### 0 

## TRANSMITTA Lof OMAHALEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R
SAI D 

# * : 1^ 0 

# ^ Date : 

# t q Address : 

# H^^ ^ V\M U 

# ^ f Remediatio nContractor : Coasta l Environmenta l Group _ Year : 20 0 SOI LREMEDIATIO N PROPERT YFIL EFOLDE RDOCUMENT S Vide o o f propert y (DVD ) 

# i Executiv e Summar y EPA-provide dpropert y sketc h Signe dAcces s Agreemen t for subjec t propert y Signe dAcces s Agreement(s ) for adjacen t propert y 

# 4 Restoratio nAgreemen t Settlemen t document s (i.e. , for damag e o r to replac e plants , etc. ) Confinnatio ndat a Photograph s 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 Prcpm y infjetrmationfro mDougla s Count y Assessor s Offic e


# a 

# W(
. Dat e 3005485 9 Superfun d

# • I

Propert y Acces s Checklis t Property ID:2^qQ7 ^ nWOR K STARTE D ON : Property Address : i^-a^mp ) ^qpV e 6\ D WOR K COMPELTED ON : Owner : Rente r 

## "^ar^ Vo'S.oJf ^ Address : Phone : Fa,\ : Cell/Page n Phone : " J Additional Information : 

# w X^ZVi ? Fax : Cell/Pager : D NotificationLette r Sent : / / By : H ^ Acces s Agreement By:£. C Signed : _g./4i!t/-0 3 H ^ Restoratio nAgreement Signed : A / \ ^ ' 0 ^ 

## By : £. r
• Topsoil Samplin g (i f applicable ) 1 1 By : D Disposa l Samplmg (i f applicable ) 1 1 By : nGarde nSamplin g (i f applicable ) 1 1 By : J3 ^ Utilit y Clearanc e 

### Called : y_/i^/D 9 By:^/lW(9 ^ ^ Video/Photo s (Before) 

## On:±,lL!.IJ ^ By : D Video/Photo s (During ) On : / / By : D Video/Photo s (After) On : / / By : D Video/Photo s (30-Day) On : / / By : ""^ JProperty CompletionAgreement Signed : _/D/i£?/ ^ By : ' r t l Fina l Report By : Issued : / / Air Monitorin g (a s applicabl e • Communit y • Cre w On : / / By : Results : D Communit y D Crew On : / / B, = Results : D Communit y Q Crew On : / / By : Results :
Omah a Lea d Sit e 

# 1

## Propert y I D # Propert y Address : Initia l Contact : Secon dContact : Fina l Contact : Final Action :

Comment : Owne r Commen t (s) : Sit e Coordinato r Commen t (s) : CONTAC TFOR M ?A'AO Z 

# ^m n

# ^a^ ^ is\ : Date : Time ; Action :

Date : Time : Action : Dale : Time : Action : Transmi t to EP AD Othe r Action : D

### Dougla s County Accoun t Infona^io n Pag e 1 of 2
Dougla s County , Nebrask a Propert yRecor d - R090897000 0 Prin t Repor t NE WFeatur e - Parce l Dimension s availabl e @ scal e 0-5 0 ft wes t o f52n d S t - ViewO n Ma p Informatio n i s vali d a s o f2009-8- 3 Treasurer' s Ta xRepor t Ne wFeatur e ->-•- > Aut o Sale s Searc h Owne r PUSC H JA N E P O BO X 54043 2 OMAH AN E 68154-000 0 Propert yInformatio n Ke yNumber : 089 7 OOO O 0 9 Accoun t Type : Residentia l Parce l Number : 090897000 0 Parce l Address : 434 0 MAPL E S T OMAH AN E 68111-000 0 Lega l Description : CREIGHTO N HEIGHT S LO T2 2 BLOC K9 S 1 1 F TL T2 2 BL K1 COVELL S AD D & 5 0 X 90. 4 Valu e Informatio n
200 9 200 8 200 7 200 6 200 5 200 4 Lan d $5,400.0 0 $5,400.0 0 $5,400.0 0 $5,400.0 0 $5,400.0 0 $5,400.0 0 Improvemen t $44,400.0 0 $44,400.0 0 $44,400.0 0 $44,400.0 0 $12,400.0 0 $11,300.0 0 Tota l $49,800.0 0 $49,800.0 0 $49,800.0 0 $49,800.0 0 $17,800.0 0 $16,700.0 0 Lan d Informatio n Acre s 0. 1 S F 4500. 0 U nit s 1. 0 Dept h 90. 0 Widt h 50. 0 Vacan t N o Improvement Informatio n Buildin g 1



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R09. . . 8/11/200 9

### Dougla s County Accoun t InforiM^o n Page l of l rn^ c

<S«>M«P1LES T

Sacon d Fteo rp-— '
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Br* » Floo r I* " Lss i 860. 0 W|.4t , " ' <i r

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f«4W=IJ.<.M.W.t.llMH.-W.III.«i.'gna5m m CLICKX O E N LARG E JMAe E CLIC KTO ENLARG E IMAG E 

### ] Squar e Footage : 1444. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : I Fai r Uni t Type : Condition : I Fai r

Buil t As : 1 1/ 2 Stor yFi n Cond o Squar e Footage : I 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : i 8. 0 Exterior : Fram e Sidin g Units : \ 1. 0 Interior : Drywal l Baths : | 1. 0 Roo fCover : Compositio n Shingl e Bedrooms : 4. 0

Roo fType : Gabl e 

### Stories : 1. 5 Floorcover : Allowanc e Foundation : Bloc k Sprinkle 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 190 0 0 0 % 190 0 10 9 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 680. 0 Carpor t Detache d 360. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Porc h Sla b Roo fCei l 226. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R09. . . 8/11/200 9

### Pag e 1 o f 1

" > Creat e Anothe rTicke t Bac k t o Irt h Interne t j Sen d Emai l



### • YOU RTICKE TNUMBE RI S 2374307 . Origina l Cal l Date : 9/28/0 9 Time : 2:2 6 p m Op : ELIZABETH1879 0 Wor k t o Begi n Date : 9/30/0 9 Time : 3:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 434 0 Street : MAPL E S T Twp : 15 NRng : 13 E Sect-Qtr : 08-NW-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : lea d remediatio n Locatio n o f Work : LOCAT E ENTIR E PROPERTY , AL L EASEMENT S AN D T O TH E PEDESTA L Remarks : FAX AL L CLEAR S TO : (877)662-421 1 : UNSUR E O F CORNE R LO T : RESEN T DU E T O WOR K EXTENDING . PLEAS E REFRES H PAIN T AN D FLAG S Compan y: COASTA L ENVIRONMENTA L SERVIC E Contac t Name : ELIZABET H Phone : (877)662-421 0 Wor k Bein g Don e For : coasta l Dept ho f Excavation : 4f t Corne r Lot : NFront : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Phon e Numbe r Utilit y Typ e Day : 402934046 9 CXCAT V CO XCOMMUNICATIONS , IN C HEIDI Alt : 402934046 9 Emerg : 402932975 7 

### Day : 402504782 3 MUDO l METROPOLITA NUTILITIE S DISTRIC TSAND YAlt : 

### Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCIT YO FOMAHA-TRAFFICSEWE RRON 

### Al t 402444516 1 Emerg : 402444516 0 Day : 406728934 3 0PPDGPR 5 OMAH APUBLI C POWE RDISTRIC TN A 

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

### Alt : 406207149 4 Emerg : 888728934 3
http://v^ww.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/28/200 9

# As-Buil t Drawin g COASTA L 

# Omah aLea dSuperfun dSit e 

# llllll l 2940 2 Exterjp rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : JA N ERI C PUSC H ig^oo d Sit e Sketc h Address : 434 0 H/IAPL E S T •Poo r 

# f

Phone : H : r rNo t pain t Sampl e Numbe r RYASCPXA-2940 2 RYBSCPXA-2940 2 RYCSCPXA-2940 2 nYDOOPX A2040 2 RDZSCPXA-2940 2 r^OgOGPXA-2040 2 nrgoonxA-2040 2 F l F 2 B 1 BS - D Z GZ ­ -P Z

: OLS# : 2940 2 ; Dat e Excavated : 10/7/0 9 Dat e US£PASitineidt>fft? t 

### \re aSodden : 1926 s af t Lea d Concentratio n Sampl e Collecte d LA B 

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## / V ^

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### Legen d Concret e Dri p Zon e Excavate d Quadrant s Excavate d Are areplace dwit h Are areplace dwit h Are alef t bar e So d' ' Rock/Mulc h 

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

# 2940 2

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### Omah a Lea d Sit e Owne rName : JAN ERI C PUSCH [g^oo d 

### Sit e Sketc h Address : 4340 MAPL E S T •Poo r 

# f Phone : H : W : [] ] No t pain t Sampl e Numbe r Lead Concentratio n Sampl e Collecte d LA B Sample s Collecte d Firm : /Y\FS.'/\.f(./OJ
. RYASCPXA-2940 2 F l pp m 

## D Date : It/fi/o S RYBSCPXA-2940 2 RYCSCPXA-2940 2 ^YDOCPX; ^ 2040 2 F 2 B l -BS r 

# 5^g ^^ 7 pp m pp m

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# n D Date : //'/g~^^ ^ RnZOCrXA-2040 2 P 2 pp m 

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## 2940 2 Exterjp rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : JA N ERI C PUSC H [g^oo d Sit e Sketc h Address : 434 0 MAPL E S T 

# [ •Poo r 

# f Phone : H W : Q No t paint Sampl e Numbe r RYASCPXA-29402 RYBSCPXA-29402 RYCSCPXA-29402 nYDSOPXA-20402 RDZSCPXA-29402 nOZOGPXA-20402 nPZOCPXA-20402 F 1 F 2 8 1 -B2 ­ D Z G2 ­ -P 2 Lead Sampl e Concentratio n Collecte d pp m 

# c r ^9 e pp m pp m 

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. Omati aLea dSit e 4613 0,v^t o sr4
.

COASTA l ENVtKONM fXTA I ''^ < Pno't" ^ C H 0 U r. IN C 

## Coinsen t fc fAcces s T o FrQ'pert^ / 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 Name : Daytim e Phone :



### Jot
. 

### <> V^^^ ^ 

# -7^g - •'Vi?^ ^
Addres s o fPropert y covere d b ythi s 

## ^^ ^ 

# /U/v f It ^ 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 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 contac t th e Granto rin-perso n t o discus s th e wor k t o b e performed , 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 w/ritte n documentatio n fro m EP Atha t th e propert y ha s bee n remediated
. ENVIRONMENTA L RESPONS 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 fperfomnin 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.^-'^If'^v , 

### . ^

"* ! PflO ^ COASTA L IPtVIKONKFKTA I C I I D U * IK C


### « Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , wo piles , do g houses , etc ; o d
e Remov e flowe rbulb s o rplant s tha t th e Granto ro rth e Grantor' s tenan t ma yw t o save ; is h
cWate ran d maintai n replacemen t vegetation , includin g fertilize rapplication , necessary ' subsequen t t o a n initia l waterin g perio d b yEPA ; a s cAbid e b yhealt h an d safet yguidanc e provide d b yEPA ; fI fth e propert yi s rented , assis t EP Ai n obtainin g tenan t approva l fo racces s th e properti ' t o perfor m th e work
. t o cAllo 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
.^ 1 gran t acces s t o m ypropertie s D I d o no t gran t access t o mypropertie s

Sianature 'HJ ^ f\ u Dat e Signature Dat e 

# ^

W
Q I woul d lik e t o b e presen t during ! an ysamplin g tha t i s required
.

Pag e 2 o f2COASTA L 

## Restorataoi TAgreemen t Th e purpos e ofthi s agreemen t i s t o provid e amutual agreemen t a s t o condition s ofth e propert y prio r to remediatio nactivities . Thi s wil l als o serv e a s documentatio nfor th e purpos e o f assurin g tha t restoratio n activitie s ar e complete dt o th e satisfactio nofth e property owne r an dth e Unite dState s Environmenta l Protectio nAgenc y (EPA) .

Propert y ID : Qj^^lf
- Q ^ Propert y Address : 6^'^ Q J^A^U i " ^ V ; Owner : 

# 1 <y ^ 'C yus ^ • ^ . 

## Phone: 75 ^ T^I( , O nth e attache ddiagram(s ) indicat e area(s ) to excavate , surfac e structure s an dlandscapin g feature s and acces s iocation(s ) to b e use db y th e contractors . Indicate distances , depths , material types , etc . Photographicall y andVideographicaJl y documen t the existin g condition s ofth e property andth e basemen t i f necessary . 

### item s t o b e Remove d b yth e Owne rbefor e Star t o fRenriediation : Th e lemoval , storage , disposal , and/o rretur n o fthes e Hem s i s th e Owner' s responsibility
. ttem: 

## W-w / ^ -^v/ / PLd^^r^J c ttem : Kem : Item ;



### Item s t o be^Remove d b yth e Contracto rDurin g Remediatio n an d No t Replace d Item : 

# C L. S^lj ?^|, ( bJ k ^^^x. A Item : 

# • f
Item : Item :

a Pag e 1 o fCOASTA L 

## Item s t o B e Remove dB y Contractor During Remediatio nan dRegiace ^ Item : Kem : 

# SoO ^ Kem : Item :



### Ite m Pre-existin g propert y area , that wil l b e excavated , that i s covere dwit hgrass . Numbe r o f tree s > 2 inc h tmn 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 . All.it haskeicl i ol th e "•rrii'klo i l;!\'.uii Numbe r o f an dsiz e o f eac hgarden / flower be d area . All;\cl l ; i skL-lcl i o l ri-!;HiVL ' M/f S nii dloc;lIi(^^ ^ Agree dupo nvalu e o f plan t material s no t to b e replace db y contractor . Voi r llii ' ^Hlllc wil l h i lisrt . Il l I; ; 11 1 . ; iilKn i »oiiC)U TU l ili e |:riipcii > u^

^ ner . 

# T l 

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# fi;f a Quadrant s 

# I Eac h Eac h ( ^ Eac h / ^

Eac h Squar e Fee t ( '

S 

### /

Easemen t Area , t o b e Eac h excavate d
Pag e 2 o f/#

COASTA L

* Additiona l Comment s / Instructions :



# L
. Q 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
. Bycheckin 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
.

^ I agre e nId o no t agre e

/ Owner' s Signatur e j O ^ nat o r'nn«..o/.tnri c ciimot.,.., , r r««« . Contractor' s Signature 

# '-^Z)- y Pag e 3 o f (_

## BVID#c2g^^ ^ XR F PROPERTY SAMPL E SHEE T Dat e 

### )OIQ^O ^ Addres s 

# i/^t/ Q moAit r 

# S E Project Omah a lead F P 2n d yea ropilo n Sampl e tim e am/p m XRFID # sampl e lengt h 3 0 se c

Shot # Readin g Sanipl e are a Shot # Readin g Sampl e are a 

# i f^ rk/( ^ 

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# £1 

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# I Dept h Dept h 

# ?^^ C ll^?"^/? - .IZ X Averag e \ ^ / JI I | (_ ^ Averag e
RETES TAREA S Shot # Readin g Sampl e are a Shot # Readin g Sampl e are a Dept h Dept h Averag e Averag e la b sampl e # La b resul t Sampl e are a XR F Avg
. Signatu n 

# ££Mm ^ Prin tiy\oaY£)}f\ Coc.a ^ o?^JOL \ 

### Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 ^J^^v ' I % ' ­ p * %Pnott^' ^ Coasta l Environmenta l Grou p Inc
. www.coastalhazmat.co m VI ^? ' COASTA L ENVmONHENTA L CROUP , IHC
. 

# EXECUTIV ESUMMARY : BVI D #29402-(434 0 MAPL EST )

^No Issue s or Concern s Q] Issues/Concern s Detai l Explanation :4 

# f 

# • I ^£•• 1 Bf t 

## EP APropert y Clos e Ou t For m Propert y # : "2.^4^7- . Date/Time : Owner' s Name: . ,^.X\,Y^^±(0
- Quad s Excavated : p ] f-'-^ . fi\Di L Contracto r Grou p QC^KI^iO J CJ ( 

## jTMiogi^P
- Ye s N o Excavatio nGenera l 1 . I f necessaiy , wer e th e correc t quadrant(s ) excavate dan drestored ? t / 2 , I f necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? 

## iy ^ Ye s N o 1 , Doe 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 ? 

# t y 2 , Ha s so dbee nlai di nal l area s tha t wer e excavated ? 

## l y ' 3 , Doe s th e so dappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e if inspecte da t a3 0 Gradin g So dan dVegetatio n 

# y da y tim e period ) _^_ _ 4 . Ar e sodde darea s generall y firman devenl y graded ? 

# \ y 5 . Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte da t a3 0 day 

## t / tim e period ) 6 . Wa s th e propert y grade dsuc hthat wate r wil l no l poo l onth e property ? 

## y 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? \ / Gates , Fence s an dRetainin g Wall s Ye s No I , D o gate s ope nan dclos e freely? (I f applicable ) 

## 1 / Wer e al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (Ifapplicablc ) 

## \ y ' 3 , Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) 

# 1/ ' 4 , Wa s damag e t o retainin g wall s avoided ? (I f applicable ) Foundation , Sidinnan dGutter s Ye s No 1 . Wa s damag e t o th e sidin g o r tri mavoided ? ( / ' 2 . Wa s damag e t o th e foundatio navoided ? 

# T ^ ^ 3 . Wa s damag e l o window s avoided ? Wa s damag e t o window s o r doo r screen s avoided ? 5 , Wa s damag e t o downspout s o r downspou l extension s avoided ? 

# ^7 - Sidewalk s an d Driveway s (Concrete ) Ye s N o 1 , Wa s damag e l o drivewa y surface s avoided ? 2 , Wa s damag e t o walkwa y surface s avoided ? 

# IP '

## Ov^ner s comments :

Inspectio nnotes :

Remova l an drestorationactivate s complet e mcluding th e 30-da y sodwarranry : EP ARepresentativ e jJo H nO^J^ y Date : /Of^^/0 9Frora:COASTA LENVIRONHENTA L 87 7 66 2 421 1 to/ 2 

### 9 

### 10:5 6 #45 1 P , 002/00 3 

### < #

Propert yConripletio n Agreemen t llit b agreemen t dwuineni * lh e completio n o t remedia l acliviiie s perfoiirc d o n m yproperl yM ysignaiui c wil l desi^nai E ilia i I a m satisfiis d wit h th e rcsicialio n o fm yproperly , an d Iha l n o ncm s ar ci n qiitstion s now . o ra i an yinn rii i lh e future , excep i ihos e iiem s liste d tielciw , i fan y

Propert ym : ^QLT).; ^ f>riytrc yAddrc..« : { j "3 , L/f ^ M apl ^ S V I Phone : p^^ ; -15ft - 2 a 7A Restaratio n Hem s i n Question :

Iterr : Item : Jtem : Item : Item : Jtem : 

# 1 1 Additiona l Comments ;

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