## TRANSMITTA Lo f OMAH A LEA D SITE SOI LREMEDIATIO N FDL EFOLDE R SAI D # : ^^^.^ ^ Date : 3JL ^ . Address : L^U^ ^ iOpra/u M .^TfRemediatio n Contractor : R i • APJ" ^ ^r'JA3s^ r . . Year : ol< 3 ( (p . SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S d B d d D d Vide o of propert y (DVD ) Executiv e Summar y EPA-provide dpropert y sketch Signe dAcces s Agreement fo r

subject propert y Signe dAcces s Agreement(s ) fo r

adjai^«n t propert y Restoratio n A^eemen t D 0 Settlemen t document s (i.e. , fo r

damag e o r

t o replac e plants , etc. ) Confirmatio n data 

# d d d t z d

• D 

## Photograph s

As-buil t sketc h Satisfactor y restoratio n signe db y Propert y Owner Property close-out check lis t signe db y EPA Descriptio n o f area s no t meetin g RO D cleanup criteri a Utilit y clearance s 

## Propert y informatio n fromDougla s Count y Assessor' s OfiSc e D D &^- % 8|t^^ " 

## Signature Dat e 3026078 1 Superfun (Fin d Recoix l Remediatio n Quer yI Lea d Remainin g Quer yI Propert yDamag e Query 

### Backfill :

Sampl e Area : 2642 8 - 443 7 DECATU R S T Owner : Resident : Contract : n Owne rOccupie d Residen t Name : Contractor : Owne rName : 1 PAYN E TRAC TM Owne rAddressi : |C/ 0 OMAH AHABITA TFOR HUMANFT Y Owne rAddress2 : |220 4 AME S AV E City : |OMAH A Owne rPhone : 

# 1 State : Zi p Code : |N E |6811 0 Alternat e Phone : 

# 1 PAYN E TRAC TM Propert yAddress : |443 7 DECATU R S T 

### Zi

p Code : |6811 1 Residen t Phon e 

# I |PRUDENT2009_S Contrac t Optio n |OPnO N 2 Assessment : Quaiifyin g Grou p 

# po o Assessmen t MaxXR F Value : 

# r 45 1

### PROPERT Y SUMMAR Y Datef;z>/15/201 0 | Omah aLea dSit e Reniedia l Actio n Contract¥EP-R7-07-0 6 T0# 1 | Mont hof : /J Q ^/ Propert y Address : 443 7 DECATU RS T A EXECUTIV ESUMIVIAR Y A. l 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 : NONE CONFIRMATIO N SAMPLIN GDATA/RESULTS : F l = 8 5 PP M @ 3" ; E A = 9 2 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 dfor crossin g odier propertie s 3 ) Pre-Excavatio n digital vide o clip/photograph s 4 ) Post-Excavatio ndigital vide o clip/photograph s 5 ) Documentatio n - Complete dClose-ou t Checklis t 6 ) As-Bu i I t sketc h­ i ) Shal l includ e final lea dlevel s v ) Legen d il ) 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 di nth e individual property file, i f available , o r obtaine dinclude : i ) Pre-excavatio n agreemen t detail s (ifan y ar e mad e withth e property owner ) ii ) Property Statu s For msigne db y property owne r iii ) Excavatio n digita l vide o in MPEG , WM V (Window s Medi aVideo ) o r SWF(Flas hPlayer) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory ' restoratio n v ) Descriptio n ofarea s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES , INC .TECHNOLOGIES , INC . Propert y # : 2<^*^'2. ^ Date/Time ; Quad s Excavated : p - \ 

# EP A EP A Propert y Clos e Ou t Propert y Address : 44^ 7 Q e r^-V<^i r ^ 1 Owner'sName : "Tr-^^j/^t ^<i.i^Y^-e . Contracto r Group : Pruden t Tccnnoiogies , Inc. , Excavatio n Genera l Ye s No 1 .I f iiecessar\' . were lh e correc l qiiadraiit(s ) excavate dan dreslored ? / 2 .I f neeessaiy , wer e Ili e correc t area s ofdri p zon e excavate dan dreslored ?

. / Gradin g So dan dVegetatio n Ye s No 1 .Doe s Ui e gradin g aroun dtli e perimete r of th e house in excavate darea s generall y slop e away fro mth e house': ' 

# A 2 .Ha s so dbee n lai di n al l area s llia t wer e excavated ? 

# A 3 .Doe s tli e so dappear t o b e generall y health y an dgrowing ? (Only evaluat e i f inspecte dal a," 0 da

y lim e period ) 

# A 4 .Are sodde darea s generall y finn an devenl y graded ? 

# d .>

. Arc di e joint s belwee n th e so dstrip s generall y tight ? (Onl y evaluat e if inspecte dat a-3 0 da y lim e period ) 

# y 6 .Wa s th e property grade dsuc htlia t wate r wil l no l poo l o n th e property ? / 7 .

Wa s damag e l o landscapin g o r plan t material s avoided ?

. / Gates , Fence s an dRetainin g Wall s Ye s No 1 .

D o gale s ope n ;ui dclos e freely ? (If applicable ) / 2 . Were al l gale s o r fence s take n dow n diuin g restoratio nactivitie s reinstalled ? (Ifapplicable ) 

# y 3 . Wa s dmnag e l o gale s o r fence s avoided ? (Ifapplicable ) 

# d 4 . Wa s danuig e lo relainin g wall s avoided ? (Ifapplicable ) 

# d Foundation . Sidin g an dGutter s Ye s No 1 .

Wa s d;imag e l o th e sidin g or tri mavoided ? 

# d 2 .Wa s damag e l o di e foundatio n avoided ? 

# d 3 .

Wa s diunag e t o windows avoided ? 

# d 4 .Wa s damag e to window s o r doo r screen s avoided ? / 5 . Wa s damag e t o downspout s or downspou t extension s avoided ? 

# d Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 .

Wa s dam;ig e l o dnvewa y surface s avoided ? / 2 .Wa s damag e l o walkway surface s avoided ? 

## y

# %^3" ^ O^caju n ^t

Owner s comments :

Inspectio n notes :



## BpR s close-oor ' PuR W 

# 7

Remova l an drestoratio n activate s complet e includin g th e 30-day so dwarranty : EP A Representativ e f^c ^ / ^ Date : /^JlEJi n y@0002/O00 3 J.*, . \*ij . t.wM O £.u.iJ M fA A

••:;:.^i;i{(«.ai',>AtpV.- ; 

## Propert y Compietio n Agreemen t Tin s agroenicn l dociimevUf . th o con\pletioi" i o f reinoval activitie s perionne do n lli c licio w [i^ied)iropcri\- . "I'li c pi'0|.%cr b (ivvncr' s s)L!,n,nl.'i.ir o aidic-atc s tiial . th e propert y owne r i s siili.sf'tcc l w.it' i t.h e rcinoratio n ol " inc . .subjoci propci'ty . ••m d;.iia ! n o ilcni. ^ HV C i n ql.lt-st:^?^i, no^v , o v a t an y vinic i n the ; i'tniirc , c.^cchidiiig :.in v ror.isinin g \\'nrr,n.ii.i y (3 0 da^'. s foitif ) excep t tiio. w item s liste dbelow , i f .lui y 

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Item : Requii-er f conTicV;ion s f; o compicf e t.'.^ e property :

i agre e resforatioi" : i s Cionipieieci . 

### i ci o -no t agre e restoratio n 1 3 comptete da t (noteddeficiencie s above ) 

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### TECHNOLOGIES , IMC . l^ruden t Technologies , Inc . (Prudent )is unde r contrac t withth eU.S. Environmenta l Proiectio n Agenc y (HPA ) to cle.i nup lead coiUaniinatc d.soil s at n numlie r oi " propertie s locate dmOtnaha , Nebraska , includin g th e propert y locate d at

. Th e EP A request s you r permissio n to allo w Pruden tto performasoi l cleanu pat this property lo remov e lead-contammate dsoil . By signin g thi s form , th e property owne r gram s permissio n lo Pruden i lo perform aclmtie. s relate dto th e cleanu p includin g soi l sampling , remova lof lead-contaminate dsoil , an drestoratio n ofth e reference dproperty . If

yo u hav e any question s abou t th e soi l cleanu p planne dfor you r property , pleas e contac t Pruden t "s . . fo r th e Oiniih aLea dSil e cleanup ,at (402 ) • • . Genera l question s abou t th e Omah aLeadSit e cleanu p ca n bc directe dto th e EP A Publi c InfomialionXenter s at (402 ) 73 1 -304 5 (SoathOmah aoffice ) or (402 ) 991-958 3 (NorthOraah aoffice) . Property Acces s Grante dBy ; 

# i(gto , yv\ . y \(Fleas e hTm t Name ) Property Owne r Signatur e (Date ) PROPERT YINFORMATIO N -(T o bccomplete d byresiden t and/o rpropert yowne r— pleas e print ) RESIDEN TNAME : Owne r Rente r 

# 1 

# ^^r—N - A ^ RESIDEN ADORESS : tN T

TAUDRbSS : n f IF RENTAL , PROPERT YOWNE D BY : OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBE R - HOME : J L WORK :



## i\(?2 ^ .-^^ o - M3ZZ ^ AG E OF HOME? : YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WPf H SIDIN G SINC E 1978 ? YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y IN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR SPECIA L INSTRUCTIONS : JI.E . DOGS , ENTR YGATES , ETC. )

AUTHOKIT Y l-'ORENVIRONMENIA LRESPONS EACTIONS : Th e activitie s to be implemente d by EP A unde r thi s agreemen t ar e puisuan t lo Sectio n 104 ofCERCLA , 42 U.S.C . 9604 . EPA' s righl of

acces s to th e piopert y is provide dfo r in Sectio n 104(c ) of CERCLA , 42 U.S . C 9605(e) , wliic hprovide s entry fo r "determinin g th e nee dfo r response , or choosin gor taldn g any respons e aclio n under thi s lille , or otiierwis e enforcin g th e provision s ofth e title. "

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mMa p BVID : Piant s & Permanen t Landscapin g T o Remai n I n Plac e Descriptio n & Locatio n 

# 0 pisyJr S

Pre-Existin g CoHiditio n o f Structure s Doe s you r Basemenl : liav e aiiistor y o f leaking ? Ve s N o ItemN O On Ma p Descriptio n & Lo-catioiii i

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KCHNOl.tJtUTS . INC . 

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### OIVIAH A LEA D SUPERFUN D SIT E 2642 8 Exterio rPain t Nort h /^ro w Owne rName : TRAG I M PAYN E Omah a Lea d Sit e [3^Goo d Address : 443 7 DECATU R S T^'* ® Sketc h • Poo r Phono : H : W : • No t pain t Sampl e Numbe r Lea d Sampl e Sample s Collecte d LA B Concentratio n Collecte d Firm : f c m^ Rf t \'CTC J RYASCPXA-2642 8 F l Date : O l . ^'i , - f^ M

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# fl Dougla s County-Omaha , N E

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# E S E

YOU RTICKE T NUMBE RI S 2394433 . Origina l Cal l Date : 10/27/0 9 Time : 9:2 8 a m Op : SIVA1896 7 Wor k t o Begi n Date : 10/29/0 9 Time : 10:0 0 a m State : N E County : DOUGLA S Place : OMAH A Address : 443 7 Street : DECATU R S T Twp : 15 NRng : 13 E Sect-Qtr : 17-NW Twp : Rng : 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 PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : UNSUR E CORNER S Compan y: PRUDEN T TECHNOLOGIE S Contact Name : SIV AJAMPAM A Phone : (402)733-118 8 Wor k Bein g Don e For : EP A Dept h o f Excavation : 6 F T Corne r Lot : NFront : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Numbe r Utility Typ e CXCAT V CO X COMMUNICATIONS . IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE R RICH/TRAFFI C 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T 

### N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

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### Pag e 2 o f 2 Day : 406728934 3 QLNNEI C QWES T LOCALNETWOR K 

### Alt : 406207149 4 

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