TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID^-: Date: -i U l ll 

Address, ^1\' > 9^^M\H> 'f < 

Reinediation Contiacior: Coastal EnNJronmcntal Group Year: _2010ARRA 

SOILREMEDIATJON 

PROPERTV FILE FOLDER DOCUMENTS 

/ Video of properly (DVD) 

/ Executive Summary 

EPA-provided properly sketch 

Signed Access Agreement for subject properly 

Signed Access Agreement(s) for adjacenl properly 

Restoration Agreement 

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

Confinnation data 

i / Photographs I F (JV<^lA1lCM ^ tyCh/Mo*^ \ ^<P<n 

7 As-built sketch 

7 Satisfactory restoration signed by Property Owner 

7 

7 

Property close-oul check list signed by EPA 

Description of areas not meeting ROD cleanup criteria 

Utility clearances 

Property ipieflmation from Douglas County Assessor's Office 

Superfund 
p 

Property Access Checklist 

PropertylD: Q.5i\-<^«^ 

D WORK STARTED ON: / /_ 

D WORK COMPELTED ON: / / Property Address: :i^ ^ A S^ 2i«'«.% JuA., JS\., 

Owner: . . _, . . ., 

RcnteiAddress: -^ ' Phone: 

Fax: 

Cell/Pager: 

Additionul Information: 

Phone: H*^ . ^v,^ ^-^^o 

Fax: 

Cell/Pager: 

D Notification Letter Sent: / / By: 

" S Access Agreement Signed: \o />•/« © By: 

\>»'t\C 

' ^ Restoration Agreement Signed: vt> / > lyo By: 

»iSO C 

D Topsoil Sampling (if applicable) 1 1 By: 

Q Disposal Sampling (if applicable) 1 1 By: 

Q Garden Sampling (if applicable) 1 1 By: 

Q Utility Clearance Called: \o /\f, U o By: 

i«»/ax/»o vu..iv, »»/»»->«" 

\ ^ Video/Photos (Before) On: w /

 > /% o By: va t c_^L^ 

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

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

• Video/Photos (30-Day) On: / / By: 

D Property Completion Agreement Siened: / / By: 

D Final Report Issued: / / By: 

....... 1 

Air Monitoring (as ai)plicable) 

J D Community Q Crew On: By: 

Results: q 

D Communif?' D Crew [ On: / / 

Results: 

• Community CU Crew On: By: 

Results: 

Omaha Lead Site 
Douglas County Account I I^^B J ation Page 1 of 1 

Douglas County, Nebraska Property Record - R2213460000 

Print Report 

View Interactive GIS Mao Information is valid as of 2010-8-30 Treasurer's Tax Reoort 

New Feature -> •• ^ Subdivision Sales Search 

Owner 

ALLIANCE BUILDING COMMUNITY 1 

C/O MICHAEL B MARONEY 

2221 N 24 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 1346 0000 22 

Account Type: Residential 

Parcel Numtter: 2213460000 

Parcel Address: 2815 SEWARD ST 

OMAHA NE 68111-OOOO 

Legal Description: SHINNS 3RD ADD LOT 3 BLOCK Y W 30 FT 30 X 127 

Value Informatio n 

Land Improvement Totai 

2010 $300.00 $0.00 $300.00 

2009 $300.00 $0.00 $300.00 

2008 $300.00 $0.00 $300.00 

2007 $300.00 $0.00 $300.00 

2006 $300.00 $0.00 $300.00 

2005 $300.00 $0.00 $300.00 

Show All Transactions 

Land Information 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R221... 9/2/2010 
Page 1 of2 

"> 

Create Another Ticket [ Back to Irth Intemet ) Send Email 

• YOUR TICKET NUMBER IS 2627054. 

Original Call Date: 10/26/10 Time: 5:28 pm Op: ELIZABETH18790 


Work to Begin Date: 10/28/10 Time: 6:00 pm 


State: NE County: DOUGLAS Place: OMAHA 


Address: 2815 Street: SEWARD ST 


Twp: 15N Rng: 13E Sect-Qtr: 16-NE 


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 IF CORNER LOT. 


Company : COASTAL ENVIRONMENTAL SERVICE 


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


Work Being Done For: COASTAL 


Deptli of Excavation: 4 FT Comer Lot: N Front: Y Rear: Y 


Involves Tvmneling or Horizontal Boring : N Explosives: N 


CXCATV LEVEL3 MUDOl OMAHACOF OPPDGPRS QLNNEIC 


Service Area Contact Phone Number UtiUty Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVELS LEVEL3 COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFICSEWER RICH/TRAFFIC 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?Tet=<RESULT... 10/26/2010 
Page 2 of2 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT Alt: 4062071494 ELM LOCATING 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK

Day:

 ELM LOCATING Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT... 10/26/2010 
25939 

As-Built Drawing 

COASTA L Omaha Lead Superfund Site 

OLS#: 25939 

Date Excavated: 10/28/2010 

Date USEPA Sianed Off: 12/9/2010 

Area Sodden: 1465 sa ft 

Omaha Exterior Paint North Arrow Owne Lead Site r Name: CURRY TEMPLE COMMUNIT 

Sit • Good Address e Sketch : 2815 SEVVARD ST • Poor Phone: ": W: I [ 3 Not paint 

Sannple Lead Sample Samples Collected Number LAB Concentration Collected Firm: A5>J fcfuir ^ 

RYASCPXA-25939 F1 ZS'B ppm D Date 

RYBSCPXA-25939 F2 I'^B ppm D Time _ilZ2_ RYCSCPXA-25939 B1 'i2/ > ppm D Samples Analyzed RYDSCPXA-25939 B2 (o/» 3 ppm I D

PBgOCnXA ZIOOOO ppm D XRF Unit: JO 3 1 Book: 152 . D ••RI323CrXA--25939 " " ppm D Date D /O'/Z-o ^ 

RPZ3ePXA-25939 -pz- ~ ppm D Time D 

Staff: ^ Number of Samples = 

Legend: Fl = Front Left, F2 = Front Right, Bl = Bacl< Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

ENTERiED 

SEP 1 9 i m 

Concrete Drip Zone Excavated 
 Quadrants Excavated 

Area replaced with Area replaced with 

So Area lef t bare d ' ' Rock/Mulch 

Contrac t #: EP-R7-07-05 Coasta l Environmenta l Group In c 
i % 

25939 

C\p.rf.r vv, \ofa?? 

Exterior Paint North Arrow Owner Name:_CURRY TEMPLE COMMUNIT Omaha Lead Site

Sit • Good e Sketch Address : 2815 SEWARD ST • Poor 

Phone: H: W: [^ Not paint l

Sample Numt>er Lead Sample Samples Collected LAB Concentration Collected Firm: A5i.J r<ilui ^ 

RYASCPXA-25939 F1 Z^8 ppm D Date: '^il'blo^ 

RYBSCPXA-25939 F2 ppm D Time: WTb 

RYCSCPXA-25939 Bl -JZAO ppm D Samples Analyzed RYDSCPXA-25939 B2 U3> ppm I D .-Jf-''* nD^ccp^^ JCQOO—B2- ppm D D XRFUnit: I/>^ 1 Book: f92r \ 

RGZSCrXA-^g5839 &S- ppm D D Date: /O'/T.-QS ' RPZ3CPXA-25939 PZ- ppm D D Time: f^.

Staff: Number of Samples =_r i ^ f^ 

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

AD quadrants are as viewed from tt>e street, facing property 

7<Li)///L£Y 

r/yo~iy) 
25939 

Omah Exterior Paint North Anww Owne a Lead Site r Name: CURRY TEMPLE COMMUNIT • Good Site Sketch Address: 2815 SEWARD ST • Poor 

Phone: » w: I. 0 Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collected Firm; A<f,^ r<^ A* ^ 

RYASCPXA-25939 Fl 

ppm D Date: "^flVOf o ^ 

i 

RYBSCPXA-25939 F2 

133_ ppm D Time: ___il£2_ 

RYCSCPXA-25939 B1 

-i^a ppm D Samples Analyzed RYDSCPXA-25939 82 U3 ppm 

RD^OG^Xl^ aoooo—o ^ ppm D n 

XRF Unit: / a 3 1 Book: /5 Z 

-G2­ rrczocr)(A^ji5039 ppm D D 

Date: _ D /O'/T.-OS' 

RPZOGPXA-259a9 -PZ- ppm D D Time: _ Pr77 

Staff: L A Number of Samples = j ^ 

Legend: Fl = Front Left, F2 = Front Right, 81 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

ENTEEED 

SEP 1 9 2005 

C/^o^iA ) 
25939 

Omah Exterior Paint North AfTow Owne a Lead Site r Name: CURRY TEMPLE COMMUNIT 

Sit • Good e Sketch Address: 2815 SEWARD ST • Poor Phone: H: w. Q Not paint l

Sample Number Lead Sample Samples Collected LAB Concentration Collected Firm: A^ ^ f^!'- ^ 

RYASCPXA-25939 F1 gjTg ppm n Date: ^fiyiO[o£\ _ 

RYBSCPXA-25939 F2 

_ppm Time: ),: S'b iM. D 

RYCSCPXA-25939 Bl 3 2 ^ ppm a Samples Analyzed RYDSCPXA-25939 B2 (?^ 3 ppm n 

f^DZOOPXA 26030 DZ. D D XRF Unit: 703 1 Book: I3 Z 

RSZ3ePXA"20909 GZ- _ I ppm D n Date: _ /0'/2.-a^ RPZ3CPXA-25999 PS- " ppm D n Time: _

Staff: f^ Number of Samples = } i f 

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

All quadrants are as viewed from the street, fadng property 

ENTERJEID 

SEP t 9 Z005 

Rev 4' 046141 0123 
.v>'>^ 

y'l 

/ C 0 /> £ 1 A I p - t ^ If l ViHOhKt f lA l 

t P 0 U I y H 

C:OI\S;BII\ 1O! /',(-.(.-.(n^i-. 'K^ rioiH-ii\y 

RIGHT OF ENTRY TO PREMISES 

Granlot (the property' ownei) conseiils to and authorizes the United States 

Enviionmental Protection Agency (FPA) oi its authorized representatives, collectively 

the Grantee, to enter and perform certain enviionmental lesponse activities upon the 

following described premises: 

...... . ..... 7S*\'i'^_ 

Ovt'nei's Kame: Daytime Phone 

3-41 '-Z-^Od 

Address of Property 

covered by this y^i s yeu/csv6 

Agreement: 

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 coniaminated 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 Sile remediation program. 

A representative of Coastal Environmental Group, contracted by USEPA. will contact 

the Grantor in-person to discuss the work to be perfonned, 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, al all reasonable times 

and with prior notice, for the sole purpose of performing the work This access shall 

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

agrees to; 

Page 1 of 2 
C CA S "1 A 1 

C fc O U ' ' »• t 

I Remove obstructions including boats, traileis, vehicles, pieyscafie iiemr, wooo' 

piles, doo houses, etc; 

< Remove flov/ei bulbs oi plants that the Grantoi ot the Giantoi's tenent may wish 

to save; 

Water and maintain teplacement vegetation, including ferliii?.er application, as 

necessary' subsequent to an initial watering period by EP/\; 

< Abide by health and safety guidance provided by EPA; 

' If the property is rented, assist EPA in obtaining tenant appioval foi access to 

the property' to perform the work 

I Allow videotaping and/or photographing of the properly 

AGREEMENT NOT To INTERFERE 

The Grantor agrees not to interfere ot tampei with any of the work activities, oi with any 

of the work done, or with the equipment used on his properly, or to undertake any 

actions regarding the use of said property which would tend lo endanger the health or 

vk^elfare 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 

1 grant access to my properties G I do not grtnt access fo my properties 

jature \ J Date Signature Date 

• f would (ike. to be presehi duririg any sampling ihat Is lequiied. 

Paae 2 of 2 
COASTA L KNVIRONMCNTA L 

C II O U P , IN C 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of the 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: ^ . ^ ? J ^ 

Property Address: ~Z^ ^ f ^ S <^ U-J-O-T 6 "^ Y 

Owner: / ^ )fcK.n C e 

Phone: y jl^ 7^30 ^ 

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 Videographically document the existing conditions ofthe property and the basement if 

necessary. 

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

The removal, storage, disposal, and/or return of these items is the Owner's responsibility. 

Items to be Removed by the Contractor During Remediation and Not Replaced 

Item: 

^ 9 ^ ^ 

Item: 

Item: 

Item: 

Page 1of - ^ 
c o A""* T A L ENVIHONMINTA L 

GROUP . IN C 

Items to Be Removed By Contractor During Remediation and Replaced 

Item: 

< ; ^ / ) 

Item: , 

Item: 

Item: 

Landscape Inventory 

Item Quantity Unit Condition/Type/Species 

Pre-existing property area, J7 2. Quadrants that will be excavated, that 

is covered with grass. 

Number of trees > 2 inch y y ­ Each 

trunk diameter 

Number of trees <= 2 inch (0 y Each 

trunk diameter 

Number of Sprinkler 

Zones, Control Valves, 

Each Timers, Heads, etc. ^ ^ 

Attach a sketch of the 

sprinkler layout. 

Number of and size of 

each garden/ flower bed Each 

area. Square Feet 

Attach a sketch of relatixe ^ 

sizes and locations. 

Agreed upon value of plant 

materials not to be 

leplaced bv contractor. 

$ \otc this \aliie «ill be 

used Id issue a plant ^ 

voucher «> the properU 

owner. 

Easement Area, to be y/y^ Each 

excavated 

Page 2 o. ^ 
m^ & . 

COASTAL * • NVInONHCNTA L 

CROUP , IN C 

Additional Comments / Instructions: 

The city of Omaha ordinances may prohibit you from using dirt or gravel areas on your property 

as driveways or vehicle parking areas. The Environmental Protection Agency (EPA) may be 

removing and replacing soil underlying a gravel or dirt area on your property that you may be 

using as a driveway or vehicle parking area. If this is the case, you should understand that this 

removing and replacing of soil does not mean that any illegal driveway or parking area on your 

property is made legal. To the contrary, you may be cited by the city if you use a gravel or dirt area 

as a driveway or parking area, not withstanding any removal or replacement of soil by the EPA. 

If you have any question about legality of a certain driveway or parking area, you may contact 

the city of Omaha's Planning Department at (402) 444-5150. 

O Please check this box if you understand the information outlined above. 

t u Check the box if Owner does nol want CEG to document interior foundation walls and possible 

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

interior of house. Including foundation cracks or fissures. 

t agree 

/7-^7'/^ 

^A^^y^^ ^ i ^ ^ 

fier's Signat Date Contractor's Signature Date 

Page 3 of 1 
BVID #_253^ _ 

XRF PROPERTY SAMPLE SHEET 


Date / ­ ZO -ZO H Address 

Project Omaha Lead ARRA Sample time am/pm 

XRF ID# 3^0ZA Z sample length 30 sec 

Shot# 

41 

4-5 

44 

Average 

Reading 

iS5 i n 

\Z^ t I9i 

I0°l t (^ 

Li \ i Iff 

Sample area 

HZ 

Depth 

10" 

7 

Shot# 

Average 

Reading Sample area 

Depth 

Shot# Reading Sample area Shot # Reading Sample area 

Depth Depth 

Average Average 

Shot# Reading Sample area Shot# Reading Sample area 

Depth Depth 

Average Average 

Average 

Shot# Reading 

y ? 

y / 

RETEST AREAS 

Sample area 

Depth 

Shot# 

Average 

Reading Sample area 

Depth 

I^V/S Urr^) 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerica, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

AVERAGE 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

Supervised By: 

Certificate of Verification 

45 

SOIL 

2011-01-20 14:23 

90.64 

Final 

Avg of 42-44 

2815 SEWARD ST 

82 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 155.545 

Supervised By: 

Certificate of Verification 

42 

SOIL 

2011-01-20 14:22 

30.20 

Final 

25939 

2815 SEWARD ST 

B2 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 19.987 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 129.429 

Supervised By: 

Certificate of Verification 

43 

SOIL 

2011-01-20 14:22 

30.22 

Final 

25939 

2815 SEWARD ST 

B2 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

db 18.779 
Thermo 

SCIENTIFI C 

Thermo Fisher Scientific 

900 Middlesex Turnpike 

Billerlca, MA 01821 

XL3t-39022 

Reading No 

Mode 

Time 

Duration 

Sequence 

Flags 

BVID 

ADDRESS 

QUADRANT 

DEPHT 

XRF TECH 

MISC 

NOTE 

ppm 

Pb 109.532 

Supervised By: 

Certificate of Verification 

44 

SOIL 

2011-01- 20 14:23 

30.22 

Final 

25939 

2815 SEWARD ST 

82 

10" 

C.PADILLA 

CONFIRMATION 

CLEAR 

± Error 

± 17.774 
#• Q A Omaha Lead Site—Fixed Price EP-R7-07-05 

S ^^^ ^ I Coastal Environmental Group Inc. 

\~^^l? vinww.coa8talhazmat.com 

'-"tPBOt*^ COASTA L INVIIONHINTA l 

C HO U P, IN C 

EXECUTIVE SUMMARY: 

BVID # 25939 - (2815 SEWARD ST) 

No Issues or Concerns | ^ Issues/Concerns 

Detail Explanation: • 
EPA Property Close Out Form 

Property #: asj\3t»_ ^ Proptrty Abdrwr. -'3^&AS ^iaSbii^l—St— 

Dstt/Tlrne: _ ^ Owntr's Nanif MV^^O^ . ^ ^ V4 Lt^eL_C^'*" *" *" "^ ' "'"^ 

Qusdi F.xcBvaltd: yl ^ Conlraclor Group __^fit*>iyY^. 

Excavation General J e* No 

I If ncctsswj', were the correct quadranl(i) excavated and resiored'' 

/ 

2 if netessaf>', were the correct areas ofdnp 7one excavated and restored'' y 

Grading Sod and VrKctatiop 

! I Docs the grading around the perimeter oflhe hou.ie m excavairri area* generally ^IIIJH- awav 

y\ I from tbe house? 

2 Has sod been laid in all areas that were excavaled? y 

i Docs the sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 

day time period) 

y

4 Are sodded areas generally firm and evenly graded"' y 

-I ^ Are the joints behveen the sod strips generally tight? (Only evaluate if inspected at a ?n da\ 

time period) _ y 

r 6 Was the property graded such that water will nol pool on ihf propenv'' y 

7 Was damage to landscaping or plant materials avoided'' Y 

Gates, rtpces and Retainint Walls 

Do gates open and close freely'' f If applicable) ^ y - • 

^- i-i Wert all gates oi fences laken down during restoration acliviiies remsialledV (11 apoticahlf i ; y I 

Was damage to gates or fences avoided? (IfapplicablcJ 177' 

4 Was damage to retaining walls avoided"" (Ifapplicable) 17 .^ 

Foupdation, Siding and Gmters _ _ _ 

I Was dainage to the siding or trim avoided"' 

2 Was damage to the foundation avoided"' 

Was damage ic windows avoided'' 

I-

.J: 

'J Was damage to windows or door screens avoided'' 

."^ Wa.<; damage to downspouts or downspoui exien.siuns a\iiidcd' 7 

j^ulewalks and Driveways (Concrete) 

I Was damage to driveway surfaces avoided' 

2. Was damage to walkway surfaces avoided"' 1 / f 
O^'vent comments: 

fnsT>«'ction note*;: 

KernoN'al and re.sicifation arlivait^.s coinpiele iiickiding lhe .^0-day sod waniiiU) 

h-PA Hcpu-spniaiivc _^Y'^P^.. .Date: vlhl'" 
Property Completion Agreement 

I Ins agreement documenls the completion ol remedial activiiies perlbimed nn my pioperly My signaiuie 

will designate that I am satisfied with (lie restoration of my properly, and thai no items are in questions 

now, or al any lime in the future, except those items listed below, ifany 

fl^'opcify fO: ~l//\^ ^ 

PropertyAddress: l^\y ~ ^i^p^\ j l/\ / 

Owner: fi^u^^^ b^}l^}y\U _(jlMA\AA\/V\\ 7 ^ 

Phone: \\. ^ ^(^1 ^ I'yj.g ^ 

Restoration Items in Question; 

Item: 

Item: 

Item: • " 

Item: 

Item: 

Item: 

J 

Additional Comments: 1 

I ajircc I c^toi alion n complrird , rxccpt »s noleri 

( _J I rio nol a(;rfc rfsloratinn \y (ompfctcd 

Ow'iiei *s SignafiiJe ' IDat e 

jTjiy Ctin d ailo i 's Signalure 

^h y 

Dale 
Property Owner Assessment of Performance Form 

American Recovery and Reinvestment Act (ARRA) 

Omaha Lead Superfimd Site 

2009/2010 

Remediation Contractor: Coastal Environmental Group - EP-R7-09-06 

Property Identifier Number; i^^'y ^ 

Property Address: ^^JS (^t\l7M^ ^ f 

Property Owner's Name: %\A\O0.^CI: i>ulit?lv1f/) Co^ni^U'/iii^ 

-l^i^1^•l^1^-l^•l^.•^^il.if1^•^^1^i^1^•lf.1^1^1^1^1^-l^•l^•l^•l^•l^i^•^^•l^•t^-^•^^•l^•^^•^^^^ 

Instructions to the Property Owner: 

This form serves to record the Property Owner's assessment of performance (Incentive 1 

- Quality Assurance Stirveillance Plan) involving the listed remediation contractor, as applicable 

to the Omaha Lead Site. This form documents the timeliness of punch list resolution, business 

relations, complaint resolution and the overall quality of work. If need be, the Property Owner 

may utilize this form to record problems and/or issues not specifically tied to an assigned 

address, for example, business relations that generally don't follow the guidelines set forth in the 

Performance Work Statement. 

The Property Owner will indicate his/her assessment of performance with the contractor's 

work by checking a numerical rating on the table below using the ntmierical definitions fix)m 

the rating scale below, then sign & date the form. 

9-10 "excellent" 

7-8 "very good" 

5-6 "acceptable" 

3-4 "poor" 

1-2 "very poor" 

Propertv Owner's Assessment of Performance Regarding the Contractor's Work 

10 y 5 

9 4 

8 3 

7 2 

6 1 

Propertv Owner Additional Comments from (optional; continue on back page if needed) 

Property Owner Signature: .//'/-^- '^/l-y A/ ^ C-iy ' ^Date: JYY_Y.y_^^