## TRANSMITTALo f

OMAH ALEA D SIT E SOILREMEDIATIO NFIL EFOLDE R
SAID^- : Date : 

# -i U l l l Address , ^1\' > 9^^M\H > 'f < Reinediatio nContiacior : Coasta l EnNJronmcnta l Grou p Year : _2010ARR A
SOILREMEDIATJO N PROPERT V FIL EFOLDE RDOCUMENT S / 

### Vide o o f properl y (DVD ) / 

### Executiv e Summar y EPA-provide dproperl y sketc h Signe dAcces s Agreement fo r subject properl y Signe dAcces s Agreement(s ) fo r adjacenl properl y Restoratio nAgreement Settlemen t document s (i.e. , fo r damag e or t

o replac e plants , etc. ) Confinnatio n dat a i

/ 

### Photograph s IF(JV<^lA1lC M ^ tyCh/Mo* ^ \^<P< n 

# 7 As-buil t sketc h 

# 7 Satisfactory restoratio nsigne db y Property Owner 

# 7 

# 7 Property close-ou l check lis t signe db y EP A Descriptio no f area s not meetin g RO D cleanu p criteri a Utilit yclearance s 

### Property ipieflmationfro mDougla s County Assessor' s Offic e

Superfun d

# p

Propert yAcces s Checklis t PropertylD : Q.5i\-<^« ^ D WOR K STARTED ON : / /_ D WOR K COMPELTE D ON : / / Propert y Address : :i^ ^ AS ^

2i«'«. % JuA. , JS\. , Owner : . . _ , . . . , Rcntei

Address : -^ ' Phone: Fax : Cell/Pager : Additionu l Information : Phone : H*^
. ^v, ^ ^-^^ o Fax : Cell/Pager :
D Notificatio nLette r Sent : / / By :
" S Acces s Agreemen t Signed : \ o />•/« © By : \>»'t\ C ' ^ Restoratio nAgreemen t Signed : vt > / > ly o By : »iSO C D Topsoi l Samplin g (if applicable ) 1 1 By : Q Disposa l Samplin g (if applicable ) 1 1 By : Q Garde nSamplin g (if applicable ) 1 1 By : Q Utilit y Clearanc e Called : \ o /\f , U o By : i«»/ax/» o vu..iv , »»/»»->« " \ ^ Video/Photo s (Before ) On : w / > / % o By : vat c_^L ^ D Video/Pboto s (During ) On : / / By : D Video/Photo s (After) On : / / By :

• Video/Photo s (30-Day ) On : / / By : D Propert y Completio nAgreemen t Siened : / / By : D Final Repor t Issued : / / By : 

# ...... . 1 Ai r Monitorin g (a s ai)plicable ) J D Community Q Cre w On : By :

Results : 

# q
D Communif? ' D Cre w [ On : / / Results :

• Communit y C U Cre w On : By : Results :
Omah a Lea d Sit e

### Dougla s County Accoun t I I^^B J 

### atio n Pag e 1 o f 1
Dougla s County , Nebrask a Propert yRecor d - R221346000 0 Prin t Repor t Vie wInteractiv e GI S Ma o Informatio n i s vali d a s o f2010-8-3 0 Treasurer' s Ta xReoor t Ne wFeatur e - > • • ^ Subdivisio n Sale s Searc h Owne r ALLIANC E BUILDIN G COMMUNITY1 C/

O MICHAE L B MARONE Y 222 1 N 2 4 S T OMAH AN E 68110-000 0 Propert yInformatio n Ke yNumber : 134 6 000 0 2 2 Accoun t Type : Residentia l Parce l Numtter : 221346000 0 Parce l Address : 281 5 SEWAR D S T OMAH AN E 68111-OOO O Lega l Description : SHINN S 3R D AD D LO T3 BLOC KYW3 0 FT3 0 X 12 7 Valu e Informatio n Lan d Improvemen t Tota i 201 0 $300.0 0 $0.0 0 $300.0 0 200 9 $300.0 0 $0.0 0 $300.0 0 200 8 $300.0 0 $0.0 0 $300.0 0 200 7 $300.0 0 $0.0 0 $300.0 0 200 6 $300.0 0 $0.0 0 $300.0 0 200 5 $300.0 0 $0.0 0 $300.0 0 

### Sho wAl l Transaction s

Lan d Informatio n



### http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R221.
.. 9/2/201 0Pag e 1 of 2

" > Creat e Anothe rTicke t [ Bac k t o Irt h Inteme t ) Sen d Emai l

• YOU RTICKE T NUMBE RI S 2627054
. Origina l Cal l Date : 10/26/1 0 Time : 5:2 8 p m Op : ELIZABETH1879 0 Wor k t o Begi n Date : 10/28/1 0 Time : 6:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 281 5 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 : LOCAT E ENTIR E PROPERTY , AL L EASEMENT S AN D T O TH E PEDESTA L Remarks : FA X AL L CLEAR S TO : (877)662-421 1 : UNSUR E I F CORNE R LOT . 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 Deptl i o f Excavation : 4 F T Come r Lot : N Front : Y Rear : Y Involve s Tvmnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V LEVEL 3 MUDO l OMAHACO F OPPDGPR S QLNNEI C

Servic e Are a Contac t Phon e Number UtiUt y Typ e
CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7
LEVEL S LEVEL3 COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4
MUDO l METROPOLITA NUTILITIES DISTRICT SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0
OMAHACO FCIT Y OFOMAHA-TRAFFICSEWE RRICH/TRAFFI C Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3
http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?Tet=<RESULT..
. 10/26/201 0

### Pag e 2 of 2

0PPDGPR 5 OMAH APUBLI C POWE RDISTRIC T Alt : 406207149 4

EL M LOCATIN G Emerg : 888728934 3 QLNNEI C QWES T LOCA LNETWOR K Day :

EL M LOCATIN GAlt : 406728934 3 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT.
. . 10/26/201 02593 9 

# As-Buil t Drawin g COASTA L 

# Omah aLea dSuperfun dSit e OLS# : 2593 9 Dat e Excavated : 10/28/201 0 Dat e USEP ASiane d Off : 12/9/201 0 Are a Sodden : 146 5 s a f t Exterio rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : CURR YTEMPL E COMMUNIT • Good Sit e Sketc h Address : 281 5 SEVVAR D S T • Poo r Phone : " : W : 

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# ENTERiE D SE P 1 9 i m

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## 2593 9 Exterio rPain t North Anw w Omah a Lea d Sit e Owne rName : CURR YTEMPL E COMMUNIT • Goo d Sit e Sketc h Address : 281 5 SEWAR D S T • Poo r

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s viewe d fro m th e street , facin g propert y 

# ENTEEE D SE P 1 9 2005



# C/^o^i A)

# 2593 9 Exterio rPain t Nort h AfTo w Omah a Lea d Sit e Owne rName : CURRYTEMPL E COMMUNI T • Good Sit e Sketc h Address : 281 5 SEWAR D S T • Poo r Phone : H : w . 

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# ENTERJEI D SE P t 9 Z00 5

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# y' l / C 0 / > £1 AI p - t ^ If l ViHOhKt flA l t P0 U I y H C:OI\S;BII \1O ! 

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### rioiH-ii\ y RIGH TO F ENTR YTO PREMISE S 

### Granlo t (th e property ' ownei ) conseiil s t o an d authorize s th e Unite d State s Enviionmenta l Protectio n Agency(FPA ) o i its authorize d representatives , collectivel y th e Grantee , t o ente ran d perfor m certai n enviionmenta l lespons e activitie s upo n th e followin g describe d premises :



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

Ovt'nei' s Kame : 

### Daytime Phon e 

# 3-4 1 '-Z-^O d
Addres s o f Propert y covere db y thi s 

# y^i s yeu/csv 6 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 remove soi l tha t contain s elevate d concentration s oflea 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 coniaminate 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 Sil e remediatio n program . Arepresentativ e o fCoasta l Environmenta l Group , contracte d byUSEPA
. wil l contact th e Granto rin-perso n t o discus s th e wor k t o b e perfonned , 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 y ha s bee n remediated
. ENVIRONMENTA L RESPONS E ACTION S 

### Bysignin 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 l al l reasonabl e time s an d wit h prio rnotice , fo rth e sol e purpos e o fperformin g th e wor k Thi s acces s shal l remai n i n effec t unti l th e wor k ha s bee n satisfactoril ycomplete d Th e Granto i als o agree s to ;

Pag e 1 o f2C CA S "1 A1
C fc O U ' ' » • t 

### I Remov e obstruction s includin g boats , traileis , vehicles , pieyscafi e iiemr , wooo ' piles , do o houses , etc ; < Remov e flov/e i bulb s o i plant s tha t th e Granto i o t th e Giantoi' s tenen t ma ywis h t o save ; Wate ran d maintai n teplacemen t vegetation , includin g ferliii?.e rapplication , a s necessary ' subsequen t t o a n initia l waterin g perio d b yEP/\ ; < 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 appiova l fo i acces s t o th e property ' t o perfor m th e wor k I Allo wvideotapin g and/o rphotographin g o fth e properl y AGREEMEN TNO TT o INTERFER E 

### Th e Granto ragree s no t t o interfer e o t tampe i wit h an yo fth e wor k activities , o i wit h an y o fth e wor k done , o rwit h th e equipmen t use d o n hi s properly , 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 l o endange rth e healt h o r vk^elfar 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 mypropertie s G I d o no t grtn t acces s f o mypropertie s

jatur e \ J Dat e Signatur e Dat e

• fwoul d (ike
. t o b e preseh i duriri g an ysamplin g iha t I s lequiied
.

Paa e 2 o f2COASTA L KNVIRONMCNTA L C I I O U P , IN C 

## Restoratio n Agreemen t Th e purpos e o f thi s agreemen t i s t o provid e amutual agreemen t a s t o condition s o f th e property prio r t o 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 dt o th e satisfactio no f th e property owne r an dth e Unite dState s Environmental Protectio nAgenc y (EPA)
.

Property ID : ^
. ^ ? J ^ Property Address : ~Z ^ ^ f ^ S < ^ U-J-O- T

### 6 "^ Y Owner : / ^ )fcK. nC e 

## Phone : y jl ^ 7^30 ^ O nth e attache ddiagram(s ) indicate area(s ) t o excavate , surfac e structure s an dlandscapin g feature s an d acces s location(s ) to b e use db y th e contractors . Indicate distances , depths , material types , etc . Photographicall y an dVideographicall y document th e existin g condition s ofth e property andth e basement if necessary . 

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



### Item s t o b e Remove d b yth e Contracto rDurin g Remediatio n an d No t Replace d Item : ^ 9 ^ ^ Item : Item : Item :

Pag e 1o f - ^co A"" * TAL ENVIHONMINTA L GROUP
. IN C 

## Item s t o B e Remove d ByContracto rDurin g Remediatio n an d Replace d Item : < ; ^ / ) Item : , Item : Item :


## Landscap e Inventory Ite m Quantit y Uni t Condition/Type/Specie s Pre-existin g property area , 

# J 7 2
. Quadrant s tha t will b e excavated , tha t i s covere dwit hgrass . Numbe r o f tree s > 2 inc h Eac h 

# y y ­ trunk diameter Number o f tree s < = 2 inc h 

# ( 0 y Eac h trunk diameter Numbe r o f Sprinkler Zones , Contro l Valves , Eac h Timers , Heads , etc . ^ ^ Attac hasketc hof the sprinkler layout
. Numbe r o f an dsiz e o f eac hgarden / flower be d Eac h area . Square Fee t Attac hasketc hof relatix e ^ size s an dlocations
. Agree dupo nvalu e o f plan t material s no t t o b e leplace db v contractor . $ \ot c thi s \alii e «il l b e use dI dissu e aplan t ^ vouche r « > th e proper U owner . Easement Area , to b e Eac h 

# y/y ^ excavate d 

### Pag e 2 o. ^

# m ^ &
. COASTAL *
• NVInONHCNTA L CROUP , IN C
Additiona l Comment s / Instructions : Th e cit yo fOmah a ordinance s ma yprohibi t yo 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 yb 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 yb 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 withstandin g an yremova l o rreplacemen t o fsoi l b yth e EPA
. 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
. O Pleas e chec k thi s bo xi fyo u understan d th e informatio n outline d above
.

t u Chec k th e bo xi fOwne rdoe s no l 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
. 

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# 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 Sequenc e Flag s AVERAG E ADDRES S QUADRAN T DEPH T XR F TEC H MIS C NOT E

Supervise d By : 

## Certificat e o fVerificatio n

4 5 SOIL 2011-01-2 0 14:2 3 90.6 4 Fina l Av g o f42-4 4 281 5 SEWAR D S T 8 2 10 " C.PADILL A CONFIRMATIO N CLEA R

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

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

pp m P b 155.54 5 Supervise d By : 

## Certificat e o fVerificatio n

4 2 SOI L 2011-01-2 0 14:2 2 30.2 0 Fina l 2593 9 281 5 SEWAR D S T B 2 10 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 19.98 7

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

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

pp m P b 129.42 9 Supervise d By : 

## Certificat e o f Verificatio n

4 3 SOI L 2011-01-2 0 14:2 2 30.2 2 Fina l 2593 9 281 5 SEWAR D S T B 2 10 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r d b 18.77 9

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

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

pp m P b 109.53 2 Supervise d By : 

## Certificat e o fVerificatio n

4 4 SOI L 2011-01

- 2 0 14:2 3 30.2 2 Fina l 2593 9 281 5 SEWAR D S T 8 2 10 " C.PADILL A CONFIRMATIO N CLEA R

± Erro r ± 17.77 4

## # • QAOmah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 S ^^^ ^

I Coasta l Environmenta l Grou p Inc
. \~^^l ? vinww.coa8talhazmat.co m '-"tPBOt* ^ COASTA L INVIIONHINTA l C H O U P , IN C 

# EXECUTIV ESUMMARY : BVID #2593 9 - (281 5 SEWARD ST ) No Issue s o r Concern s | ^ Issues/Concern s
Detai l Explanation: •

## EP APropert y Clos e Ou t For m Propert y # : asj\3t»_ ^ Proptrt y Abdrwr
. -'3^&A S ^iaSbii^l—St — Dstt/Tlrne : _^ Owntr' s Nani f MV^^O^
. ^ ^ V 4 Lt^eL_C^'* " * " * " " ^ ' "'" ^ Qusd i F.xcBvaltd : yl ^ Conlraclo r Grou p __^fit*>iyY^
. Excavatio n Genera l J e * N o I I f ncctsswj' , wer e th e correc t quadranl(i ) excavate dan dresiored' ' / 2 i f netessaf>' , wer e th e correc t area s ofdn p 7on e excavate dan drestored' ' 

# y Gradin g So dan dVrKctatio p ! I Doc s the gradin g aroun dthe perimete r oflh e hou.i e mexcavairr i area * generally ^IIIJH

- awa v 

## y\ I fromtb e house ? 2 Ha s so dbee nlai dinall area s tha t were excavaled ? 

# y i Doc s the so dappea r to b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t a3 0 

# y da y tim e period ) 4 Are sodde darea s generall y firmandevenl y graded" ' 

# y

- I ^ Are th e joint s behvee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte da t a?nda \ tim e period )
_ 

# y r 6 Wa s the property grade dsuc htha t water will nol poo l o nih f propenv' ' 

# y 7 Wa s damag e t o landscapin g o r plan t material s avoided' ' 

# Y Gates , rtpce s an dRetainin t Wall s D o gate s openan dclos e freely'' f I

f applicable ) 

### ^ y - 

### • 

# ^- i- i Wer t all gate s o i fence s lake ndowndurin g restoratio nacliviiie s remsialled V (1 1 apoticahl f i 

## ; yI Wa s damag e to gate s or fence s avoided ? (Ifapplicablc J 

# 177 ' 4 Wa s damag e t o retainin g wall s avoided" " (Ifapplicable ) 

# 1 7
. ^ Foupdation , Sidin g an dGmter s ___ I Wa s dainag e t o th e sidin g o r tri mavoided" ' 2 Wa s damag e t o th e foundatio navoided" ' Wa s damag e i c window s avoided' ' 

### I - 

# .J : 'J Wa s damag e to window s o r door screen s avoided' ' ." ^ Wa.< ; damag e to downspout s o r downspou i exien.siun s a\iiidcd ' 

# 7

j^ulewalk s an dDriveway s (Concrete ) I Wa s damag e to drivewa y surface s avoided ' 2
. Wa s damag e t o walkwa y surface s avoided" ' 

# 1 / f

## O^'ven t comments :

fnsT>«'ctio nnote*; :

KernoN'al an dre.sicifatio narlivait^. s coinpiel e iiickidin g lh e .^0-day so dwaniiiU ) h-P AHcpu-spniaiiv c _^Y'^P^.
. .Date : vlhl' "

## Propert yCompletio n Agreemen t
I In s agreemen t documenl s th e completio n o l remedia l activiiie s perlbime d n n m ypioperl yM ysignaiui e wil l designat e tha t I a m satisfie d wit h (li e restoratio n o fm yproperly , an d tha i n o item s ar e i n question s now , o ra l an ylim e i n th e future , excep t thos e item s liste d below , ifan y fl^'opcif y 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 ^ Restoratio n Item s i n Question ;

Item : Item : Item : • " Item : Item : Item : 

## J Additiona l Comments : 

# 1

I ajirc cI c^to i alio n n complrird , rxccp t » s noler i ( _J I rio no l a(;rf crfsloratin n \ y(ompfctc d

Ow'iie i *s SignafiiJ e ' IDat e 

# jTji y Ctin d ailo i ' s Signalur e 

# ^hy
Dal e

# Propert y Owne r Assessment of Performanc e For m America nRecover y andReinvestmen t Act (ARRA) OmahaLea dSuperfim dSit e 2009/201 0 Remediatio nContractor : Coasta l Environmenta l Grou p - EP-R7-09-0 6 Propert y Identifie r Number ; i^^'y ^ Propert y Address : ^^J S (^t\l7M ^ ^ f Propert y 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^•^^•^^^ ^ 

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

- Quality Assuranc e Stirveillanc e Plan ) involvin g th e liste dremediatio ncontractor , a s applicabl e t o th e Omah aLeadSite
. Thi s for mdocument s th e timeliness o f punc hlis t resolution , busines s relations , complain t resolutio nan dth e overal l quality o f work
. If nee dbe , th e Property Owne r ma y utiliz e thi s for mt o recor dproblem s and/o r issue s no t specificall y tie dt o a nassigne d address , for example , busines s relation s that generall y don' t follo w th e guideline s set fort hi nth e Performanc e Work Statement
. Th e Property Owne r wil l indicat e his/he r assessmen t o f performanc e withth e contractor' s work b y checkin g anumerica l ratin g o nth e tabl e belo w usin g th e ntmierical definition s fix)m th e ratin g scal e below , the nsig n& dat e th e form
. 9-1 0 "excellent " 7- 8 "very good " 5- 6 "acceptable " 3- 4 "poor " 1-

2 "very poor " Propert v Owner' s Assessmen t o f Performanc e Regardin g th e Contractor' s Wor k 

## 1 0 y5 9 4 8 3 7 2 

### 6 1 Propert v Owne r Additiona l Comment s fro m(optional ; continu e o nbac k pag e i f needed )
Propert y Owne r Signature : .//'/-^

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