### TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAID# : ^n f ' Date : U^/Z/Jo ? : Address : /^ f S i JZ ^ ^ H Remediatio n Contractor : Coasta l Environmenta l Group

_ Year : _2007 _ SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S y Vide o o f property (DVD ) 0 ^ Executiv e Suminary , . ' ^ EPA-provide dpropert y sketc h M Signe dAcces s Agreemen t for subjec t propert y D Signe dAcces s Agreement(s ) fo r adjacen t propert y M Restoratio n Agreemen t D Settlement document s (i.e. , fo r damag e o r t o replac e plants , etc. ) 2

1 Confirmatio n dat a, y Photograph s ' ' As-buil t sketc h. , y Satisfactory restoratio n signe db y Property Owne r y Propert y close-ou t chec k lis t signe db y EP A Ih y 

### ^ M Descriptio n o f area s no t meetin g RO D cleanu p criteri a D Utilit y clearance s D Propert y informatio n fi-omDougla s County Assessor' s Offic e D D . 

# ^4M­ 4031786 7 

# IHiH i Superfun d

# i3a ^ S <3 o 

# "Sr^ - Fina l Repor t Propert y Chec k Lis t (piease plac e wit heac hnie) Har dCop y Informatio n I Q Property Chec k Lis t ]2 l Site Workin g Drawin g Ma p 3 . EP A original s Ma p 13 / Dougla s County Assessor' s Ma p |5! ] Property Contac t Sheet Agreemen t iH Acces s Agreemen t |2 3 Restoratio n Agreemen t Miscellaneou s Document s ^TJFinal Ma p fromth e Fiel d yz i Chang e Order s P 7 XRFDat a 4 . Any email s o r P O correspondence s Propert y Completio n IT

] Executiv e Summar y 2 . A S BUIL T |2 l Property Completio n Agreemen t ^ Any buyou t inf o o r reimbursemen t inf o Q Chec k o r mone y orde r copie s ^ EPA Property Clos e Out For m iT) Attache dBegi n Vide o Electroni c Documentatio n Drawing s jl ] EPA original \Z ^ Workin g Drawin g

3 . A S Built.vs o 4 . A S Built.jp g Photo s • ^egi n Photo s v^During/Excavatio n Photo s v'So dPhoto s v^O-Day So dPhoto s

Scanne dDocument s • ^ina l Document s VExecutive Summar y V^eo s HBegi n Vide o 7M y Movi e

## Propert yAcces s Checklis t PropertylD : ^Qj'^ l D WOR K STARTE D ON : / / Pn.pert y Addrcs.s : / ^^ ^ ^ ^ ^1/^5 ^ n WORKCOMPELTE D ON : / / Renter : 

# Owner : l)^^Q^d k

7iiznyllt r Addrc.s.s : f- ^ ^ ^^^ ^ ^_ ^ Phone : Fax : Cell/Pa^cr : Additiona l Information : 

# •'""" - 3^i-3Db y Fax : Ccll/PaRcr : ® Notificatio n Lette r Sent : G / ;3 / (^ 7 

# Bv : ^.J k CT Acces s Ajjrccmcn t Signed : ( O 1 /3 l 0' 7 By://,^^/ ^ Q Restoratio n Agreemen t 

### Siened: 6 //, 3 l0 7 

## B.V : /Z/c U [ U Topsoi l Samplin g (i f applicahlc ) 1 1 By : n Disposa l Samplin g (ifapplicable ) 11 By : O Garde n Samplin g (ifapplicable ) 1 1 By : Q Utility Clearanc e Called : (i ? /5 " / ^ 7 

## By : -y j i6iy- , 1'[ / >9?>6il i 

# : y [3 - Video/Photo s (Before ) 

## On : ll_li± l Cy i 

# ^r-fUc y H Vi<leo/Photo s (During ) 

### On:J_'Al ' (^' T By : H Video/Photo s (After ) 

## On:^/Lg./_0 7 By : 6 Video/Photo s (30-Day ) On : ^ / i^ f O f By : ^ Propert y Completio n Agreemen t Sinned : 7 / 3i / ^ 7 By : 1 1 Fina l Repor t Issued :/ / By : Ai r IVIonhorin g (a s applicahle ) n Communit y \// \Cre w On : / / 

### By : 1 Results : n Communit y C D Cre w On : / / By : Results : n Communit y C H Cre w On : / / By : Results :

_^_-.^ ^ Omah a Lea d Sit e

.- tPropertyClassification : 80 0

Descriptio n o f post excavatio n areas : Fl , ft-ont yar d left-han d quadrant ; F2 , fron t yard right-han d quadrant ; 81 , backyard left-han d quadrant ; B2 , backyard right-han d quadrant ; DZ . dri p zon e (1- 3 foo t are a o f soi l aroun d th e foundatio n o f th e house) .

### Print Previe w Pag e 1 o f 1 Dougla s County-Omaha , N E

Parce l I D Owne r Nam e Propert y Addres s Cit y Zi p Owne r Addres s Owne r Addres s 2 Owne rCit y Owne r Stat e Owne rZi p 221889000 0 KITZMILLE R DEBORA H C 132 9 S 2 6 S T OMAH A 6810 5

132 9 S 2 6 S T OMAH A N E 6810 5 Sec-Twn-Rn g Owne r Addres s Additio n Bloci f Lo t Lega l 1 Lega l 2 Lega l 3 Lega l 4 Assesso r Websit e Lin k 27-15-1 3

SHULL S 2N D AD D 1 0 1 5 50X12 7

http://douglasne.mapping online.com/DouglasCoNe/static/accountinfo.jsp ? accountno=R221889000 0 Disclaimer : Ma p an d parce l dat a are believe d t o b e accurate , bu t accuracyi s no t Ma p Scal e guaranteed . Thi s i s no t a lega l documen t an d shoul d no t b e substitute d fo ra titl e search , 1 inc h = 22 8 fee t appraisal , survey , o rfo rzonin g verification . 

### http://www.dogis.org/dogi s alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 6/9/200 7

## Property ID # Property Address : Initial Contact : Secon dContact : Final Contact : Fina l Action : 

# }^i\7iU) ^ Comment : Owne r Commen t (s) : Site Coordinato r Commen t (s) : CONTAC T FORM 

# ^on i /i ^ S.t^O^S-h . Date:]^J_l>__Time : \lV(/ 

## Action : K<^^ ^

Date : Time : Action : Date : Time : Action : Transmi t t o EP A D Othe r Action : D 

# 5^1 

# >Sz .

1

## y^ir: % COASTA L ENVIRONMENTA L CROUP . 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 rIts authorize d representatives , collectlvel 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 : >t:^C^^^iT2-yw ( LU ^ Daytim e Phone : 5 41 ' 3 < ^

3c X

Addres s o f Propert y 

# / 3X^ 5 . 3 e 

# ^i^ . covere d b ythi s 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 f lea 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 Its 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 f Coastal 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 rvvil 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 

### Bysignin g thi s Acces s Agreement , th e Granto ri s grantin g th e EPA , Its 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

### . # C O ASTAJ L 

## \

y ENVIRONMENTA L GROUP , INC . 

### 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 ; Ifth 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 o f th 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 f th e wor k done , o rwit h th e equipment use d o n hi s property , o rt o undertak e an y action s regardin g th e us e o f sai d propert ywhic h woul d ten d t o endange rth e healt h o r welfar e o f th 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 . Should you 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 s Q I d o not gran t access t o m ypropertie s 

# C -IP..^ 7 Signatur e \ ) Dat e Signatur e Dat e

n I woui d lik e t o b e presen t durin g an ysamplin g tha t i s required .

Pag e 2 o f 2

# !^M7 \CLCGe & C^y aammi ^ COASTA L 

## 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 followin g describe d premises :

Owner' s Name : Daytim e Phone : 

# '\by\s.auiyf : Addres s o f Propert y covere d b ythi s Agreement : 

# LadHss- b h aiKicthbOK ) 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 f lea 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 wli^^ e restore d t o itspriglna l condition . Thi s wor k I s bein g performe d unde rth e Om^^'OeadtiSif^rlvi W $lte?l|^n5i^ia'tiQ} ] pcpgram . Arepresentativ e o f Coastal 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 Ijeglns . 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 

### Bysignin g thi s Acces s Agreement , th e Granto rI s grantin g th e EPA , it s employees , contractor s an d subcontractors 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 2COASTA L 

## \

y ENVIRONMENTA L GROUP . INC . 

### Remov e obstruction s includin g boats , trailers , vehicles , playscape 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 ; Ifth 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 o f th 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 f th 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 f sai d propert ywhic h woul d ten d t o endange rth e healt h o r welfar e o f th 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 .

. . . -;: . 'v . /y / ^ •: • 

### Should 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 . 

# Ci LAccc u 4o \y2f i $,ic r©^*^ n I gran t acces s t o m ypropertie s D I d o not gran t acces s t o m ypropertie s Signatur e ur e Dat e G I woul d lik e t o b e presen t durin g an ysamplin g tha t i s required .

Pag e 2 o f 2

### % COASTA L • M V IRO M M X NrA L an e u r . INC . 

### Restoratio n Agreemen t The purpos e o f thi s agreement i s t o provide amutua l agreement a s to condition s ofth e propert y prior to remediatio n activities . Thi s will als o serv e a s documentatio n fo r th e purpos e o f assurin g tha t restoratio n activitie s are complete dto th e satisfactio n o f th e propert y owne r andth e Unite dState s Environmental Protectio n Agenc y (EPA) .

Propert y ID : ^ m \ Propert y Address : \l^l ^ tC^^^- ^ y Owner : 

## \y\oV ^ iJlTirAiLLfc t Phone : 

# M vy % On th e attacheddiagram(s ) indicat e area(s ) t o excavatedan ddept ho f excavation , locationo f all known utilities , subsurfac e features , surface structure s an dlandscaping features , acces s location(s ) t o be usedb y contractor , an dthe directio n o f North . Indicat e distances , depths , materia l types , etc . Indicat e digita l photo s b

y referencing the photo-lo g numbe r wit ha narrow indicating direction o f view . Item s T o B e Remove d B yOwne rBefor e Star t O f Remediation : (Use additiona l sheets a s necessary ) Th e removal , storage , disposal , and/o rretu m o f thes e item s i s th e Owner' s responsibility . Item : 

# 01 b 

# ^ ^ Hem : hem : r 

## ./hAjfWlo^ / ~"~~^ , Item : 

### J Hem : ^ ^ - ^ " Hem : ^.^-^' ^ Hem : ^^ ^ Hem : ^,.y ^ Pag e 1o f y

# t

Item s T o B e Remove d B vContracto rDurin a Remediatio n An d No t Replace d (Us e additiona l sheet s a s necessary ) Item : . 

## 4l(/iri/t/ftL( ^ Hem : \ ) ^ Hem : 

# i^ v[^j^^o^Pnyf] U v- iy ? ^^ i H(rf ^p, ^ Hem : 

## 1 

# "^•Uo^ ^ 

# % \

^ 

# h v Hem : Item : 

### i x

### ( \ik ] 

### ^ y Hem : 

# , hof" ^



# \ ^'^( y 

# y ^ Hem : y Hem : 

# x ^ Hem : 

# X / Item : Hem : ^ Hem : y y Hem : y

Pag e 2 o f y i

# t

C O AS TAC • N V I RONM * NTA L C I t O U f > . INC . Item s T o B e Remove d B yContracto rDurin g Remediatio n An d Replace d (Use additiona l sheet s a s necessary ) Hem : 

# ^ ^ c

# _ " ^ Rem : / Hem : / Item : / Item : / Hem : Item : Hem : Item : Item : / / Item : / Hem : / Hem : / Hem : / Hem :

Pag e 3 of .% COASTAL . INViKONMCNTA L anour . INC . 

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

### Item

Pre-existin g propert y area , tha t wil l b e excavated , tha t i s covere dwit hgrass .

Number o f tree s > 2 inch trunk diameter

Number o f tree s < = 2 inch trun k

diaineter

Number o f Sprinkler Zones , Contro l Valves , Timers , Heads , etc . Attachasketc ho f th e sprinkler layout . Number o f an dsiz e o f eac hgarden / flowe r bed area . Attac hasketcho f relativ e size s an dlocations . 

### Quantit y



# • ;-i i



# 9 

# y Uni t
Square fee t

Each

Each

Eac h 

# 1 Eac h Square Feet 

### Condition/Type/Specie s



# te>^ ^i^y" 

# '^^ ' ^^^ ^

Pag e 4 

## o f UCOASTA L 

### Item Agree dupo n valu e of plan t material s no t t o b e replace dbv contractor . Note thi s valu e will b e use dt o issu e aplan t vouche r t o th e propert y owner . Agree dupon lis t o f plant material s tha t wil l b e replace db y contractor . B e ver y specifi c anddetailed . Includ e asketc ho f wer e eachplant will b e place d b

y th e contractor . Agree dupon are ao f propert> ' t o b e replace d wit hgras s sod . Include asketcho f th e area(s ) t o b e replace dwit h gras s sod . Are ao f Cit y o r Count y propert y t o b e landscape d per thei r requirements . Include asketcho f th e area(s )

Easement Area , t o b e excavate d 

### Quantit y Unit

$ 

### Condition/Type/Specie s 

# r Eac h 

# ^^1 1 S F 

# r

r ^ S F

S F 

# '^l\?^ll r 

# \ioA- e ^l^&i/02^;uyiB'yiy^^^^y ^

Page s of_ ^% COASTA L
Additiona l Comment s / Instructions :



# - fl ) UyiL t C(t < ^t\(.^\&> ^ 

# ^ ^ H (^h<^ t

turn( ^ 

# y ( 7 Q 

# \]9y/(Ayt ^ (y\(> W 

# ^^^i^ u i- ^ UC69( , 

# m 

# a

• Chec k th e bo xi 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 bo xCE G i s no t responsibl e fo ran ydamag e don e t o th e interio ro f house , includin g foundatio n crack s o rfissures .

I agre e n I d o no t agre e 

# 0 ^ '^vVtvj(ia /

(,-i2> - ^ 1 

# :^^s ^ 6 |> i Owner' s Signature / Dat e ntractor' s Signatur e Dat e Pag e 6 

# o'- UCOASTA L ENVIRONMENTA L CROUP . INC . 

## 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 ofth e property prio r t o remediatio n activities . 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 are complete dt o th e satisfactio no f th e property owne r an dth e Unite dState s Environmenta l Protectio n Agenc y (EPA) .

Property ID : 

# ^ n \ Property Address : I'l'^, ^ C j 'Zh' ^ ^ f Owner : Phone : 

## ^.^1 - V ? On th e attache ddiagram(s ) indicate area(s ) t o excavate dan ddept ho f excavation , locatio n o f all know n 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 n o f North . Indicate distances , depths , material types , etc . Indicate digital photo s b y referencin g th e photo-lo g number wit ha n arro w indicatin g directio n o f view . 

### Item s T o B e Remove d B yOwne rBefor e Star t O f Remediation : (Us e additiona l sheet s a s necessary ) Th e removal , storage , disposal , and/o rretur n o f thes e item s i s th e Owner' s responsibility . Item : 

# Oi l 

# ^ ^ Item : 

# f m Item : 

# {c,c y \\UMU , 

# [Cyi^^Wi\/ ^ . lhAA^(MA^ . 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 ) Item : 

## \/\^h M ^li/J^W^ ^ Item : 

# W u \) r Item : 

## Spli\77 ] 

# f v(iv^^^^ l U v -vy ? 

# k W Vidf ^ Item : 

## ^y\^ i 

# y Item : 

# W^\ Y % \

yi^ v Item : 

# fir(fv ^ \}j^o\ / Item : 

# W^1? 7 

# 1^ 7 • 

# ~ y Item : 

## 'ii4/3iZ ^ , foOi^ ^

] ^O w Item : y Item : y Item : 

# y Item : y Item : X Item : X Item : / /

Pag e 2 

### of I ? 

# 1COASTA L ENVIRONMENTA L CROUP . IN C 

### 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 : 

## t^Ji J _ . - , — > Item : / Item : / Item : / Item : / Item : / Item : / Item : / Item : / Item : Item : / / Item : / Item : / Item : / Item :



### Page s 

## o fi/ ^

# (^f e COASTA L ENV I RONMENTA L CROUP , INC . 

### 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 , that i s covere dwit hgrass .

Numbe r o f tree s > 2 inch trun 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 . Attac hasketc ho f th e sprinkle r layout . Numbe r o f an dsiz e o f eac hgarden/ flower be d area . Attac hasketc ho f relativ e size s an dlocations . 

### Quantit y



# • ^^1 1



# S 

# y

y j o ' Uni t

Squar e feet 

### Condition/Type/Specle s

Eac h

Eac h

Eac h

^Eac h Squar e Fee t 

## tv^^ ^ HiW1^ ^ 

## KV^ '

Pag e 

### 4o f UCOASTA L 

### Ite m Agree dupo n valu e o f plan t material s no t t o b e reolace 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 n lis t o f plan t material s that wil l b e replace db y contractor . B e very specifi c an ddetailed . Includ e asketc ho f wer e eac hplan t wil l b e place d by th e contractor . Agree dupo n are ao f property t o b e replace d wit hgras s sod . Includ e asketc ho f th e area(s ) t o b e replace dwit h gras s sod . Are ao f Cit y o r Count y property t o b e landscape d pe r thei r requirements . Includ e asketc ho f th e are a(s )

Easemen t Area , t o b e excavate d 

### Quantit y Uni t

$ 

### Condition/Type/Specie s

I .

/ 

# 7 

# r Eac h 

# y\ S F 

# y S F 

# Vi^Ai ^



# y S F 

# ^l^^i^l^,^^,^,y::^^^^M^^^^kr^ ^

Pag e 5 o f ^COASTA L ENVIRONMENTA L GROUP . INC . Additiona l Comment s / Instructions : 

# hm lo^y . CMy> ­

<? Q 

# \]pi/k^h ^

n 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 f house , includin g foundatio n cracks o rfissures .

I agre e n I d o no t agre e 

# 6-/ 3 ^^7 Owner' s Signaturft j Date Pag e 6 

# ofj ^

# 5 5 OlIlQlO l /32 9 3oy>(j- ^ ^^o/il ) GA^L J 

# <rPr)7/n S (/[Ifb/ J (/ 7 .^^T ) OtO-7-5 / /1b£m^ 6 7^yi7/,77^7po ncX 7t9q y y/ m/m" ^ )^ 0 

# ^im ^ i^o/ ^ yt7Qiu^o ^"^•^^ 0 7:^7^/ ^ Qy:tu / 7^^971^^/Z7 r fM^ ^ ^ mm/?7(/' ' , iCTy^ ^ 

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Descripiio n o f post excavalio n areas , Fl , fron t yar d left-han d quadrant ; F2 , fron t yard right-han d quadrant ; 81 . backyard lefl-han d quadrant ; B2 . backyar d right-han d quadrant ; DZ , dri p ion e (1- 3 foo t are a o f soi l aroun d th e foundatio n ofth e house )PROPERT YCLEARANC E WORKSHEE T

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# RESTORATIO N CHANG EORDE R OMAH A LEA D Propert y I D #cPO|l^ l Propert y Addres s /^^f ' - 5 ^/^5r Owne r Nam e Z^/^^s^/t ^ Mz/eT z Dat e yr/^'O y Comment s /^^Mous - ra p /^^/c/^axJ ) nfr< ^ f/^-n7 ^ P"/ ^ F ^

Owne r Signatur e

# ^jpi ^ \^^ L Contracto r Signatur e VPropert yClassification : 80 0

•o n o f po« ( excavatio n area i Fl . front yar d left-han d quadran t F2 . fron t yar d nghl-^an d quadrant . Bl . backyar d lefVhan d quadran t B2 . backyart nght-han d quadran t oe . drt p zon e (1- 3 foot are a o f so l aroun d «i e foundMo n o f ttie house )• ( # 

### Omah a Lea d Site—Fixe d Pric e EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc . www.coastalhazinat.co m COASTA L ENVIRONMENTAl . GROUP , INC . 

## EXECUTIV ESUMMARY : t h 

## 20171—132 9 Sout h26' " S T I I N o Issue s o r Concern s [V | Issues/Concern s Detai l Explanation : Property Owne r was issue dagif t certificate #252 5 in th e amoun t o f $300.0 0 a s reimbursemen t fo r variou s flower bead , bushe s an dshrub s remove dfromth e property durin g excavation .

# As-Buil t Drawin g A COASTA L 

# Omah aLea dSuperfun dSit e Tota l Quadran t Squar e Footag e t o b e Excavate d = 525 7 Propert yClassificalion : 8(X ) Tota l Dri p Zon e Linea rFoolag e l o be Excavate d = 11 4

B l = 18 2 PP M B 2 = 40 9 PP M

D

Z = 89 PP M 

## .,.4-- .



# r f "Sout h 2 6 Stree f '^" ^

OLS# : 2017 1 Nort h Arro w Omah a Lea d Sit e Omaha . Netirask a yDateiektj^vated : 7/19/0 7

Dait e USCP*"Sfpe d Off : 8/8/0 7 Propert yNumbe r OLS - 2017 1 I . . i Existin g Stiuciure Scal e Propert yAddres s » — • — • * Fenc e 1 Inct) - 2 0 feet o r1 gri d = 5 x5 ft 132 9 S 2 6 S T ^ ^ Permanen t Landscapin g

—

——Quadran t Boundar y .•^" X Pos t Excavatio n Concentration s (ppm ) Stree t Boundar y F l B 2 Pla yArea 

# A/ • HG L F2 O Z Easemen t // > Tree/Stioi b ^ : t^nW* ^ B 1 Garde n Othe r Omcripticv^ o l pos t RKcavatio n afM s Fl . fron l yai d lefl-iMn d quadrani : F 2 Iion l yar d nghl.|iandquadrant . B1 . badtyar d left-han d quadrant . B2 . bacityar d nghl-tian d quadrant . DZ . tln p zon e (1. 3 Itxj t are a ra l so l amun d v-r n foundalio n d t Hi B Kousa ) 

### Legen d Are ano t Excavate d Dripzon e Excavate d Quadrant s Excavate d Contrac t # : EP-R7-07-0 5 Coasta l Environmenta l Grou p Inc .

## EP A Propert y Clos e Ou t For m/j ^ f ^ ^ J^^. ^ Propert y # : ^7^ 1 i ^ I Propert y Address : I>atc/rime : Owner' i Name : Quad i Excavalrd : Contracto r Grou p Excavatio B Genen l 1 .Ifnecessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 2 .Ifnecessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? Gradin g So dan dVecetatio n 1 .Doc s th e gradin g aroun dth e perimeter ofth e hous e i n excav ate darea s generall y slop e awa y frDmth e house? 2 .Ha s sodbeen lai din al l area s tha t wer e excavated ? 3 .

Doe s th e sodappea r t o b e generall y healthy andgrowing ? (Onl y evaluat e i f inspecte da t a3 0 da y tim e period ) 4 .

.\r e sodde darea s generall y fir man devenl y graded ? 5 .Ar e th e joint s berwcc n th e so dstrip s generall y tight ? (Onl y evalaat e i f inspecte da t £} 0 da > tim e period ) 6 . Wa s th e property grade dsuc htha t wate r v

, ill not poo l on th e propeT)" '

" . 'A'a s damag e t o landscapin g o r rla.n t —aterial s a ^ cided' ^ Gaic v FtDcc s an c ReiainiD t '^^ai'i s 1 D o gate s apc n an dclos e freely';' (Ifapplicable ) 2 .'V^'er e all gate s or fence s lake n dov.- n durin g restoralion acti s itjt s -eir.sialle-d' ? .Taprlicable ) i3 . Wa s damag e t o gate s or fence s avoided ? 'ifapplicable ) 4 "A'a s damag e t c retainin g vt-alls avoided" ? (Ifapplicable ) Foundation , SidiB g an dGutter s 1 .Wa s damag e t o th e sidin g o r trii nB \oided ? 2 .wi s damag e t o th e foundatio n avoided ? 3 .Wa s damag e t o V Nindow s avoided ? 4 .

Wa s damag e l o window s or door screen s avoided ? 5 .Wa s damag e t o do^^^lspout s o r downspout extension s avoided ? Sidewalk s an dDrivewty s (Concrete ) 1 .'y^'a s damag e t o drivewa y surface s avoided ? 2 .Wa s daraag e t o walkwa y surface s avoided ? 

## '?7 ^

Ye s No \ y t . y Ye s !So

^ y y ^ y

- ^ y y Ye s N o 1 ^ 1 y

^ \ ^ Ves N' c y . y

> y y 1 1 y Yes N o 1 y y

### Owner s comments :

I Inspectio n notes :

Remc\a l an dresloratio n acti\£te s corr.r'et e incl'adir. e ih e 30-da\ ' so d•^•'.arrar. n EP.' ^ Representativ e 

## V^^X£.^=X^Daie : S'^'7) 7

## Propert yCompletio n Agreemen t TiiK s agreement documenl s tli c complelio no f remedial aclivilie s performe do n m y properly . M y signaUir c will dcsignal c lha l I a msalisric dwil hihc rcsloialio n o f m y properly , an dlhal n o item s ar c i n questions , now . o r a

l an y lime i n Ih c fuUiic , cxccp l thos e ilcm s liste dbelow , if any . Pmperl y ID ; 

# 'zy/y 7 Propert y Ad drcs.s : J-^-^ ^ < 7 7 ^ ^*^7 ~ Ovvner : D^y^^^_ ^ /^yT^y^yy^/ C Phone : 

# ^/ - ^^ r Restoratio n Item s i n Question : Item : Item : Item : Item : Item : Item : Additiona l Comments :

r I 1 ;if;i w rrstorHlio n i s voiiiplrtrd , cxvcp t a s note d \I J I <l< > iio l at;re< ' irstoratio H i.s coii)ple(e<l 

# \ h M Owncr'' x Sij;natur c Dal e Coiilnictor'. s Sienatur e Dat e

## Omah aLea dSuperfun dSit e Miscellaneou s Landscapin g Replacemen t Certificat e Propert y Owne r Debora hKitzmille r Propert y Addres s 132 9 S . 2 6 S t 

### Propert y Identificatio n Numbe r 2017 1 Materia l Remove d Replacemen t Valu e 1 Rosebus h Flowe r be dare a
Tree s 3 bushe s Itemize d 1 0 bushe s shrubs/bushe s 2 evergree n Tota l 300.0 0 Th e acceptanc e o f th e replacemen t certificate andth e signatur e belo w i s fiill acknowledgemen t b y th e propert y owne r that thi s i s afai r andreasonabl e compensatio n fo

r plan t material s remove ddurin g remediatio n activities , bu t not plante do r installe db y th e governmen t o r it' s contractors . Th e tota l amoun t o f $ 300.0 0 ha s bee n receive db y th e owne r in th e for mo f agif t certificate , #2525 . t o b e utilize da t 132 9 S . 26* ^ St . .

Iti / 

## .A0 7-M'^ 7 y 

# ,2W^ ^ Property Owner' s Signatur e Dat e Contractor' s Signatur e Dat e