Property Access Checklist 

Property ID: ^Z-lcSSL? 

D WORK STARTED ON: 

D WORK COMPELTED ON:_ 

Property Address: L\'p ^ ^ NIA<W ^ St * 

0>yncn 

Loi Renter s Rm^e,r\ 

Address Phone: : -y 

Hi m MasDA5f 

Fax: 

Cell/Pagen 

Phone: Additional Information: 

4*^ ^'^'=1? 

Fax: 

Cell/Pagen 

D Notification Letter Sent: / / By: 1 

^ Access Agreement Signed: 9_/i.09 . By: 

^ Restoration Agreement Signed: 3_/^/ ^ By: 

D Topsoil Sampling (if applicable) / / By: 

1 

D Disposal Samplhig (if applicable) / / By: 

D Garden Sampling (if applicable) / / By: 

D Utility Clearance Called: / / By: 

O Video/Photos (Before) On: / / By: 

D Video/Photos (During) On: / / By: 

D Video/Photos (After) On: / / By: 

D Vldeo«»hot08 (30-Day) On: / / By: 

D Property Completion Agreement Signed: / / By: 

D Final Report Issued: / / By: 

_ ^ 

Air Monitorine (as applicable 

D Community QCrcw On: / / By: 

Results: 

D Conununity QCrew On: / / By: 

ResuHs: 

Q Community QCnjw On: / / By: 

Results: 

Omaha Lead Site 

30054794 

nniii 

Superfund 
Douglas County Account Ii]|Hjmatio o&aas n Page 1 of2 

Douglas County, Nebraska Property Record - R1618640000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - Viev ^ O n Ma p Information is valid as of 2009-8-3 Treasurer's Tax Report 

Nevw Feature - • ^ - • Auto Sales Search 

Owner 

ENGMAN LOIS M 

4247 MASON ST 

OMAHA NE 68105-0000 

Property Informatio n 

Key Number: 1864 0000 16 

Account Type: Residential 

Parcel Number: 1618640000 

Parcel Address: 4247 MASON ST 

OMAHA NE 68105-0000 

Legal Description: LEAVENWORTH HEIGHTS LOT 222 BLOCK 0 45 X 108 

Value Informatio n 

Land Improvement Total 

2009 $5,600.00 $82,800.00 $88,400.00 

2008 $5,600.00 $82,800.00 $88,400.00 

2007 $5,600.00 $82,800.00 $88,400.00 

2006 $5,600.00 $82,800.00 $88,400.00 

2005 $5,600.00 $64,500.00 $70,100.00 

2004 $5,600.00 $64,500.00 $70,100.00 

Sales Informatio n 

Sales Date: 2008-07-25 

Deed Type: QC Booilr: 2008 Page: 075779 

Price: $0.00 

Grantor: SOUKUP CINDY R 

Grantee: ENGMAN LOIS M E 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.11 4860.0 1.0 108.0 45.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accoimtinfo.jsp?accountno=R16... 8/22/2009 
Douglas County Account Injamatio ij^jma n Page 2 of2 

Building 1 

ism TI 

" Silt * ^— ^ 

l!?!.^ 5.*IAPJ"——-

RANCH 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE ] 

Square Footage: 1002.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: Ranch Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Frame Stucco Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.0 

Floorcover: Allowance Foundation: 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1916 0% 1916 90 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Blocl< 8 ft 974.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 308.0 

Porch End Screen 160.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R16... 8/22/2009 
CONTACT FORM 

Property ID # 

Property 

Address: 

Initial Contact: 

Second Contact: 

Final Contact: 

Final Action: 

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 

x\C)*hW 

M?.^-^ ^^Q.soK^ SV 

Date: Time: 

Date: Time: 

Date: Time: 

Transmit to EPA D 

Action: 

Action: 

Action: 

Other Action: D 
Page 1 of2 

# 

"> 

Create Another Ticket |rj^ Back to Irth internet , ] SendEmaXI ] iL-.u. i > ­

• YOUR TICKET NUMBER IS 2362527. 

Original Call Date: 9/12/09 Time: 6:28 pm Op: ELIZABETH18790 


Work to Begin Date: 9/16/09 Time: 7:15 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 4247 Street: MASON ST 


Twp: 15N Rng: 13E Sect-Qtr: 20-SE-SW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: lead remediation 


Location of Work: LOCATE ENTIRE PROPERTY, ALL EASEMENTS AND TO THE PEDESTAL 


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: 4ft Comer Lot: N 

Involves Tunneling or Horizontal Boring : N 

Front: Y

Explosives: N 

 Rear: Y 

ALTS72 

UNOTEL 

BSHPCLKS CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 

Service Area Contact Phone Number 

UtiUty 

Type 

ALT872 WINDSTREAM COMMUNICATION NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

BSHPCLKS NEBRASKA HEALTH SYSTEM NA 

Day: 4025523460 

Alt: 4025523347 

Emerg: 4025595111 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

Day: 4025047823 

METROPOLITAN UTILITIES MUDOl DISTRIC SANDY Alt: T 

Emerg: 4025047970 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.,. 9/12/2009 
Page 2 of2 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RON 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT NA 

QLNNEIC QWEST LOCAL NETWORK NA 

ANDREW UNOTEL UNIVERSITY OF NEBR/OMAHA TAYLOR 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4025543599 

Alt: 4025543036 

Emerg: 4025542648 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/12/2009 
Page 1 of2 

% 

"> 

[. _ _^Creatj3 Another Tteket j [;Ba^^ ^ InterneT Send Email 

• YOUR TICKET NUMBER IS 2365470. 

Original Call Date: 9/16/09 Time: 10:53 am Op: ELIZABETH18790 


Work to Begin Date: 9/18/09 Time: 11:30 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 4247 Street: MASON ST 


Twp: 15N Rng: 13E Sect-Qtr: 20-SE-SW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: lead remediation 


Location of Work: LOCATE ENTIRE PROPERTY, ALL EASEMENTS AND TO THE PEDESTAL 


Remarks: FAX ALL CLEARS TO: (877)662-4211 


: tJNSURE OF CORNER LOT 


Company : COASTAL ENVIRONMENTAL SERVICE 


Contact Name: ELIZABETH Phone: (877)662-4210 


Work Being Done For: coastal 


Depth of Excavation: 4ft Corner Lot: N Front: Y Rear: Y 


Involves Tunneling or Horizontal Boring : N Explosives: N 


ALT872 BSHPCLKS CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


UNOTEL 


Service Area Contact Plione Nuniber 

Utility 

Type 

ALT872 WINDSTREAM COMMUNICATION NA 

Day:

Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

BSHPCLKS NEBRASKA HEALTH SYSTEM NA 

Day:

Alt:

 4025523460 

 4025523347 

Emerg: 4025595111 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

MUDOl METROPOLITAN UTILITIES 

DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/16/2009 
Page 2 of2 

% 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RON 

Day:

Alt:

 4024447197 

 4024445161 

Emerg: 4024445160 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT NA 

Day:

Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

QLNNEl C QWEST LOCAL NETWORK NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

UNOTEL UNIVERSITY OF NEBR/OMAHA ANDREW 

TAYLOR 

Day: 4025543599 

Alt: 4025543036 

Emerg: 4025542648 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/16/2009 
OLS#: 21056 As-Built Drawing ^ Date Excavated:9/22/09 

Date USEPA Signed Off: 11/10/09 

C OASTA L Omaha Lead Superfund Site Area Sodden: 1356 so ft ENVmOMHENTAL 

; n o u r, INC . 

Name: _ Omaha Lead Site Date: ^-/^ ^ NorthArrow 

Address: Stte Sketch Time: 

Phone: 

Team "Vh^y y^A/A-^/$jK>s BVID # 7/<r5"^ XRF Code fTV O ' ^ 

Sample Number Lead Concentration Confimiation Sample 

Z 7 I XZ.J 

ppm fl-ies a No K3 

|FYft<;r Ox A - 2.)o.vC a-73 ^3 ^ 

ppm ^iYe s n No ca 

ppm ,7 I Yes Q No CB fVnSrPXA - Z/o.s£. ppm f ?Yes • No B 

ppm ^2Ye s • No ^ 

ppm Yes • No a 

ppm • No • 

IV^^C'f "//. Omaha Lead Site 46130 

Legend 

Concrete Drip Zone Excavated Quadrants Excavated 

Area replaced with Area replaced with 

Area lef t bar e Sod Rock/Mulch 

Contrac t #: EP-R7-07-05 Coastal Environmental Group Inc . 
ft 9|l(^ ^'S^l^^ r^^Qn-^^ 

1 ^: 

Name: _ Omaha Lead Site Date: ^-3^ } North Arrow 

Address; 92 1 7 t^i5oh Site Sketcti Time; 

Phone: '^p~L-^T/ - fffT -

t ^ ^^Ah ^ / . naha Lead Site 46130 
1^ 

Name: Omaha Lead Site Date: f-3^ } North Arrow 

Address: 9 1 1 7 i^i5ih Site SIcetch Time: 

Phone: '-ic -2^-^r/ - *ffT -

Team / k ^ Y x^/^/j^fe" ^ BVID # 7/.r5" ^ XRF Code 'S'FTO ^ 

Sample Number Lead Concentration Confirmation Sample 

ppm /^/Yes ° No 13 

f'^n.'^cii x A - z-iovi:. a-73 r 2.; 

ppm /"Z-Yes O No El 

ppm .7 / Yes Q No CB 

ppm /^?Ye s • No 13 

gKr^S^PKA- - :^|os-u ppm No ^ 

ppm ^ Yes • No n 

ppm Yes a No • 

hi^AAh "y/. Omaha Lead Site 46130 
.•v^'l^^V, 

COASTA l f HVIXONnihTA l 

CROUP . IN C 

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: Daytime Phone: 

Ldp, ^r. 

^i^'^i ^ 

Address of Property 

covered by this 

Agreement: ^2^7 k^on ^f. 

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 perfomied, 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 wori^. This access shall 

remain in effect until the work has been satisfactorily completed. The Grantor also 

agrees to: 

Page 1 of 2 
e 

COASTA L INVtKOMHtKTAl 

C It O U » IN C 

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

piles, dog houses, etc; 

c 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,

necessary subsequent to an initial watering period by EPA; 

 as 

« 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. 

e> 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 (402) 991-1199 

grant access to my properties 

D I do not grant access to my properties ^ 

fy^ ^ 'r-^^'^^y^^ ^ 9l7.9^\6 ^ 

Sibnature Date Signature Date 

D I would iike to be present during any sampling that is required. 

Page 2 of 2 
COASTA L 

c « o u r IN C 

Restoration Agreement 

Tlie purpose of this agreement is to provide a mutual agreement as to conditions ofthe 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 States Environmental 

Protection Agency (EPA). 

Property ID: ' 7 lO*^/; 

Property Address: t^-^ OiyviMvr- 1/2 U 7 ^ ^ ^.^v, ^ t 

Owner: l .. ^ y _ 

Phone: ^5/^ ^ 

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 types, 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 renK>val, storage, disposal, and/or return of these items Is the Owner's responsibility. 

Item: 

4-^,1 ? U . Item: 

/ 

/ 

/ 

Item: / 

Item: 

/ 

Item: / 

Item: 

/ 

Page 1 of. 
COASTA L fl >* V «ft O H r* t M T A L C It O M r . t M c 

Items To Be Removed By Contractor During Remediation And Not Replaced 

(Use additionai sheets as necessary) 

Item: 

^gt.U^t4-.Ui^ 'yy^^^jl Pl^Jb> 

Item: 

Item: 

Kem: 

Kem: 

Item: 

Kem: 

Kem: 

Item: 

Item: 

Kem: 

Kem: 

Kem: 

Item: 

Kem: 

Page 2 of. 
C g A S T A L • NVtftOMntMTAL C n o u r I N c 

Items To Be Removed By Contractor During Remediati'on And Replaced 

(Use addKional sheets as necessary) 

Item: 

" ^ /^o ; / g / 

Item: 

Item: 

Item: 

Kem: 

Kem: 

Kem: 

Kem: 

item: 

Item: 

Kem: 

Kem: 

Item: 

Item: 

Item: 

Page 3 of. 
COASTA L CN'v IRON MIM TAL C « O U r . t M C 

Landscape Inventory 

(Use additional sheets as necessary) 

Item 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch 

trunk diameter 

Number of trees <= 2 inch 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed 

area. 

Attach a sketch of relative 

sizes and locations. 

Quantity 

Bl 

1 

/ 

f 

Unit 

Square feet 

Each 

Each 

Each 

Each 

Square Feet 

Condition/Type/Species 

•^ 

Page 4 of. 
COASTA L 

Item Quantity 

Agreed upon value of 

plant materials not to be 

replaced bv contractor. 

Note this value will bc 

used to issue a plant 

vouche

owner. 

r to the property p

Agreed upon list of plant 

materials that will be 

replaced by contractor. Be 

very specific and detailed. 

Include a sketch of were 

eac

by th

h plan

e contractor

t will b

. 

e placed A

Agreed upon area of 

property to be replaced 

with grass sod. 

Include a sketch of the A 

area(s) to be replaced with 

grass sod. 

Area of City or County 

property to be landscaped 

per their requirements. 

Include a sketch of the 

area (s) 

/ 

Easement Area, to be 

excavated 

\ 

Uriit Condition/Type/Species 

$ 

Each 

SF 

SF 

SF 

^ e^i,^A\^<L^^\^< > 

Page 5 of. 
C OAST A L • MV*R«HMCHTA L • «iewr . IM C 

AddKional Comments / Instnicttons: 

^^^ \ \ toeej?. VL c^c l KJ<k.\yy.^^__ 

J^Chec k the box if Owner does not want CEG to document inferior foundation walls and possible 

pre-existing damage. By checking this box CEG is not responsible for any damage done to 4ie 

interior of house, induding tbundatton cracks or fissures. 

I agree O I do not agree 

Owner' ner'ss Signatur Signaturee Date Contractor's Sienatsre Date 

Page 6 of. 
BVID ,cZ/056 

XRF PROPERTY SAMPLE SHEET 

Date 

Project q-zjz-cpf 

Omaha lead FP 2ncl year option 

Address 

Sample time 

H2.Hh 

am/pm 

XRFID # sample length 30 sec 

Shot# Reading Sample area Shot# Reading Sample area 

<5oi 

HO 2 . 

^0 3 

'^O H 

^«n

5?

in^

^(o

 t II 

 tq t-u ti o 

^ 

Depth 

» " 

^^6U 

on 

Od 

^o ^ "\yo

/^ s

 -^ ^ 

 ^f £ 

gi 

Depth 

Average llliQ Average 17^-' ^ 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading Samplearea Shot# Reading Sample area 

Depth Depth 

Average Average 

RETEST AREAS 

Shot# Reading Sample area Shot* Reading Sample area 

Depth [Depth 

Average Average 

lab sample # Lab result Sample area XRF Avg. 

Signature ^ 

prinir,UftrtV-rtVAC^oi?€<; 
i\QL\ Omaha Lead Site—Fixed Price EP-R7-07-05 

I ^^^^A L I Coastal Envlronmental Group Inc. ^^^^ y 

^^^T # www.coa8talhazmat.com 

XpROrt?^^ COASTA L iMVIIOHNIMTAl 

GlO U P . IM C 

EXECUTIVE SUMMARY: 

BVID #21056-(4247 MASON ST) 

No Issues or Concerns [^ Issues/Concerns 

Detail Explanation: 

-COASTAL TO RE-IMBURSE THE PO FOR A CLEMATIS PLANT. (COMPLETED 01/30/10) 

-COASTAL TO PUT BACK THE CLOTHES LINE (COMPLETED 11/9/09) 
# 

Property Damage Settlement 

Property ID 21056 

Property Address 4247 Mason St 

Owner Lois Engmen 

Phone (402) 551.9392 

I have received from the contractor, Coastal Environmental Group Inc. (Coastal), the sum of $8.00 to 

compensate for plants that were removed during the removal of lead impacted soilfixjm the property. 

Compensation type Check 1884 

Value of Check; $8.00 

Check to the order of Lois Engmen 

Description of Damage 

While excavating 4247 Mason St (BVID 21056) Coastal damaged some plants beyond salvage. Property 

owner received a check for the amount of $8.00 dollars for the replacement ofthe plants and river rock. 

My signature below acknowledges the replacement of my plant; further, I acknowledge that this work 

was completed satisfactory and within my and release Coastal Environmental Group, Inc. from 

luilhei- ofrliqatlops or liability related to this property. 

1884 

OMAHA, NE 68105 

^^lio 

27-5/1040003 6247372904 

DATE 

'^^t^Acr lJ)\A fni^man $g & 

. DOLLARS 0 0»iaii* on 

WUknigogank,ltA. 

FOR W\\) 9JChifi 42H1 MM.SrtnXf- '^^VuMy^/ d^lQl^r ^ 

•1101.00005ai: &21,737Bqoi,ii- oiaai. 

C^-t-A-* t

ner's Signature Date Contractor's Signature Date 

Page 1 of 1 
EPA Property Close Out Form 

Date/Tlroc: 

Quads Excavated: Contractor Group C>0 

Excavatio Yes No n General 

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

2. If necessary, were the correct areas ofdrip zone excavated and restored? t y ^ 

Gradin Yes No g Sod and Vegetation 

1. Does the grading around the perimeter ofthe house in excavated areas generaUy slope away zr from the house? 

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

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 nrm and evenly graded? 

5. Arc the joints behveen the sod strips generally tight? (Only evaluate if inspected at a 30 day vr time period) 

6. Was the property graded such that water will not pool on the property? 

7. Was damage to landscaping or plant materials avoided? 

Gates. Fences and Retaining Walls 

1. Do gates open and clo.sc freely? (Ifappiicable) 

Were all gates or fences taken down during restoration activities reinsulled?

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

4. Was damage to retaining walls avoided? (Ifappiicable) 

Foupdation, Siding and GuHers 

I. Was damage to die siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

4 Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspoul extensions avoided? 

Sidewalks and Driveways (Concrete) 

1 Was damage lo driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

ZZ 

y 

Ves No 

zA 

 (Ifappiicable) Z7 z^n 

• y ' i 

Yes No 

^' 

y 

xy 

Yes y, No l7t 
Owners comments: 

Inspection notes: 

Removal and restoration activates cowplet* including the 30-day sod warran 

EPA Representative AJCT K U^lAJ ^ Date: \{ffO. 
% m 

Property Compietion Agreement 

Jhis agreement documenis the compielion ol remedial acliviiies perfoiined on my properly My signaiure 

Will designale ihal I am satisfied with lhe rcstoralion of my propeily, and ihal no iiems are in questions, 

now, or al any lime in the future, excepl Ihose ilems hsled below, ifany 

Property tP: C:^\Cf^L 

Property Address: L(gLtf: ^ t^A^.^OVn 51 " 

Owner: /^t S f^YXAAJ^y^APhone: ^<=5\^q' ^ 

Restoration Items in Question: 

Item: 9 u "f cUQ74e5^:nJB v^/4cK Ox" 

Item: Ci^^A^:ii> PL^ f - ^^PLx^c^ t 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

i^Jsl,«('rcc rcstoralion is complcttd, except as nolert 

[ I Irto not a^rec restoration is compleled 

Owner's Signature Date Conti actor's Signature Date'