action \7l^A,/! ^ lA^CA/tOk ( 

Date: Time: Action: 

Transmit to EPA D Other Action: D 

l/^y72ryyt A^<T<^AA 

\ 
X 

Omaha Lead Site—Fixed Price EP-R7-07-05 

Coastal Environmental Group Inc. 

www. coastal hazm at. com .<P* COASTA L "IPBO-I* ^ ENVIRONHENTAL 

C R 0 U f , IH C 

EXECUTIVE SUMMARY: 

12788—3721 S 24 ST 

No Issues or Concerns Issues/Concerns 

Detail Explanation: 
C CAST A L 

As-Built Drawing ^ 

% maha Lead Superfund Si ite 

12788 

Exterior Paint North Arrow Owner Name: J^u>e.£:S SerTpj/A? Omaha Lead Site 

[[] Good 

Address Site Sketch : 3721 8 24 ST • Poor Phone W: : H: 0^o t paint 

Sample Lead Sample Samples Collected Number LAB Concentration Collected Firm: (n£s s-ivv, KA^ 

RYASCPXA-12788 Fl 3&Z ppm D Date: 

~i-i«-otc. 

RYBSCPXA-12788 F2 1-^8 ppm D Time: Q. <^^pfy^ 

RYCSCPXA-12788 Bl ppm D Samples Analyzed RYDSCPXA-12788 B2 ppm D 

RDZSCPXA-12788 DZ ppm n XRF Unit: lODl Book: /^ q 

ROgQQDCA-12700 S2­ ppm D D Date: Q - I - 0(c' 

nPZOOPXA-12700 PZ ppm 

D n Time: Prr, 

RYCSCPXA -fife r 7 8 ^ 

Staff: M'^uJ Number of Samples = 

Legend: F1 = Front Left, F2 = Front Right, 81 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

OLS#: 12788 

Date Excavated: 11/10/07 mm 

Date USEPA Signed Off: 12/4/07 

ENTERED 

^J'-'Z^ ' 

DZ=112PPM 

(d> 14 " 

Q-z. 

3T;I(52H5T 

COM:c Ul 

DX=l^s 

CONG 

3Qi EA-W=150PPM Z-lS 

WM-K 

.s.m.m. 04«I4L0123 

Legend 

Area not Excavated ^ Dripzone Excavated Quadrants Excavated 

Contract #: EP-R7-07-05 Coastal Environmental Group Inc. 

Property Completion Agreement 

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

will designate that I 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: [ ^- y ^ ^ 

Property Address: "^7 ^ | <g^ ^ ^ ^-\^. 

Owner: \(l^^j,^^; ^ l^.cl x 

Phone •• ^A^ - ^ ^ ' ^ ^ 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

1 

• 

N 

I agree restoration is completed, except as noted j ' 

 I I do not agree restoration Is completed 

1^-3-07 

Owner's Signature Date Mgnftture 

I
s^ EPA 

EPA Property Close Out Form 

Property #: \Xlo % Propertv Address: ^7^ 1 ^ - ^^" ^ ^t . 

Date/Time: !l J ^<^ Owner's Name: \f; f.•H^r^V. W^,r^r K 

Quads Excavated: Ri ^ 02^ £ A Contractor Group Cx><x^^o~] 

Excavation Yes No General 

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

\ y ^ 

2. If necessary, were the correct areas of drip zone excavated and restored? 

y 

Grading Sod and Vegetation 

Yes No 

I. Does the grading around the perimeter of the house in excavated areas generally slope away u y from the 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 

day time period) _^___ 

4. Are sodded areas generally firm and evenly graded? 

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

time period) ___^___ _ 

6. Was the property gilded such that water will not pool on the property? u ^ 

7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and Retaining Walls 

Yes No 

1. Do gates open and close freely? (If applicable) 

fJA 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) Uk 

3. Was damage to gates or fences avoided? (If applicable) 

hjK 

4. Wasdamagetoretabing walls avoided? (If applicable) 

tJ!^ 

Foundation, Sidiog and Gutters 

Yes No 

1. Was damage to the siding or trim avoided? 

1 / " 

2. Was damage to the foundation avoided? .X 

3. Was damage to windows avoided? 

y 

4. Was damage to windows or door screens avoided? y 

5. Was damage to downspouts or downspout extensions avoided? y 

Sidewalks and Driveways (Concrete) Yes No 

1. Was damage to driveway surfaces avoided? y 

2. Was damage to walkway surfaces avoided? y 
Inspection notes 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA RepresentativA^7^^;^:,,^,.,^^^^^.Sj:^ Date: /4W^ 7 
PROPERTY CLEARANCE WORKSHEET 

Dat:e j-ld'O l 

Project Omaha Lead - Fixed Price 

XRFID 

Shot * Reading 

t s i (9/ 

2^5 N t 

2M m 

Sample Area 

Aliquot 

1 

2 

3 

4 

5 

I n Situ 

Reading 

w\ 

If 

sU 

n 

Sample Area 

I n Situ Aliquot Reading 

1 

2 

3 

4 

5 

Sample Area 

I n Situ Aliquot Reading 

1 

2 

3 

4 

-) 

Sample Area 

I n Situ Aliquot Reading 

1 

2 

3 

4 

5 

Sample Area 

I n Situ Aliquot Reading 

1 

2 

3 

4 

5 

0107-51 

Sample Area 

BJ L'S 

b l , iz-iH 

£A^\ J 

Rl (*-8 

Composite Readings 

(Bag) 

11 

P 

XRF Correcte h d Value - > 

(use calibration chart or add 

20% to value) 

DZ IZ-IH 

Composite Readings 

(Bag) 

111 

iK 

tHO 

XRF Corrected Value - > 

(use calibration chart or add 

20% to value) 

^A,-\t i 

Composite Readings 

(Bag) 

l^fl 

m 

XRF Correcte m d Value —> 

(use calibration chart or add 

20% to value) 

Composite Readings 

(Bag) 

XRF Corrected Value - > 

(use calibration chart or add 

20% to value) 

Composite Readings 

(Bag) 

XRF Corrected Value —> 

(use calibration chart or add 

20% to value) ^.-^—<i 

Property ID 

Property 

Address 

Measurement 

Count/Time 

Field Shots 

Shot # 

Composite 

Average 

(Bag) 

& J 

/»3 

Composite 

Average 

(Bag) 

H I 

ifo 

11786 

2yM ^ ^ 37 Zl ,S. 

Reading Sample Area 

Composite Analytical Lab Analytical 

(Dried & Spilt Sent Number Results Sieved) ? 

Pass/Fai l ? 

Composite Analytical Lab Analytical 

(Dried & Spilt Sent Number Results Sieved) 7 

Pass/Fai l ? 

Composite 

Average 

(Bag) 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

•? 

Lab 

Number 

Analytical 

Results 

ISO 

I9S 

Pass/Fail ? 

Composite 

Average 

(Bag) 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

7 

Lab 

Number 

Analytical 

Results 

Pass/Fail ? 

Composite 

Average 

(Bag) 

Composite 

(Dried & 

Sieved) 

Analytical 

Spilt Sent 

•? 

Lab 

Number 

Analytical 

Results 

i 

IJSt ADDI I lilHAI SHtr n I I 

XRF Technician's Signiture N i l III II 
o.e<^^ 

- * 

COASTA L ENVIRONMENTA L 

C H C U P , INC . 

Consent For Acces s 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 Narr \j\t\HV(><\Uu^ ' Daytime Phone: f^ ^ ^fc/ ^ 

Address of Property 

covered by ttiis 372( 5 zq-sT 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 al! 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 
t^^~T~^j *

 r n * « T & I \ "' " , / COASTAL ENVIRONMENTA L 

CROUP . IN C 

• 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; 

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

property to perform the work. 

• Allow videotaping and/or photographing of the 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. 

I grant 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 
Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of the property 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 Slates Environmental 

Protection Agency (EPA). 

Property ID: /^7 ^ 

Property Address: ^ "7/^A 3 ^^^"^ ^ 

Owner: //rTT^ ^ ^^^ 4 

Phone: Z^^^^'^^ ^ 

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 t>pes, etc. Indicate digital photos 

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

Items To Be Remove d By Owner Before Start Of Remediation: 

(Use additional stieets as necessary) 

•"he rencval, storage, disposal, and.'or return of these items is the Owner's responsibility. 

Item: 

Item: 

Item: 

Item 

Item: 

Item: 

Item: 

Item: 

Page 1 of. 
COASTA L 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additional sheets as necessary) 

Item: /\ 

tp po^SCBt^" 

Item: , 

t ^ \ ] / VuAy ^ 

""'5MA^( plM/tS-^BUSK^S 

Item: 

Item: 

Item: 

Item: 

! Item: 

Item: 

Item: 

1 

1 

Item: 

I Item: 

Item: 

Item: 

Item: 

Page 2 of. 
COASTA L 

Items To Be Remove d By Contractor Durin g Remediation An d Replaced 

(Use additional sheets as necessary) 

Item: Soh 

Item: 

S^ii-- Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 3 of. 
COASTA L 

Landscape Inventory 

(Use additional stieets as necessary) 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

iTunk diameter 

1 

Number of trees • = 2 inch 

trunk diameter 

1 

1 

Number of Sprinkler 

! Zones. Control Valves. 

1 Timers. Heads, etc. 

•-.lUivli a skcici; i-;' :''r 

:.:ir:,-.kle:' !i;;. ova. 

Number of and size of 

each garden flower bed 

area. 

^i.'c- ;;:"ij. !oc:iIio;•:^. 

Quantity Unit Condition/Type/Species 

Square feet 

Each 

^ 

t 

Each 

^ 

1 

1 

1 

(A Each 

i 

i 

. 0 Each 

Square Feci 

Page 4 of. 
i 

Item Quantity Unit Condition/Type/Species 

Agreed upon value of 

plant materials not to be 

replaced bv contractor. 

Note this \alue will be 

used to issue a plant 

\oucher to the propert> 

o\> ner. 

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a bkeich o\' were 

each plant \\\\\ he placed 

b\ ihe contracio!'. 

.Agreed upon area of 

properTN lo be replaced 

v\iih grass sod. 

::i.-k:ile .. -^L-U•:l >:' .! r 

,.:'eui>! U' :~t.' :cri.i.c.:: ••;'". 

1 .Area of Cir> or Count\

1 prope.rn to be landscaped 

' per iheir requirements. 

.:'! _ 1. : t: v ^ .-.t'lv"'' ' , •: • . 

Easement .Area, to be 

excavated 

0 $ 

Each 

( ^ 

SF 

j ^ . 

^ 

t>eTaziuoJd! 

SF 

SF 

Page 5 of. 
COASTA L CNVIMOMMIMTAL C n O U P , INC . 

Additional Comments / Instructions: .~^^ ( ^ i r Nv x-% 

CU 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. 

f-^I agree agree 

2 ^ td ?c.lcn 

Owner's Signatup^ A Dat atee 7 V f nntrarfnr'« ^iai 7 Contractor's Signature Date