TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID ,: L^M Date: \\'^ \u\0 

Address: ^ ^ t^^^^^ ^ ^ ^ 

Remediation Contractor: Coastal Environmental Group_ Year: _200& 

SOIL REMEDIATION 

PROPERTY nL E FOLDER DOCUMENTS 

(/ Video of property (DVD) \ ^ ' tyoCf^^il<^ 

M Executive Summary 

s/ EPA-provided property sketch 

iZ Signed Access Agreement for subject property 

-£' Signed Access Agreement(s) for adjacent property 

S/ Restoration Agreement 

<3- Settlement documents (i.e., for damage or to replace plants, etc.) 

-B" Confirmation data 

B / Photographs \Vc' tT^^^V.&v[ ic f^^A^fttlt^^ 

s/ As-built sketch 

0 Satisfactory restoration signed by Property Owner 

^ Property close-out check list signed by EPA 

-B- Description of areas not meeting ROD cleanup criteria 

0 Utility clearances 

a Property information from Douglas County Assessor's Office 

30055258 

Ml 

Superfund 
Property Access Checklist 

Propc,T,ID:/^q^Oqf D WORKSTAJlTtD ON / / 

PropcmAddre»:f3|H<2^ ^)o,^ ^ ^ ^ D WORK COMPELTED ON: 

Rcnier. 0>vnc.: Xctphn ^ N'ippfi. r 

Address Phone: *5cirr\je. PiLv: 

Cell/Pager: 

Phone: 5Q5^-L^<^; D Additional Inlnrmiition; 

F<-i: 

CclL/Pagen 

D Notificiition L«llcr Sent: / / By: 

E f Access Agreement Signed: % / 22.1 01 

B>- flOdaKAO 

[ 0 ResiomtlOD Agreement Signed: 8-^22/139 ^y \ftr\-W\f 

1 O Topsoil Sampling (if applicuble) / / By: 

• Disposal Sampling (K applicable) / / By: 

D Ciirdcn Sampliog (if applicable) / / By: 

- ^ Utility Clearance Called: J^/^/C ^ By: 

P Video/Phofos (Before) On: / J By: 

• Video/Photos (During) On: / / By: 

n VIdeo/Pholos (Aher) On: / / By: 

D Video/Photos (30-Day) On: / / By: 

•^C^Propcrty Completion Agreement Sifncd: f^ / 'Z- /^ ^ By: 

D Final Repon Issued; / / By: 

Air Monitoring (*s applicable) 

D Community [~) Crew / / By: 

RciiuJis: 

D Comrouniti' CD Crew On: / / Bv: 

Remits: 

D Communiri D Crv^y On: / / 

Results: 

Omatia Lead Site 
CONTACT FORM 

Property ID # toM^D^ 

Property 

Address: ^)HS R]nn^(^ <;4-

Initial Contact: Date: Time: Action: 

Second Contact: Date: Time: Action:_ 

Final Contact: Date: Time: Action: 

Final Action: Transmit to EPA D Other Action: D 

Comment: 

Owner 

Comment (s): 

Site 

Coordinator 

Comment (s): 
Douglas County Accoimt InfonjMdo ril|ic n Page 1 of3 

Douglas County, Nebraska Property Record - R0842900000 

Print Report 

NEW Faature - Parcel Dimensions avaiiabie 1^ scale 0-50 ft west of 52nd St - VlO W O n Ma p Information is valid as of 2009-8-3 Treasurer's Tax Report 

New Feature ^ -» ^ Auto Sales Search 

Owner 

NIPPER ZAGHARY G 

5143BL0ND0ST 

OMAHA NE 68104-0000 

Property Informatio n 

Key Number: 4290 OOOO 08 

Account Type: Residential 

Parcel Number: 0842900000 

Parcel Address: 5143 BLONDO ST 

OMAHA NE 68104-0000 

Legal Description: COUNTRY CLUB DIST LOT 10 BLOCK 23 55 X 110 

Value Informatio n 

Land Improvement Total 

2009 $13,600.00 $134,400.00 $148,000.00 

2008 $13,600.00 $134,400.00 $148,000.00 

2007 $13,600.00 $134,400.00 $148,000.00 

2006 $13,600.00 $134,400.00 $148,000.00 

2005 $13,600.00 $134,400.00 $148,000.00 

2004 $15,100.00 $87,500.00 $102,600.00 

Sales Informatio n 

Sales Date: 2002-09-23 

Deed Type: WD Book: 2222 Page: 555 

Price: $113,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Sales Date: 1998-12-30 

Deed Type: D Book: 2115 Page: 426 

Price: $113,000.00 

Grantor: 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accotmtno=R08... 8/14/2009 
Douglas County Account Inforn^ion Page 2 of 3 rn^K 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.13 6050.0 1.0 110.0 55.0 No 

Land Attributes 

Attribute Attribute Description 

Negative Influence Traffic 1 

Improvemen t Informatio n 

Building 1 

1 1/2 Story Fin 5143 Blonde St 

WHeCta* 

tasg n 

a » 

avundFtaur 

45tC5q FT 

•Of aor . 

MHCM i?(r 20 

ISO Sa n 

it o 

UB : 

B O « • 1 aitnaip i 

CLICK TO ENLARGE IMAGE aai»ip*wW H 

CLICK TO ENLARGE JMAGE 

Square Footage: ! 1480.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: 1 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Masonry Common Brick Units: 1.0 

Interior: Drywall Baths: 3.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1929 0% 1929 80 

Detail Type Detail Description Units 

Add On Fence Wood 1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R08... 8/14/2009 
Douglas County Account Infornution Page 3 of3 rn^ c 

Appliance 

Appliance 

Appliance 

Basement 

Basement 

Fixture 

Fixture 

Garage 

Porch 

Porch 

Porch 

User 

Allowance 

Fireplace Masonry 

Security System 

Bsmnt Block 8 ft 

Finished 

Base Fixtures 

Bath Full 

Attached 

Open Slab 

Slab w/Steps 

Wood Deck 

Traffic 

1.0 

1.0 

1.0 

1024.0 

450.0 

1.0 

3.0 

180.0 

144.0 

96.0 

120.0 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R08... 8/14/2009 
Page 1 of 1 

[ Create AnotherTicket__j][ _ jagk.to^lilllJntjenri-Ql .-_.| }[ Send Email J 

• YOUR TICKET NUMBER IS 2348616. 

Original Call Date: Q/2i/0 9 Time: 5:42 pm Op: ELIZABETH18790 

Work to Begin Date: 8/26/09 Time: 6:15 pm 

State: NE County: DOUGLAS Place: OMAHA 


Address: 5143 Street: BLONDO ST 


Twp: 15N Rng: 13E Sect-Qtr: 07-SE-SW,18-NE-NW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: LEAD REMEDIATION 


.Location of Work: INCLUDE ALL EASEMENTS LOCATE ENTIRE PROPERTY LOCATE 


: ENTIRE PROPERTY, ALL EASEMENTS AND TO THE PEDESTAL 


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


: UNSURE OF CORNER LOTS 


Company : COASTAL ENVIRONMENTAL SERVICE 


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


Work Being Done For: COASTAL 


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


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number Utility Type 

CXCATV COX COMMUNICATIONS, INC HEIDI

Day: 4029340469 

 Alt: 4029340469 

Emerg: 4029329757 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY

Day: 4025047823 

 Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC.SEWER RON 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

OPPDGPR5 OMAHA PUBLIC POWER DISTRICT NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK NA 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

http://wwvi^.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 8/24/2009 
• • 

^ (P As-Built Drawing ^ ^ 

COASTA L Omaha Lead Superfund Site 

64809 

Omaha Lead Site Extenor Paint North Arrow 

Site Sketch • Good 

|~| Poor 

Sampling Address: 5143 BLONDO ST [ 3 Not paint 

Sample Number Lead Sample L A B Samples Collected 

Concentration Collected Fimi; F^ A Pg-A J 

RYASCPXA-64S09 Fl 

ppm n Date: /,-g-<?' 7 

RYBSCPXA-64809 F2 *1 1 o ppm n 

Time I P 13 A M 

RYCSCPXA-64809 B1 I H ppm i D

Samples Analyzed RYDSCPXA-64809 B2 1-12. ppm D 

RDZSCPXA-64809 DZ 2.<^2. ppm Ef n XRF Unit: IDSfo'Z. Book: ZH / 

ROZSCnXA 64800 Ggr- ppm D n Date: 7-o^-g ? 

RP2SCPXA 6'1800 -432. — ppm n Time n 

Numbe Staff: /^<v^/ r of Samples = | £> \ \ Q | 

Legend: Fl = Front Left. F2 = Front Right. B1 = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play A l quadrants are as vie>A«d from the street, facing property 

OLS#:64809 


Legend 


• Concrete ^ Drip Zone Excavated mQuadrants Excavated 

Area replaced with Area replaced with 

Area left bare 
 Sod Rock/Mulch 


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

64809 

Omah Exterior Paint a Lead Site 

Sit • Good e SIcetch • Poor 

Sampling Address: 5143 BLONDO ST 13 Not paint 

Sampl Lead Sample 

Samples Collected e Number LAB Concentration Collected Firm. FPA Pg-A,7 

RYASCPXA-64e09 Fl ppm D Date A-g-g- ? 

RYBSCPXA-648a9 F2 H I O ppm D Time II - 15 A M 

RYCSCPXA-64809 B1 i y _ ppm D 

Samples Analyzed RYDSCPXA-64809 B2 \i z ppm D 

RDZSCPXA-64809 DZ ppm Si D XRF Unit: ID8fe ^ Bool< ZH I 

RCZSCPXA 6<1800 Sg- ppm a n Date 7 - OZ-O f 

RPZ6CPXA fiiiaOO PS- ppm D D 

Time: Pr n 

Staff Numt^er of Samples = | 5 I | Q | nw 

Legend: F1 = Front Left, F2 = Front Right, B1 = Back Lett, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

A l quadrants are as viewed from the street, facing prcperty 

2. 

I' 

Rev 2001 Cmle d IO-Fct>-OQ 

/ 

^ 

i 
64809 

Omaha Lead Site 

Site Sl(etch 

Sampling Address: 51 i3 BLONDO ST 

Extenor Paint 

n Good 

• Poor 

(3 Not paint 

No^ri Arrow 

Sample Number 

f?vASCPXA-e4ao9 

RYBSCPXA-64e08 

RYCSCPXA-64809 

RYDSCPXA-64809 

RDZSCPXA-64809 

nCZGGPXA 64600 

I^PgSCPXA S'lBQO 

Lead 

Concentration 

tt» ^ ppm 

Hi O ppm 

~?H ppm 

1 7 2 . ppm 

..Z°lZ ppm 

~ ppm 

~ ppm 

LAB 

Number of Samples = $ 

Samples Collected 

ft>A Pg-A.T 

11- g AM 

Samples Analyzed 

XRF Unit |D8(bZ Book: 2 H ) 

Date 7 ­ OZ-Q ? 

Time Pf ^ 

Staff n^ w 

Legend: F1 = Front Left. F2 = Front Right, B1 = Back Left, 82 = Back Right DZ = Drip Zone, GZ = Garden. PZ = 

AJ ouadranfs are as viewed from Ihe street, facing DroD|i1y 

2_ 

::!: 

^^ 

: ^ 

i 

s 

•j ^ 

^ ^ 
64809 

Omaha Lead Site Exterior Pamt North AiTow 

Stte Sketch • Good 

n Poor 

Sampling Addratt: 5143 BLONDO ST Q Not paint 

Sample Number Lead Sample Samples Collected 

I

I 

LAB Concentration Collected Fimi: F=J>A MAr r 

RYASCPXA-€4809 Fl ppm D Date: A-e-t?T 

RyBSCPXA-64809 F2 **' 0 ppm D Time: l|:15 A M 

RYCSCPXA-64809 B1 U L - ppm D Samples Analyzed RYDSCPXA-64809 B2 ppm D 

RDZSCPXA-64809 DZ 2^2. ppm D

XRF Unit: lOBfiA Book: 2*11 

nOZeOPXA 64800—62- ppm D D Date: 7.02-0 ? 

RPZeCPXA 6<I800 PZ- ppm D D Time: P^ 

Staff:. AlW Number of Samples = | $ \ \ Q | 

Legend: F1 = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

Al qmctaitt are u viewed from ttw street, fadng property 

/ 

RwSIOt Croud: tO-F«l>4» 
COASTA L INVfRONHEHTAL 

C I 0 U P. 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: 

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, ^N\\\ 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 perfomnlng the work. This access shall 

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

agrees to: 

Page 1 of 2 
,!, ,•<' " »r<f 

> COASTAL •>

 •<P ENViaONHENTtL 

" t PRO''* 5 a o u r. I K c 

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

piles, dog houses, etc; 

e 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; 

e Abide by health and safety guidance provided by EPA; 

e 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 (402) 991-1199 

[ ^ grant access to my properties D I do not grant access to my properties 

s-n: ^ 

Signature Date 

G I would like to be present during any sampling that is required. 

Page 2 of 2 
COASTA L 

c * o u p -M r 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions ofthe properly 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: Q^H 

Property Address: ^{4 ^ ^ LV H OO ^ X 

Owner: ZA<H*^A ^ Ki^(?p«5V^ 

I Phone; ^ O I- ^Yf e 4 t 1Q 

On the attached diagram(s) indicate area(s) to excavate, surface structures and landscaping features and 

access location(s) to be used by the contractors. Indicate distances, depths, material types, etc. 

Photographically and VideographicsJly document the existing conditions ofthe property and the basement if 

necessary. 

Items to be Removed by the Owner before Start of Remediation: 

The lenoval. stora.ge, oi&posal, and/or return of these items Is the Owner's responsibility. 

Item: 

Am^ 3yyanJi plQ^) ^ 

Kem: 

Item: 

Item: 

Items to be Removed by the Contractor During Remediation and Mot Replaced 

Kem: 

AyNv^ ^m^W pl0>fi^ Wft U>.V\\K^ 

item: 

Item: 

Kem: 

Page 1of -^ 
COASTA L 

Items to Be Removed By Contractor During Remediation and Replaced 

Item: 

^ \ V -^", Vz 

Hem: 

S/10 fi F:^ 

Kem: 

Item: 

Landscape Inventory 

(tern Quantity Unit Condition/Type/Species 

Pre-existing property area, 

that will be excavated, that 

is covered with grass. 

1 

Number of trees > 2 inch 

trunk diameter 

F2. Quadrants 

Each 

Number of trees <= 2 inch 

trunk diameter 

Each 

Number of Sprinkler 

Zones, Control Valves, 

Timers, Heads, etc. 

Aiiath .-I skcich ol the 

Each 

Number of and size of 

each garden/ flower bed 

area. 

Alliith ;i skcicli 1)1 a-!;ilivi.' 

' ^i/i'S mid loc;ili(iM'. 

Fjjrh 

Square Feet 

Agreed upon value of plant 

materials not to be 

replaced by contractor. i 

u>< ner. 

Easement Area, to be 

excavated ^66 Fach p W f A ^ 

0 

Page 2 ..: > 
COASTA L 

< Additional Comments / Instructions: 

c fe V^iV^ Se7-v»5' P^/^^ S ^ ^ Uh-k:ih ^ 

• Check the box If Owner does not want CEG to document interior foundation walls and possible 

preexisting damage. By checking this box CEG is not responsible for any damage done to the 

interior of house, including foundation cracks or fissures. 

•i I agree O I do not agree 

g/ZZ/OQ 

Owittf's Signature Date Contractor's Sienatu Date 

Page 3 .1 
BVID # (oU^O ^ 

XRF PROPERTY SAMPLE SHEET 


Date %\A^ Address ^-IU? > TSlc^/NeJlD S>" 

Project Omaha lead FP 2ncl year option Sample time am/pm 

XRFID # sample length 30 sec 

Shot# Reading Sample area Shot# Reading Sample area 

-S2 ^ 

<^li?1 ^ 

H^^= ^ £A. Depth _SSX 

"^^ ^ 

,?-/ ^ f/ wzms P( PPPth 

^ab­ 3^ i^ ^ ^^^ ^ IcT^ \7. 

Average Oc> -' ^ f Average ^ / :t^ ['^^ 

Shot# 

^^^^=sAverage

Reading 

^ -i^f? •t 1 ^ 

i^ IE. -^il. 

Sample area 

FT - Depth 

 ^^-^ ^ /^-^— 

Pep 

Shot# 

Average 

Reading Sample area 

Depth 

Shot# Reading Sample area Shot* Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading 

RETEST AREAS 

Sample area Shot# Reading Sample area 

Depth Depth 

Average 

lab sample # Lab result Sample area 

Average 

XRF Avg. 

SignatureC/^Mfe< ^ 
# 

i^JJL\

i ^^^ ^ I

SL^^^J ^

%tp„oT*''^

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

 Coastal Environmental Group Inc. 

 www.coa8talhazmat.com 

 COASTA L eNVmONHIIITAl g n o u p, IN C 

EXECUTIVE SUMMARY: 

BVID #64809-(5143 BLONDO ST ) 

No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation 
S»L EPA 

EPA Property Close Out Form 

Property #: UMgCjfl „ Property Address: 

Date/Time: Owner's Name: 

Quads Excavated; ^ \ ^2 ^ Contractor Group 

Excavation Yes No General 

1. if necessuy, were the correct quadrant(s) excavated and restored? 

U ' " 

T:;^ 2.

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

Grading Sod and Vegetation 

Yes Np 

1. Does the grading around the perimeter ofthe house in excavated areas generally slope away 

from the house? , 

^ ^ 2.

 Has sod been laid Ln ail areas that were excavated? 

3. Doe

day tim

s th

e

e

 period

 sod appea

) ^__

r to be generally healthy and growing? (Only evaluate i

_ 

f inspected at a 30 V

4. Are sodded areas generally fum and evenly graded? 

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

time period) ____. V' 

6. Was the property graded such that water will not pool on the property'*! 17' 

L^^ 7.

 Was damage to landscaping or plant materials avoided? 

Gates, Fences and Retaining Wails 

Yes No 

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

I. Were all gates or fences taken down during restoration activities reinsulled? (If applicable) V 

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

1^ ^ 4.

 Was damage to retaining walls avoided? (If applicable) 

Foupdation, Siding and Gmicrs 

Yes No 

I. Was damage to the sidmg or trim avoided? ^ 

2. Was damage to the foundation avoided? 

l y 

7. Was damage to windows avoided? 

1 / 

4. Was damage to windows or door screens avoided? 

L / 

^ 

5. Was damage to downspouts or downspoul extensions avoided? 

^ 

Sidewalks and Driveways (Concrete) Yes j(o 

1. Was damage lo driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 
Ov*'ners comments: 

Inspection notes: 

Removal and restoratiop-ii^livates complete i^cli|ding the 30-day sod warranty: 

EPA Representative L JCP ^ / >?/^ic ^ Date: /t)/ ] / O f 
Property Completion Agreement 

Tills agreement docuinenls the completion of remedial activilies perlbrmecl on my property. My siginKure 

will designate Ihat I am salislied with the restoration of my property, and that no items are in qucstion.s, 

nnw, or at any time in the fulure, except those ilems listed below, ifany. 

Piopct ty II): /^ q <go ^ 

I'ropcrty Address: y| M 3 ^UrvD o S-V 

Owner: 'ZoLfJrvfpu- v ^^^£= J'honc: Moa-s^?-qqio 

Restoration Items in Question: 

Item: 

< 6 d /^o f<i ^ L t ^ o *-•/ ? ' n fyi^^ ( C^CCc ^

Item: 

Item: 

Item: 

Hem: 

Item: 

Additional Comments: -j—-'^ - ^'t ? ^ ^ ^ ^ ^ l<^t ^^ ^ Cell S'O^ S'lyr^l^J 

L J 

TJNfc I ajircc rrstoration is completed, except as noted 

I I I do nol agree restoration i<s completed 

Ownciwx SiRnnhir c Date Contmcrof''ss'

 Sii^natiir Signaturec Date