### TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL E FOLDE R 

# SAI D #: f3^S ¥ Date : lO/\tl^^\ ^ Address : ;?g^6:S > ^ • 3' ^ ^ ^ Remediatio n Contractor : fig^, nPr^' J T^r-\ i Nfy-oc , ]9
- <^ ^ Ir^d' i Year : "i^iO ^ SOI LREMEDIATIO N PROPERT Y FIL E FOLDE RDOCUMENT S Video of propert y (DVD ) 0 ^ 

### Executiv e Summar y EPA-providedpropert y sketch SignedAcces s Agreemen t fo r

subject propert y D 

### SignedAcces s Agreement(s ) fo r

adjaijen t propert y Restoratio n Agreemen t 0 

### Settlemen t documents (i.e. , fo r

damag e o r

t o replac e plants , etc. ) Confirmation data Photograph s As-built sketch Satisfector y restoratio n signedb y Propert y Owne r Propert y close-out check lis t signedby EP A D 

### Descriptio n of area s not meeting RO D cleanu p criteri a Utilit y clearance s Propert y infonnatio n fromDougla s Count y Assessor' s Office D D D 3023743 5 

# iniM i Superfun d 

### Sipuatur e ^ 

### DS ePROPERT Y SUMMAR Y Date : 10/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Octobe r Propert y Address ; 280 2 S 3 3 S T A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : NON E A. 2 Issue s Resolved : NON E A. 3 Uniqu e Findings : NON E A. 4 Othe r Relevan t Information : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : F 2 = 6 0 PP M @ 6" ; B l = 5 5 PP M @ 4" ; D Z = 17 3 PP M @ 8" ; E A = 6 7 PP M @ SCRAP E (~1" )

ATTACHMENT S 1 ) Property sketc hprovide db y EPA pursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfo r crossin g othe r propertie s 3 ) Pre-Excavatio n digita l vide o clip/photograph s 4 ) Post-Excavatio n digita l vide o clip/photograph s 5 ) Documentatio n - Complete dClose-ou t Checklis t 6 ) As-Buil t sketch
i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contaminatio n lef t behin darea s vi ) Contracto r identificatio n iii ) Property addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include din th e individua l property file , i f available , o r obtaine dinclude : i ) Pre-excavatio n agreemen t detail s (i f an y ar e mad e withth e property owner ) ii ) Property Statu s Formsigne db y propert y owne r iii ) Excavatio n digita l vide o i n MPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) format and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio n o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES , INC .Fin d Record Backfill :

Sampl e Area : 1548 4 - 280 2 S 3 3 S T Owner : n Owne rOccupie d Owne rName : IVIECEL J CARO L S Owne rAddressi : 

# 1 Owne rAddress2 : |280 2 S 3 3 ST City : State : Zi p Code : jOMAH A |N E |68105 - Owne rPhon e Alternat e Phone : 

# 1 

# r

Contract : contractor : )PRUDEI\n"_2010_ S Contrac t Optio n |BAS E Remediatio n Quer yI Lea d Remainin g Quer yI Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : 

# 1 Owne rAddress : 

# 1 City : 

# 1 State : 

# 1 Zi p Code : 

# 1 Owne rPhone : Alternat e Phone : 

# 1 " 1

Assessment : Qualifyin g Grou p |400/CHIL D /^sessmen t Ma xXR F Valu e j 518.2 7 Resident : Residen t Name : ISEFFRO N KENNET H A& CARO L Propert yAddress : )280 2 S 3 3 ST Zi p Code : 

### |68105
- Residen t Phon eTECHNOLOGIBS . INC . 

# EP A Propert y Clos e Ou t Propert y # : I'^iJt^ U Propert y Address : 2^07 . ^ S ^ Sb Date/Time : ^A:r]/'i©N ? Owner' s Name : lt£xfl/\cX o / V SdfA' o <r ) Quad s Excavated : Contracto r Group : Pruden t Technologies , Inc J ' Excavatio n Genera l Ye s N o 1 .

I f necessaiy , wer e tli e correct quadrant(s ) excavatedandrestored ? / 2 I f necessary , wer e th e correct area s o f drip zon e excavatedandrestored ? / Gradin g Sodan dVegetatio n Ye s N o 1 .

Doe s th e gradin g aroundthe penmete r o

f th e hous e i n excavatedarea s generall y slop e awa y 

## X fro mthe house'^ 2 .

Has sodbeen lai di n al l area s tha t wer e excavated ? / 3Doe s th e so dappea r to b e generall y health y andgrowing ? (Onl y evaluat e i

f inspecteda t a3 0 da

y tim e period) / 4 .

Ar e sodde darea s generally firmandevenl y graded ? / 5 .Ar e the joint s between the sodstrip s generall y tight ? (Onl y evaluat e if inspecteda t a3 0 da y / tim e penod ) 6 .Was the propert y grade dsuc htlia t wate r will not pool on th e property*^ / 7 .

Was damag e t o landscaping o r plan t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s N o 1 D o gate s open andclos e freely ? (I f applicable ) / 2 . Wer e all gate s o r fence s taken dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) / 3 Wa s damag e t o gate s o r fence s avoided" ^ (I f applicable ) ^ 4 . Was damag e t o retainin g wall s avoided ? (I f applicable ) 

## X Foundation , Sidin g an dGutter s Ye s N o 1 Was damag e to the siding o r tn mavoided ? / 2 . Wa s damag e t o the foimdation avoided ? / ^ 3 Was damag e to window s avoided'^ 

# X 4 . Wa s damag e t o window s o r doo r screen s avoided' ? 

# y 5 Was damag e t o downspout s o r downspou t extension s avoided ? ^ Sidewalk s an dDriveway s (Concrete ) Ye s N o / ^ 1 . Wa s damag e t o drivewa y surface s avoided* ? 2 Wa s damag e t o walkwa y surface s avoided ? ^

### Owner s comments :

Inspectio n notes :

Remova l andrestoratio n activate s complet e includin g th e 30-da y so dwa^anty : i 

### EP A Representativ e Qcu^^A ^ ^Date:___9/29^___i:CHNOI,()GIHS , l > 

### AS - BUILT DRAWING OL,S#3536 8 Dat e Excavated : 10/13/201 0 llSKP.'\Sigiicd-OITl)ate : 

### OMAHA LEAD SUPERFUND SITiy | 15484 Exterio rPain l Omah a Lea d Sit e North Mo w Owne rName : KENNET H A SE^FRO N Sit e Sketc h [3'-t3oo d Address : 2B0 2 3 3 3 S T • Poo r Phone : H W ; Q No l pain t Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d Fir m Sample s Collecte d RYASCPXA-1548 4 F l pp m D Dat e o«r- l I'-ijo C RYBSCPXA-1548 4 RYCSCPXA-1548 4 RYDSCPXA-1548 4 RDHSCPXA-1548 4 R6ZSGPXA-V&46 4 F 2 B l B 2 D Z 62
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1)/, = II 3 1'l'Mf « S " (ONTAMIN.VnO N LKi- 1 BiClllNl ) I>1; RI'. O KKQIKST : l)Z/L S (2"X10' ) 2.S5 2 I'l' M (r t SCRAI'i : i' 2 = f. 0 I'l' M « t) "

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CONTRAC T # : EP-S7-10-0 5 PRUDEN T TECHNOLOGfES , INC .

## Pr©p©r% ' C@mpi©tios i Agreemeei t Thi s agreeniciT i uocuineiit s tli e coirtplctiOi'i o f remova l activifie s perlonue doii tJie belo w liste dpiOpert y Th e prope mowner' s signatur e tndicate s tha t th e propertj
- OM/ne r i s satisfie dwithth e restoratio n o i th e subjec t piopert)- , an dtha t n o item s ar e in question , now , o r a

t an y tim e in th e future , excludin g any remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Property Property iertyX3ta 

# ^s*' ^ s r Owner 

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- /dU 6 RestoraSBom i Item s ir s QtaestioBi! :

Reqyire dcosrectaoim s t o compilet e tlh © propeBUy, '

agre e restoratio n i s completed , excep t a s note d above . I I d o not agre e restoratio n i s complete d 

# W 5 JW ^ Owneir' t SigiDaiiiur e Dai e IPmden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clea n u p lead
conlammate dsoil s at anumbe r ofOTopertie s locate di n Omaha , Nebraska , mdudin g th e propert y locate dat l^ft^ , ^ 3> ^ /v T ' Th e EP A request s you r permissio n t o allo w Pruden t t o performasoi l cleanu p at thi s propert j B y signin g thi s form , th e propert y owne r grant s permissio n t o Pruden t t o perfor m Ifopert y t o remov e lead-contaminate dsoi l activitie s relate dt o th e cleanu p includin g soi l samphng , remova l o f lead-contaminate dsoil , an drestoratio n ofth e reference dpropert y I f

yo u hav e an y question s abou t th e soi l cleanu p planne dfor you r property , pleas e contac t Pruden t southoffic e _fo r th e Omah aLea d Site cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informatio n Center s at (402 ) 731-304 5 (SouthOm^ofRce ) o r (402)291-958 3 (NorthOmah aoffice ) 

# i^^Ro /

Se/P/^dJ Property Acces s Grante dB y ^— ^ ^_ ^ (Pleas e Prin t Name ) 

## <9'n<yLo/ d Property Owne r Signature : (Si g (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r ~ pleas e print ) RESIDEN T NAME : Owne r Rente r RESIDEN T ADDRESS : 

## S ^Sf7 < ^1 ^

^^^^^jL . t^ e <b?10J I F RENTAL , PROPERT Y OWNE D BY :
OWNER' S MAILIN G ADDRESS ;
OWNER' S TELEPHON E NUMBE R - HOME : t WO2 L <3Hf>«~Q^A ^ WORK :
AG E O F HOME? : YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDIN G SINC E 197B ? YE S N O NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R O F CHILDRENUNDE R 7 YEAR S OL D WH O PLA Y I NTH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTRY GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS E ACTIONS ^ Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t ar e pursuan t t o Sectio n 10 4 o f CERCLA , 4 2 U S.C . 960 4 EPA' s righ t o f

acces s t o th e propert y i s provide dfor i n Sectio n 104(e ) o f CERCLA , 4 2 U S . C 9605(e) , whic hprovide s entry for "determinm g th e nee dfor response , o r choosin g o r takin g an y respons e actio n unde r thi s title , o r otherwis e enforcin g th e provision s ofth e titl e " 808 0 War dParkway , Suit e 40 5 560 0 S 1 0 s t ' 424 2 Medica l Drive , Suit e 425 0 Kansa s City . M O 6411 4 Oniaha . Nebrask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402 ) 733-118 8 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-667 7ENVCROMVIEIVTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

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## 1548 4 Exterio rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : KENNETH ASEFFRO N {3''l5oo d Sit e Sketc h Address : 280 2 S 33 S T • Poo r Jtak . Phone : H : W . • No t pain t Ssmpl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Collecte d RYASCPXA-1548 4 F 1 3Q ^ pp m 

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### • YOURTICKE T NUMBERI S 2580168 . Origina l Cal l Date : 8/30/1 0 Wor k t o Begi n Date : 9/01/1 0 Time : Time : 2:3 6 p m 3:0 0 p m Op : SIVA1896 7 State : N E Acddress : 280 2 County : DOUGLA S Street : S 33R D S T Place : OMAH A Twp : 15 N Twp : Rng : 13 E Rng : Sect-Qtr : 28-SW,33-N W Sect-Qtr : Lega l Given : c Typ e o f Work : SOI L LEA D REMEDIATIO NPROJEC T Locatio n o f Work : LOCAT E ENTIR E PROPERTY Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : UNSUR E CORNER S Compan y: PRUDEN T TECHNOLOGIE S Contac t Name : SIV AJAMPAM A Phone : (402)733-118 8 Wor k Being Don e For : EPA Dept h o f Excavation : 6 F T Corne r Lot : N Front : Y Rear : Involve s Tunneling o r Horizonta l Boring : N Explosives : N CXCAT V LEVEL 3 MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F Servic e Are a Contac t Phon e Nunlbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL S COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4 MUD0 2 METROPOLITA N UTILITIES DISTRICT SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE RRICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3 http://vmw.dhon.org/irthinteniet/DHONNoticeCreatioii/MessageText.asp?ret=<RESULTS. . . 8/30/201 0

### Pag e 2 of 2
OPPDGPR 6 OMAH A PUBLI C POWE RDISTRICT EL M LOCATIN G 

### Alt : 4062071494 Emerg : 888728934 3 QLNNEIFQWES T LOCA LNETWOR K

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### Day : 406728934 3

Alt : 406207149 4 

### Emerg : 888728934 3

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### ENVIRONMENTAL ENGINEERIN GAN D CONSTRUCTIO N 'BBBMNOUUSS , HO: . 

### SOLUTION S 

## SIT E SAFET Y HAZARD ANALYSI S 

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## / 6 Address : Excavatio n Date : Crew : Backfil l Date : —

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808 0 WMcHtetany . Suit e 40 5 Kansas.C^;MD:«411 4 fiSOOSIOSt Omata , Nebotf a 6810 7 424 2 Medica l Orrve , JSt ^ 725 0 Sa n Antonio , T X 7822 9 VtaMie : 1816)^363^310 3 Fax:|816)363«370 7 mmw : '.(402 ) 733-118 8 Tiaj c(402 ) 733*188 3 Phone : (2t0):822i;968 8 Fax : t210)-«7»«8T7* ^ 

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