## TRANSMITTA Lof OMAH A LEA D SIT E SOU

- REMEDIATIO NFIL EFOLDE R
SAI D # : 

# Date : I ^\z A (( Address : . "ZT^jl ^ S^^O ^ ^^ ^ Remediatio nContractor : ^Coasta l Environmenta l Group ^ 

# Year : 2^7 7
SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S Jdr

— Vide o of propert y (DVD ) 

## ^ y GExecutiv e Summar y iy EPA-provide dproperty sketc h LL y Signe dAcces s Agreement fo r subject property
• E " Signe dAcces s Agreement(s ) for adjacen t propert y L^y ^ Restoratio nAgreement -S

— Settlemen t document s (i.e. , for damag e o r t

o replac e plants , etc. ) Confiimatio ndata As-built sketc h ^ 

### Satisfactor y restoratio nsigne db y Property Owner Propert y close-out check lis t signedb y EP A Descriptio nofarea s no t meetin g RO D cleanup criteri a I—

> 

# y tilit y clearance s Propert y informatio nfro mDougla s Count y Assessor' s Oflic e

/".N ^ ^ ^ ^ 

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### 3026130 3 

# iinmiMH i Superfun d

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. n D

WOR K

STARTE D WORKCOMPELTB D ON : / / ON:__/__/
_ 0^TM«^'^=i!L\nAtf\ A?A»i\d{A A Address : - ^

Phone: 402
. 0^^.130 0 Fax : r*5Y*nai*.viS<""«'- = phone : Fax : Ccll/Pager : Additiona l Information : 1

Ccll/Pager : D J[ Q 0 D D IZ

I ^ D Q D Notificatio nUtte r Acces s Agreemen t Restomtio nAgreemen t Topsoi l Samplin g (i f applicable ) Disposa l Samplin g (if applicable ) Garde nSamplin g (if applicable ) Utilit y Clearanc e Video/Photo s (Before ) Video/Photo s (During ) Video/Photo s (After ) Sent : / / Signed : iQ/gsL/lL 

## Signed : J O AL/I L / / / / / / 

## Called : lO/Zjyl L On : / / On : / / On : / / By : 

## By:B.Muyrtt ^ 

## ^y^UixftavA ^ By : a By : By : 

## By:3.U^< A By : By : By : D D 1 D Video/Photo s (30-Day ) Propert y Completio nAgreemen t

Final Repor t On : Signed : Issued : /

/ / / / / By : By : By : Ai r Monitorin e (a s ai>plicabl c O Community D Cre w Results : On : / / By : 

# 1
D Community Results : Q Cre w On : / / By :
. C

D Community 1 Results : D Cre w On : / / By : 1

Omah a Lea d Sit e

### IRT H On e Cal l Pag e 1 o f 1
Digger s Hotlin * O f Nebrask a 

# JXtt l

Hom e Ticket Ticke t Creatio n Logou t Creat e Anotiie rTicke t G o t o Hom e Pag e Sen d Emai l

• YOU R TICKE TNUMBE R I S 2883765
. 

# i

Origina l Cal l Date : 10/22/1 1 Time : 1:3 2 p m Op : WENDY18 7 9 0 Wor k t o Begi n Date : 10/26/1 1 Time : 7:0 0 am State : N E County : DOUGLA S Place : OMAH A Address : 281 6 Street : SEWAR D S T Twp : 15 NRng : 13 E Sect-Qtr : 16-N E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D REMEDIATIO N Locatio n o f Work : INCLUDIN G EASEMEN T AN D U P T O PEDESTA L Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : EMAI L AL L CLEAR S TO : WLARA@COASTALGRP.NE T : UNSUR E O F CORNE R LO T Compan y COASTA L ENVIRONMENTA L SERVIC E Contac t Nam e WEND Y LAR A Phone : (402)991-119 9 Alt . Contac t JOS E CARDENA S Phone : (402)504-098 1 Wor k Bein g Don e For : COASTA L Dept h o f Excavation : 4 F T Corne r Lot : NFront : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N COXCAT V LEVEL 3 MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Utilit y Servic e Are a Nam e Contac t Plion e Number s Cod e Typ e COXCAT V CO X COIMIVJUNICATION S ELIVJCG X ELMCO X Day : (406)72 8 - 934 3 IN C Alt : (406 ) 32 7 - 293 6 Emerg : (888 ) 72 8 - 934 3 LEVEL 3 LEVEL 3 COMI^UNICATIONS , LEVEL 3 LEVEL 3 Day : (877)36 6 - 834 4 LL C Emerg : (877 ) 366-834 4 I^UDO l I^IETROPOLITA N UTILITIE S SAND YMUDO l Day : (402)50 4 - 782 3 DISTRIC T Emerg : (402 ) 50 4 - 797 0



### http://www.dhon.org/IRTHOneCall/Ticket/TicketCreation.aspx?ViewTicketID=87110 8 10/22/201 1

## 20'1^^^ ^ N 

# ea/GtSeuiard67

- Printed : Oct 28 , 201 1 www.dcgis.org/dogi s 

# A

## Wend yLar a 

# ^n£i i From : agt_comm(girth.co m Sent : Saturday , Octobe r22 , 201 1 7:43 P M To : Wend yLar a Subject : Respons e t o Di g Reques t

To : COASTA L ENVIRONMENTA L SERVIC E Attn : WEND Y LAR A Voice : 402991119 9 Fax : 877662421 1 Re : Respons e t o Di g Reques t Thi s i s a n importan t messag e fro mOmah a Publi c Work s replyin g t o you r reques t t o locat e ou r undergroun d facilitie s i n a n are a describe d o n th e on e cal l cente r ticket .

Ticket : 288376 5 County : DOUGLA S Place : Omah a Address : 281 6 SEWAR D S T OMAHACO F (Sewer) : Cit yo f Omah a Sewer
- N o Conflic t pe r inf o o n th e on e cal l ticke t OMAHACO F (Traffic) : Th e Cit yo f Omah a Traffi c Engineerin g Divisio n ha s determine d ou r facilit yi s no t i n conflic t wit h th e di g sit e provide d b yth e on e cal l center .

I f yo u hav e an yadditiona l question s pleas e contac t Omah a Publi c Works .

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .

## Wend yLar a 

# 3n ^ From : I RTH
. Net@qwest.co m Sent : Monday
. Octobe r24 , 201 1 4:1 2 P M To : Wend yLar a Subject : Messag e fro m Qwes t

To : COASTA L ENVIRONMENTA L SERVIC E Voice : 482991119 9 Re : Messag e fro mQwes t Attn : Fax : WEND Y LAR A 877662421 1
Messag e fro mC^wes t

Ticket : 288376 5 County : DOUGLA S Place : Omah a Address : 281 6 SEWAR D S T QLNNEIC : Th e describe d di g are a o f you r locat e reques t ha s bee n checke d an d i s clea r fo r (Jwes t Communication' s Loca l Network . I f yo u hav e an yquestion s pleas e cal l Qwes t a t 1-800-283-4237 .
Messag e fro m(Jwes t

Thi s messag e wa s generate d b ya n automate d system . Pleas e d o no t repl yt o thi s email .

### Wend yLar a ^ \^ ^

/ From : Sent : To : Subject : IRTHNet@level3.co m Saturday , Octobe r22 , 201 1 1:4 2 P M Wend yLar a Respons e t o Di g Reques t

To : COASTA L ENVIRONMENTA L SERVIC E Attn : WEND Y LARA Voice : 402991119 9 Fax : 877662421 1 Re : Respons e t o Di g Reques t Thi s i s a n Importan t Messag e fro mLeve l 3 Communication s replyin g t o you r reques t t o locat e ou r undergroun d facilitie s i n th e are a describe d o n th e On e Cal l Cente r ticket .
Ticket : 288376 5 County : DOUGLA S Place : Omah a Address : 281 6 SEWAR D S T LEVEL3 : Leve l 3 Communication s ha s determine d ou r facilitie s ar e clea r o f th e di g sit e describe d byyou r On e Cal l Cente r ticket . Leve l 3 Communication s wil l no t hav e t o locat e an yundergroun d utilitie s a t thi s di g site . I f yo u hav e an y questions , pleas e contac t Leve l 3 Communication s a t 1-800-441-0223 .

I f yo u hav e an yquestions , pleas e contac t Leve l 3' s Asse t Managemen t Tea ma t 1-800-441-0223 .

Thi s messag e wa s generate d bya n automate d system . Pleas e d o no t repl yt o thi s email .OLS#:9133 1 

# As-Buil t Drawin g COASTA L DAT E EXCAVATED:10/28/1 1 DAT E USEP ASIGNE D OF F :11/09/1 1 Environmenta l (iroup , Inc
. ARE ASODDED : 225 0 

# Omah aLea dSuperfun dSite

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. F2 •• Fron t Right
. B l = Bac k Left
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. G Z = Garden , PZ = Pla y Al t quadrant s ar e as viewe d fro m th * atrattt , facin g |

DRI P ZON E EXCAVATE D QUADRANT S EXCAVATE D CONCRET E

ARE AREPLACE D WIT H ARE ALEF TBAR E ARE AREPLACE D WIT H SO D ROCK/MULC H 

### CONTRAC T #: EP-R7-09-0 6 COASTA L ENVIRONMENTA L GROUP , INC
.

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# ENTERE D 

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## 9133 1 Exterio rPain t Nortt i Anw » Omah a Lea d Sit e • Goo d Sit e Sketc h n Poo r Samplin q Address : 281 6 SEWAR D S T ( 2 No t pain t 

# }

Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collectej d Fim, : FD A^\AJ-C C RYASCPXA-9133 1 F l 

## _L3Ji
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## D Date : 11/// 6 7 RYBSCPXA-9133 1 F 2 

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## D Sample s Analyze d RYDSCPXA-9133 1 B 2 pp m 

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## D ROZOOPXA0 1 oa i G Z pp m 

## D Date : 1 1 'tjL'/ n 

## D nPZCCPX A0138 1 P Z pp m 

## D Time : M 

# n D Staff : AlSu / Numbe ro f Sample s = i l \ Legend : F l = Fron t Left , F 2 = Fron t Right , B l = Bac k Left , 8 2 = Bac k Righ t DZ = Dri p Zone , G Z = Garden , P Z = Play Al l quadrant s ar e a s viewe d fre m tt w8treet.raci n g propert y 

# EINTEEED'
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## Con$<?r di mAcces s To Pfop&rtj ' RIGH TO F ENTR YT O PREMISE S 

### Granto r(th e propertyowner) consenl s t o an d authorize s th e Unite d State s Environmenta l Protectio n Agenc y(EPA ) o rits 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 : 

### Daytime Phone :



### ALLJAIOCI : 

## TSiD^ : cctAii/\/tJ^i y
Addres s o fPropert y covere d b ythi s Agreement : 

# LSik— ^ &uyAtL O ^ PURPOS E O F RESPONS E ACTIVITIE S 

### Th e EPAi s requestin g acces s t o collect soi l sample s an d remove 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 contact th e Granto rin-perso n t o discus s th e wor k t o b e perfomned , th e Granto rwil l have a n opportunityt o revie wan d approv e th e planne d soi l removal , an d restoratio n wor k befor e i t begins
. Once 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 property ha s bee n remediated
. ENVIRONMENTA L RESPONS E ACTION S 

### B

ysignin g thi s Acces s Agreemenl , th e Granto ri s grantin g th e EPA , it s employees , contractors an d subcontractors 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 f2COfcSVfc l m-vitoawiitit i 6 1 o v* t i n t 

### *Remov e obstruction s includin g l>oats , trailers , vehicles , playscap e ftems. , vcoo d piles , do g houses , etc ; •Remov e flovi^ rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma ywis h t o save ; « Wate ran d maintai n leplacemen t vegetation , includin g fertilize rapplication , a s necessarj ' subsequen t t o a n inrtia l waterin g perio d b yEPA ; «

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 lenan l approva l fo racces s t o th e propert yt o perfor m th e work
. «Allo wvideotapin g and/o rphotographin g o fth e property
. AGREEINEN TNO TTO 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 l o us e th e propert yi n suc h a manner . Shoul d yo u hav e an yquesiion s abou t thi s program , pleas e contac i Coasta l Environmenta l Group , a t (402 ) 991-119 9
^ 1 I gran t acces s t o mypropertie sQ I d o no t gran t access t o mypropertie s 

# TJ-l l Signatur eDat e

D

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

Page 2 o f2

### VJ COA S T AL 

## Restoratio n Agreemen t The purpos e of thi s agreemen t is to provide amutua l agreemen t as to condition s ofth e propert y prior to remediationactivities
. Thi s will als o serveas documentationfo r th e purpos e of assuring tha t restoration activitie s ar e completed to the satisfaction of the propert y owne r an dth e UnitedState s Environmenta l ProtectionAgency (EPA)
.

Propert y 111 : <- [ |3^ ) 

# ^1^ 1 Propert y Addrenn : -^^/ ^ ^OU^.'O L

Ur,7_'U/ L^<i„ ^ Owner : : '^lo2^'^/l^.^<hr ^ Phone : ^;fc?2
. "^(l"

- "Z"}* ^ Onthe attacheddiagram(s ) indicat e area(s ) to excavate , surface structure s an dlandscapin g feature s an d acces s location(s )tobe use d

by the contractors . Indicat e distances , depths , materia l types , etc . Photographicall y an dVideographicall y documen t the existing condition s ofth e propert y an dthe basemen t if necessary . 

## Item s to be Remove d byth e Owne rbefor e Start ofRemediation : Th e removal , storage , disposal , and/o rretur n ofthes e item s is th e Owner' s responsibility
. Item : ^6>o e Item : 

### Kem: Kem :


## Item s to be Remove d byth e Contracto rDurin g Remediatio n an d No t Replace d Item : 

## o/vr Item : Item : Item :

Pag e 1 of
.

## k l COA S TAL • NVIRONHB N TAL G • O U F
. INC
. 

## Item s t o B e Remove d B y Contracto r Durin g Remediatio n an d Reolace d Item : 

### sS^S.t > Kem : 

### ^£>2' U Item : Item :



## Ite m Pre-existin g propert y area , that wil l b e excavated , tbat i s coveredwithgrass . Numbe r o f tree s > 2 inc h tnin k 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 . Attac hasketc ho f th e sprinkle r layout
. Nimibe r o f an dsiz e o f eac hgarden/ flower be d area . Attac hasketc ho f relative size s an dlocations
. Agree dupo nvalu e o f plan t material s no t t o b e replace db v contractor . Not e thi s valu e wil l b e use dt o issu e aplan t vouche r t o th e propert y owner . Easemen t Area , t o b e excavate d 

## Landscap e Inventor y Quantity Unit Conditionn'ype/Specie s Quadrant s 

# h 7 F,nc h 

## A) M

/ Eac h 

### / 

# A Eac h

Eac h ^ Squar e Fee t



# f $

Fac h 

# ys o Pag e 2 of
.

## v s COA S T AL • NVIKONHBNTAI
. GROUP
. INC
.
AddKiona l Comment s / Instructions : Th e cit yo fOmah a ordinance s ma yprohib Kyo u fro m usin g dir t o rgrave l area s o n you rpropert y a s driveway s o rvehicl e parkin g areas . Th e Environmenta l Protectio n Agenc y(EPA ) ma yb e removin g an d replacin g soi l underlyin g a grave l o rdir t are a o n you rpropert ytha t yo u ma yl>e usin g a s a drivewa yo rvehicl e parkin g area . I fthi s i s th e case , yo u shoul d understan d tha t thi s removin g an d replacin g o fsoi l doe s no t mea n tha t an yillega l drivewa yo rparkin g are a o n you r propert yi s mad e legal
. T o th e contrary , yo u ma yt> e cite d b yth e cit yi fyo u us e a grave l o rdir t are a a s a drivewa yo rparkin g area , no t wKhstandin g an yremova l o rreplacemen t o fsoi l b yth e EP A I fyo u hav e an yquestio n abou t legalit yo fa certai n drivewa yo rparkin g area , yo u ma ycontac t th e cit yo fOmaha' s Plannin g Departmen t a t (402 ) 444-5150
. n Pleas e chec k thi s lio xi fyo u understan d th e informatio n outline d above
.

[ ^

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
. 

### Q I d o no t agre e 

# }o7'zi/i i iai aI 

### Date Pag e 3 of
.# 

## BVID # 7/J 3 I XR F PROPERT YSAMPL E SHEE T Dat e Projec t XR F ID #

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# o 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 13 5 Mod e Soi l Tim e 2011-11-0 5 09:1 2 Duratio n 91.0 0 Unit s pp m Sigm a Valu e 2 Sequenc e Fina l Flag s AVERAG E Av g o f132-13 4 ADDRES S 281 6 sewar d s t QUADRAN T B 2 DEPH T 4 " XR F TEC H N
. LOPE Z MIS C confirmatio n NOT E confirmatio n

P b Supervise d By :

# Therm o SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , MA0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 222.66 8 Supervise d By : 

## Certificat e o fVerificatio n

13 2 Soi l 2011-11-0 5 09:1 1 30.1 9 pp m 2 Fina l 9133 1 281 6 sewar d s t B 2 4 " N
. LOPE Z confirmatio n confirmatio n

± Erro r ± 22.87 4SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 232.59 4 Supervise d By : 

## Certificat e o fVerificatio n

13 3 Soi l 2011-11-0 5 09:1 2 30.2 4 pp m 2 Fina l 9133 1 281 6 sewar d s t B 2 4 " N
. LOPE Z confirmatio n confirmatio n
Erro r ± 23.18 3

# Oi©E°Enrti ® SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 224.07 5 Supervise d By : 

## Certificat e o f Verificatio n

13 4 Soi l 2011-11-0 5 09:1 2 30.5 7 pp m 2 Fina l 9133 1 281 6 sewar d s t B 2 4 " N
. LOPE Z confirmatio n confirmatio n

± Erro r ± 20.42 8

# c Therm o

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

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s AVERAG E ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

P b Supervise d By : 

## Certificat e o fVerificatio n

13 9 Soi l 2011-11-0 5 09:1 5 91.3 8 pp m 2 Fina l Av g o f136-13 8 281 6 sewar d s t E A 1 " N
. LOPE Z confirmatio n confirmatio n

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

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 57.53 0 Supervise d By : 

## Certificat e o fVerificatio n

13 6 Soi l 2011-11-0 5 09:1 4 30.5 2 pp m 2 Fina l 9133 1 281 6 sewar d s t E A 1 " N
. LOPE Z confirmatio n confirmatio n

± Erro r ± 12.18 8SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 43.51 6 Supervise d By : 

## Certificat e o fVerificatio n

13 7 Soi l 2011-11-0 5 09:1 4 30.2 9 pp m 2 Fina l 9133 1 281 6 sewar d s t E A 1 " N
. LOPE Z confirmatio n confirmatio n

± Erro r ± 12.65 8SCIENTIFI C Therm o Fishe rScientifi c 90 0 Middlese xTurnpik e Billerica , M A0182 1

XL3t-3902 2 Readin g N o Mod e Tim e Duratio n Unit s Sigm a Valu e Sequenc e Flag s BVI D ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

pp m P b 54.04 5 Supervise d By : 

## Certificat e o fVerificatio n

13 8 Soi l 2011-11-0 5 09:1 5 30.5 7 pp m 2 Fina l 9133 1 281 6 sewar d s t E A 1 " N
. LOPE Z confirmatio n confirmatio n

± Erro r ± 11.93 5

## i^^A^\ Omah a Lea d Site—Fixe d Pric e EP-R7-09-0 6 8 ^^^yI Coasta l Environmenta l Grou p Inc
. Vf^^Jfwww.coastalhazmatco m

^^tPHOi*' ^ COASTA L IHVItONMINTA L C • O U P , IH C 

# EXECUTIV ESUMMARY : BVID #91331

- (281 6 SEWARD ST )

~x | No Issue s o r Concern s [ ^ Issues/Concern s Detail Explanation :

## Propert yCompletio n Agreemen t I'lii S agreemen l documenl s the complciiono f remedia l aciivme s perloime do nm y properly
. M y signature wil l designat e lha l I a msalisfiedwit hIh e restoraiio no f m y properly , an dlha l n o items ar e i nquestions , now , o r a

l any lim e i nth e fuluie , excep l thos e Hem s listedbelow , ifan y Propert y ID : ^^^^ | 

## '''^"P^"^^''''^""!^ ^ 5(Hi\yc ^ > V Phone : 

## H02 , ^Htf t ?.3g Q Restoratio nItem s i nQuestion : Item : Item : Item : item : Item : Item :

pC

J 1 aj;''" ^ iwtorniio nw complcied , excep t a s noier i [_

J I rto nn t aure c resioratio ni s complete d 

# on.-i f -07'i tSJfiL f 

## EP APropert y Clos e Ou t For m
Date/rime : \ \ Quad s Excavated : Contrscto r Crou p fa/l<4fO . 

### -&3 ^ Excavatio nGenera l 1
.I f necnsaiy , wer e th e correc t quadrant(s ) excavate dan drestored ? 2
.I f necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? Gradlp g So dan dVegelatio B 1
.Doe s lh e gradin g aroun dth e perimete r ofth e hous e inexcavate darea s generall y slop e awfa y from(h e house ? 2
.Ha s so dbeenlai di nal l area s that wer e excavated ? J
.Doe s th e so dappea r to b e generall y health y an dgrowing ? (Onl y evaluat e ifinspecte da t a3 0 da y tim e period ) A

.Ar e sodde darea s generall y firman devenl y graded ? 5
.

Ar e th e joint s twtwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecie da t a3 0 da y tim e period ) 6 .Wa s th e property grade dsuc hthat wate r wil l no t poo l onth e property ? 7
.

Wa s damig e t o landscapin g o r plan t material s avoided ? Gates , Fence s an dRctoinln g Wall s 1
.D o gate s tipenan dclo.^e freely ? fl f applicable ) 2
.Wer e al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (I f applicable ) .1
.

Wa s damag e t o gate s or fence s avoided ? (Ifapplicable ) .4
.Wa s damag e t o retainin g wall s avoided ? (Ifapplicable ) Foundation , Sidia g an d Gutle n 1
.Wa s damag e t o th e sidin g o rtri m avoided ? 2
.

Wa s damag e l o th e foundatio n avoided ? 3
.Wa s damag e l o window s avoided ? A
. Wa s damag e t o window s o rdoo rscreen s avoided ? 5.Wa s damag e t o downspout s o rdownspou l extension s ovoidcd ? Sidewalk s an dDriveway s (Concrete ) >. Wa s damag e l o drivewa y surface s avoided ? 2
.Wa s damag e t o walkwa y surface s avoided ? Yes N o / 

# y Ye s M o



### / 

# y y y y 

# y 7 Ye s N( ^ 

## 7 

# y /y Ye

s No / / / / / Ye s N o 

# 7 /

## Oft'oer s cominents :

In.<pect56nnotes :

I. -



## Removal andrestoratio naclivale s complete includin g lhe 30-da y so dwarranty : F.P ARepresentativ e 9 ^ ' ^ D^g
. ^\\^^\'^

# "> 7 0
Propert y Owne r Assessmen t o f Performanc e For m America nRecovery an dReinvestmen t Ac t (ARRA ) Omah aLeadSuperfun dSit e 201 1 Remediatio nContractor : COASTA LEnvironmental Grou p - EP-R7-09-0 6 Property Identifie r Number : Q \331 , , Property Address : f.^p p 5^ll>ar d ^ . Property Owner' s Name : f^\)iai\[ p ^\xi\.d\f\e \^mvAWts.^ ^ \ (Abov e informatio nt o b e filledoutb y th e remediatio ncontracto r prio r t o utilizatio nb y th e EP ACOR ) 

### Instruction s t o th e Propert v Owner : Thi s for mserve s t o recor dth e Property Owner' s assessnien t o f performanc e (Incentiv e 1

- Quality Assuranc e Surveillanc e Plan ) involvin g th e liste dremediatio ncontractor , a s applicabl e t o th e Omah a Lea dSite
. Thi s for mdocument s th e timelines s o f ptinc hlis t resolution , busines s relations , complain t resolutio nan dth e overal l quality o f work
. I f nee dbe , th e Propert y Owne r ma y utihz e thi s for mt o recor d problem s and/o r issue s no t specificall y tie dt o anassigne daddress , fo r example , busines s relation s that generall y don' t follo w guideline s set fort hi nth e Performanc e Work Statement
. Th e Propert y Owne r wil l indicat e his/he r assessmen t o f performanc e wit hth e contractor' s wor k b y checkin g anumerica l ratin g o nth e tabl e belo w usin g th e numerica l de^nition s fromth e ratin g scal e below , the nsig n& dat e th e form
. 9-1 0 "excellent " 7- 8 "ver y good " 5- 6 "acceptable " 3- 4 "poor " 1-

2 "ver y poor " Propert v Owner' s Assessmen t o f Performanc e Regardin g th e Contractor' s Wor k 1 0 —j!:^ ^ 5 9 4 8 3 7 2 6 1 

# X

Additiona l Comment s fro mPropert y Owne r (optional ; continu e o hbac k pag e i f needed )

Property Owne r Signature : 

# i\iii4^'^^^---

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