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## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R 

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# 3/m2 SAID# : Date : Address : 

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# /i>3 / Remediatio nContractor : Coasta l Environmenta l Group _ Year : 200 7 SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S Vide o o f property (DVD ) Executiv e Summary ' Q 7 

### EPA-provide dproperty sketc h 

## £

/ Signe dAcces s Agreemen t for subjec t property D 

### Signe dAcces s Agreement(s ) for adjacen t propert y Restoratio nAgreemen t D 

### Settlement document s (i.e. , for damag e o r t o replac e plants , etc. ) 

# y Confirmatio ndat a Photograph s 

## • y As-buil t sketc h Satisfactory restoratio nsigne db y Property Owne r Propert y close-ou t chec k lis t signe db y EP A D 

### Descriptio no f area s not meetin g RO D cleanu p criteri a D 

### Utilit y clearance s D 

### Propert y infonnatio nfromDougla s Coimty Assessor' s Offic e D D , D 

# 4 ^ 4031785 5 

# l i Superfun d

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## Fina l Repor t Propert y Chec k Lis t (piease plac e wit heac hfile) [ M 0 ^ ' Har dCop y Informatio n| wloc V S > |^l^ ^ - ^ Propert y Check Lis t ; | I V^ ' /2^Sit e Workin g Drawin g Ma p 3 . EP Aoriginal s Ma p y ^ Dougla s Count y Assessor' s Ma p • y ' Propert y Contac t Sheet Agreemen t ^J-r^cces s Agreement

y Restoratio nAgreement

Miscellaneou s Document s yF'msi l Ma p fromth e Field y^Chang e Order s \sX(|;,_ ^ y^K V Data .4^Any email s o r PO a)rrespondence s Vs\O U Propert y Completio n 1 . Executiv e Summar y 2 . AS BUILT yf . Propert y Completio nAgreement jyKn y buyou t inf o o r reimbursement inf o WO ^ ^Chec k o r money orde r copie s Vv^A_ ^ y^ . EP AProperty Clos e Out Fon n 7 . Attache dBeginVide o Electroni c Documentatio n Drawing s 1 . EP Aoriginal 2 . Workin g Drawin g .3 . AS Built.vs o 4 . AS Built.jp g Photo s 

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^ y^ BeginPhoto s During/Excavatio nPhoto s So dPhoto s 30-Day So dPhoto s Scanne dDocument s ^ Fina l Document s Executiv e Summar y Video s

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## Propert yAcces s Checklis t Propert y ID : jc j g,c^ \ ON: _ 

# / / 1 nWOR K STARTE D nWOR K COIVIPELTE D ON: _ 

# / / J Propert y Address : iA.'^\
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# If , St . Owner : /_,UC' 0 Qp'^\\l0~.A . Address :



# 143 1 ^ 

# i( o ^t Phonc : 4£2
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• Notitlcatio nLette r ^ Acces s Agreemen t S Restoratio nAgreemen t nTopsoi l Samplin g (i f applicable ) O Disposa l Samplin g (i f applicable ) O Garde nSamplin g (i f applicable ) ^ Utilit y Clearanc e U Video/Photo s (Before ) D Video/Photo s (During ) D Video/Photo s (After ) nVideo/Photo s (30-Day) nPropert y Completio nAgreemen t nFina l Repor t Renter : Phone : Fax : Cell/Pager : Additiona l Information :

Sent : / / B, : Signed : _B_/iAi/D 7 By : Signed : O 1 ]A l G J By : 1 1 By : 1 1 By : / / By : R v ^'^ ^ Called : & / 1 C? / 0 7 l?>^74.0 l On : / / • • On : / / By : On : / / By : On : / / By : Signed : / / By : Issued : / / By : Ai r IVIonitorin g (a s applicabl e » • Communit y [ H Cre w On : / / 

## By : 1 Results : i 1 1 Communit y E H Cre w On : / / 

## By : _1 Results : 1
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# ^3(SS' / Exterio rPain t Nort h Arro w 

### Omah a Lea d Sit e Owne rName : LooJ o (oi^';^^;'^ ­ • Goo d 

### Sit e Sketc h Address : y^ty_} 7 ..-77 . Q Poo r Phone : 0 - Not pain t 

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### i App m 

# 0 ' D Date : ^/^^loc » RYBSCPXA - i^Q^ j F 2 "2- / P:

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## D Time : 2 . RYCSCPXA - iSQt^ f B 1 \~ l H pp m 

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# n Sample s Analyze d RYDSCPXA - IQQ^ i B 2 9.5 0 pp m 

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### Dougla s County Pag e 1 o f 1 Dougla s County , Nebrask a Propert yRecor d - R126287000 2 Informatio n i s vali d a s o f 2007-7-1 9 Prin t Repor t Value s no t finalize d unti l afte rBoar d o f Equalizatio n yiewoji^Ma p Owne r GALVA N LU C 1 0 ETA L 143 6 S 1 6 S T OMAH AN E 68108-000 0 Propert yInformatio n Ke yNumber : 628 7 000 2 1 2 Accoun t Type : Residentia l Parce l Number : 126287000 2 Parce l Address : 143 4 S 1 6 S T OMAH AN E 68108-000 0 Lega l Description : HARTMAN S AD D LO T3 9 BLOC K0 S 2 0 W 96.1 2 E 125.6 2 F TL T3 1 & N 2 5 W 96. 4 E 12 5 F T& N 5.2 3 S 5 0 W 111.8 2 E 14 0 F TL T3 9 4 5 X 96.1 2 & 5.2 3 X 111.8 2 Valu e Informatio n 200 7 200 6 200 5 200 4 200 3 200 2 Lan d $2,700.0 0 $2,700.0 0 $2,700.0 0 $2,700.0 0 $2,700.0 0

$0.0 0 Improvemen t $0.0 0 $0.0 0 $0.0 0 $0.0 0 $0.0 0 $0,0 0 Tota l $2,700.0 0 $2,700.0 0 $2,700.0 0 $2,700.0 0 $2,700.0 0

$0.0 0 Sale s Informatio n Dat e 2004-03-1 9 Typ e W D Boo k 200 4 Pag e 04641 2 Pric e $2,000.0 0 Lan d Informatio n Acre s 0.1 1 S F 5150. 0 F F 50. 0 Unit s 0. 0 Dept h 103. 0 Widt h 50. 0 Vacan t Ye s Lan d Attribute s Attribut e Attribut e Descriptio n Improvemen t Informatio n



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accounmo=R12. . . 8/10/200 7

### Dougla s Count yN E GI S Ma p I I . . I LEGEN D Mino rStreet s 

### y Ou t Majo rStreet s 

### y HatorSti««t i Interstate s 

### ^ Intmite s 

# • Parcel s parce l 2 

### I D Hydro 

## DrtvMibyWe^jGUiD r Disclaimer : Thi s ma p i s no t guarantee d t o be accurate , correct , current , o r complet e an d conclusion s draw n are th e responsibilityof th e user .

## CONTAC T FOR M Propert y I D # 

# ^^C \ Propert y Address : 

# \Ayy7ih77y. Initia l Contact : Date : & | ^ Time : Ho ^ Action : ^LV Secon dContact : Date : Time : Action : Fina l Contact : Date : Time : Action : Fina l Action : Transmi t t o EP AD Othe r Action : D

Comment : Owne r Commen t (s) : \/\J(A O 

# y [ Acn/VkYV \ 

# %% °v\ n Sit e Coordinato r Commen t (s) : 

# V-'
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# Yv>^^ ^ lAw^vi^v^u y -Z^3_V^_^-:L : Z^Z.' o K^^of^<iD,p- p (3li^ ^ /^/A/- Y( ^ COASTA L ENVIRONMENTA L CROU P INC . 

## Consen t Fo rAcces s T o Propert y 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 follov\/in g describe d premises :

Owner' s Name : [^^ci O (2>^\/A> J Daytim e Phone : ^y7-^~j / (77^ /

Addres s o fPropert y covere d b ythi s 

# \qz^ ^ 5 l-fc^ r 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 maypos 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 fCoastal 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 writte n documentatio n fro m EP Atha t th e propert yha 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 f performin 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 f 2

### y'-'J'*'-^ . 

# m V • " ^ * COASTA L '^i-^ •>. , -eC ^ EN¥l«ONMENT» L CROUP . IN C 

### •Remov e obstruction s includin g boats , trailers , vehicles , playscap e items , woo d piles , do g houses , etc ; •Remov e flowe 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 replacemen t vegetation , includin g fertilize rapplication , a s necessarysubsequen t t o a n initia 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 tenan t approva l fo racces s t o th e propert yt o perfor m th e work . •Allo wvideotapin g and/o rphotographin g ofth 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 f th 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 (877 ) 234-6270 . I gran t acces s t o m ypropertie sG I d o no t gran t acces s t o m ypropertie s



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

Pag e 2 o f2COASTA L 

## Restoratio n Agreemen t Th e purpos e o f thi s agreemen t i s t o provid e amutual agreement a s to condition s ofth e property prio r to remediatio nactivities . Thi s wil l als o serv e a s documentatio nfo r th e purpos e o f assurin g that restoratio n activitie s ar e complete dto th e satisfactio no f th e propert> ' owne r an dth e Unite dState s Environmental Protectio nAgenc y (EPA) .

Propert yID : 

# /fg5 / Propert y Address : /^^c/ ^ J ^ ^7 ^ Owner : i-UCl' d (nA:L{/y y Phon e 

# '- • q'5Z'97o T O nth e attache ddiagram(s ) indicate area(s ) to excavate dan ddept ho f e.xcavation , locatio no f all known utilities , subsurfac e features , surfac e structure s andlandscapin g features , acces s location(s ) t o b e usedb y contractor , andth e directio no f North . Indicate distances , depths , materia l types , etc . Indicate digital photo s b

y referencin g the photo-lo g number wit ha narro w indicatin g directio no f view . Item s T o B e Remove d B yOwne rBefor e Star t O fRemediation : (Us e additiona l sheet s a s necessary ) Th e removal , storage , disposal , and/o rretur n o fthes e item s i s th e Owner s responsibility . Item : 

# 17>iyr y \VJ c Item : 

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# \^i/ 3 Item : 

### Item : Item : Item : Item : Pag e 1 of .COASTA L 

### Item s T o B e Remove d B yContracto rDurin g Remediatio n An d No t Replace d (Us e additiona l sheet s a s necessary ) Ite m 

# \Ja\-^(7 r Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item :

Pag e 2 of .COASTA L 

### Item s T o B e Remove d B yContracto rDurin g Remediatio n An d Replace d (Us e additiona l sheet s a s necessary )

Item : Item : Item : Item : Item : Item : Item : Item : Item : Item : Item :

Pag e 3 of .COASTA L Er^<VIROr1lM€^4TA L cn o u p , IN C 

### Landscap e Inventor y (Us e additiona l sheet s a s necessary ) 

## Ite m
Pre-existin g property area , tha t wil l b e excavated , tha t i s covere dwit hgrass .

Numbe r o f tree s > 2 inch trun k diamete r

Numbe r o f tree s < = 2 inch trun k diamete r

Numbe r o f Sprinkle r Zones . Contro l Valves , Timers . Heads , etc . .^^ac hasketc ho f th e sprinkle r laxout .
Numbe r o f an dsiz e o f eac hgarden/ flower be d area . Anac hasketc ho f relati\ e size s andlocations . 

## Quantit y


# 7 

# 7 

# 7 7 Uni t
Squar e fee t

Each

Each

Eac h

Eac h Squar e Feet 

## Condition/Type/Specle s

Pag e 4 of . 1COASTA L CNVIRONMCNTA L 

## Ite m Quantit y Uni t Conditlon/Type/Specie s Agree dupo nvalu e of 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 . Agree dupo nlis t o f plant material s that will b e replace db y contractor . B e very specifi c anddetailed . Includ e asketc hof vver e eac hplan t will b e place d b \th e contractor . Agree dupo nare ao f property t o b e replace d wit hgras s sod . Includ e asketc ho f rh e area(s > t o b e replace dwit h gras s sod . Are ao f City o r Count y property t o b e landscape d pe r thei r requirements . Includ e askeic ho f th e are a(s )

Easemen t Area , to b e excavate d 1 

# cn^sc^^" ^ 

# 7 $ 

# p Each

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Pag e 5 of .

### # COASTA L EMvtnoNMEixrA L 

### Additiona l Comment s / Instructions :
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### • Chec k th e boxi f Owne 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 boxCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro fhouse , includin g foundatio n cracks o rfissures .

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# c?04 Sampl e Are a Pass/Fai l ? I n Sit u Composit e Composit e Analytica l Aliquo t Composit e Reading s La b Analytica l Readin q Averag e (Drie d & Spil t Sen t (Bag ) Numbe r Result s 1 (Baq ) Sieved ) 2 3 4 XR F Correcte d Valu e -- > 5 (us e calibratio n char t o rad d 2 0 % t o value ) Sampl e Are a Pass/Fai l ? I n Sit u Composit e Composit e Analytica l Aliquo t Composit e Reading s La b Analytica l Readin q Averag e (Drie d & Spil t Sen t (Bag ) Numbe r Result s 1 (Baq ) Sieved ) ? 2 3 4 XR F Correcte d Valu e - > 5 (us e calibratio n char t o rad d 2 0 % t o value ) Sampl e Are a Pass/Fai l ? I n Sit u Composit e Composit e Analytica l Aliquo t Composit e Reading s La b Analytica l Readin q Averag e (Drie d & Spil t Sen t (Bag )
• > Numbe r Result s 1 (Baq ) Sieved ) 2 3 4 XR F Correcte d Valu e - > 5 (us e calibratio n char t o rad d 2 0 % t o value ) U.T fAUDinOHM . SHffr SI f HllBI D XR F Technician' s Signitur e

### Pag e 1 of 2

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

### YOU RTICKE T NUMBE RI S 1875932 . Origina l Cal l Date : 8/28/0 7 Time : 2:5 9 p m Op : LORI1879 0 Wor k t o Begi n Date : 8/30/0 7 Time : 3:3 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 143 1 Street : S 16T H S T Twp : 15 NRng : 13 E Sect-Qtr : 27-NE-NW Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : LEA D EXCAVATIO N Locatio n o f Work : LOCAT E ENTIR E PROPERT Y Remarks : RESENDIN G DU E T O WOR K EXTENDING . Compan y COASTA L ENVIRONMENTA L SERVIC E Contac t Nam e LOR I Phone : (712)352-018 8 Alt . Contac t NON E Wor k Bein g Don e For : EP A Dept h o f Excavation : 3 6 I NCorne r Lot : NFront : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N ATTNEBR l CXCAT V LEVEL S MC I MCLEODN E METHODI S MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F QWEST 2 SPRINTN E

Servic e Are a Contac t Phon e Numbe r Utilit y Typ e ATTNEBR l AT& T 

### Day : Alt : 8002413624 9 Emerg : 8002413624 9 CXCAT V CO X COMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL 3 COMMUNICATIONS , LL C NA 

### Day : 877366834 4 Alt : 

### Emerg : 877366834 4 MC I MC I N O CAL LPE RMEMO 

### Day : 800289342 7 Alt : 

### Emerg : 800289342 7 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret-<RESULTS. . . 8/28/200 7

### Pag e 2 o f 2

MCLEODN E

METHODI S

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OMAH APUBLI C POWE R DISTRIC T QWES T LOCA LNETWOR K
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SPRIN T COMMUNICATION S C O NA
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### Day : Alt : Emerg : Day : Alt : Emerg : Day : Alt : Emerg : Day : Alt : Emerg : Day : Alt : Emerg : Day : Alt : 800289190 1 800289190 1 888847475 7 888847475 7 402504782 3 402504794 6 402444719 7 402444516 1 402444516 0 406728934 3 888728934 3 406728934 3 Emerg : 888728934 3 Day : Alt : Emerg : Day : Alt : Emerg : 800283423 7 303992192 6 800283423 7 800521057 9 800521057 9

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 8/28/200 7

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# ^3S6^ / Exterio rPain t Nort h Arrovi / rOwne rName : Loo.'^ ' (^•'>'\0(^/ ^ 

### Omah a Lea d Sit e • Goo d 

### Sit e Sketc h Address : 

### c^^.'j 6 '* y-TT' . • Poo r Phone : H-^ifS-rr^fn-^iv-W : 

## A n ^< t ^i(?' i Q ' No t pain t



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On)yh aLen dSite 4613 0

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### Marco s Mateu s From : France-lsetts.Pauletta(gepamail.epa.go v Sent : Thursday , Augus t 09 , 200 7 5:2 5 P M To : ctl@ctlehman.net ; r.brown@erllc.com ; mmateus@enviroservicesgroup.co m Subject : Acces s fo r143 4 S ! 6 

## 1^1^ ^ Marco s — Pleas e contac t Luci o Galva n a ^ 402-452-9707 . H e want s t o tal k t o yo u abou t acces s t o 1434 S 16t h Streef . H e i s als o willin g t o sig n a n acces s for mfo r samplin g a t 453 3 S 2 0 Stree t (i t i s identifie d a s a n EB L property) . 

## ^

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_ (y-^Tj - jyiMj L yyy^;r7ci~^5^^)x^ • Al l correspondenc e t o Luci o Galva n shoul d b e sen t t o \ ^ 80 8 France s Stree t \ Omaha , N E 6810 8 

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# EXECUTIV ESUMMARY : 19851—143 4 S 1 6 S T 

# No Issue s o r Concern s I I Issues/Concern s Detai l Explanation:

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### 2 3 a0 5

Dat e USEP ASigne d Off : 11/29/0 7 

### Legen d Omah a Lea d Sit e OLS# : 1985 1 Dat e Excavated : 9/6/0 7

Are a no t Excavate d j Dripzon e Excavate d Quadrant s Excavate d 

### Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc . 4613 0S3K . 

# EPA EP APropert y Clos e Ou t For m /^•^ y 57^S T Propert y # : 79^.^7 . Propert y Address:
- — - . 

### Date/Time : OwVer' s Name: . /^/,^^^^<^-:^^if^ ' Contracto r Crou p Quad s Excavated : Ye s Excavatio nGenera l I .

If necessao' , wer e th e conec t quadrant(s ) excavate dan drestored ? 2 .Ifnecessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? 

## Ii h Gradin g So dan dVetetatio n Ye s I .Doe s th e gradin g aroun dth e perimete r ofth e hous e i n excavate darea s generall y slop e awa y tro mth e Iiouse ? 2 .Ha s so dbee nlai din al l area s tha t were excavated ? 3 .Doe s th e sodappea r t o b e generall y healthy andgrowing ? (Onl y evaluat e if inspecte da t a3 0 da y time period ) 4 .Ar e soddedarea s generall y fir man devenly graded ? 5 .Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e if inspecte da t a3 0 da y tim e period ) 6 .

Wa s the propert y grade dsuc htha t water will not poo l o n th e property ? 7 .

Wa s damag e t o landscapin g or plan t material s avoided ? y Gates , Fence s an d Retainin g Wall s Ve s 1 .

D o gate s ope n an d clos e freely? (Ifapplicable ) 

### ^ ^ 2 .Wer e al l gates o rfence s lake n dow n durin g restoratio n activitie s reinstalled ? (Ifapplicable ) 

### t i ^ 3 .

Wa s damag e t o gate s o rfence s avoided ? (Ifapplicable ) 

### ^ ^ 4 .Wa s damag e t o retainin g wall s avoided ? (Ifapplicable ) 

### ^ Foundation , Sidin g an d Gutter s Ye s 1 .

Wa s damag e t o th e sidin g o rtri m avoided ? y 2 .Wa s damag e t o th e foundatio n avoided ? >y 3 .

Wa s damag e t o window s avoided ? y ' 4 .

Wa s damag e t o window s o rdoo rscreen s avoided ? y 5 .

Wa s damag e t o downspout s o rdownspou t extension s avoided ? 

### ^ Sidewalk s an dDriveway s (Concrete ) Ye s I .Wa s damag e t o driveway surface s avoided ? ^ ^ 2 . Wa s damag e t o walkway surface s avoided ? y 

## ^

No

N o

N o

N o

N o• • 

## 1 Owner s comments :

Inspectio nnotes :

1 '



## Remova l an drestorationactivate s complet e including th e 30-da y sodwarranty : F.P ARenrpspntativp^^^yy$ ^ ^^..^v^.. ^ Hatp - ///^"^/ A7

# 'i§^ Propert yCompletio n Agreemen t Thi s agreement document s the completio no f remedial aclivitie s performe donm y property . M y signature vvil l designate tha t I a msatisfie dwit hth e restoratio no f iny property , andthat n o item s are i n questions , now , or a

l an y time i nthe future , excep t thos e item s lisle dbelow , if any . Propert y ID : /f^y / Propert y Address : /^^6 / ^ 77?<: y Owner : 

# /^7C7 6 7^y!cy4y ^ Pho n 

# ­ ^^Z<97y^ y Restoratio n Item s i n Question :

Item : Item : Item : 

### Item : Item : Item :

l>g' l agre e restoratio nIs completed , excep t a s note d I I d o no t agie o restoratio ni s complete d

Ownfer' s Signatur e ' Date / I 

### Contractor' s Sienatur e I