TRANSMITTAL OF OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 21599 DATE: 1/15 

ADDRESS: 1032 S 23 ST 

REMEDIATION CONTRACTOR: PRUDENTTECHNOLOGIES. INC. YEAR: 201< 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

a PRE AND POST VIDEO OF PORPERTY (DVD) 

• EXECUTIVE SUMMARY 

1^ 2 EPA-PROVIDED PROPERTY SKETCH 

SIGNED ACCESS AGREEMENT FOR SUBJECT PROPERTY 

D SIGNED ACCESS AGREEMENT{S) FOR ADJACENT PROPERTY 

ID RESTORATION AGREEMENT 

D SETTLEMENT DOCUMENTS (I.E., FOR DAMAGE OR TO REPLACE PLANTS, ETC.) 

• CONFIRMATION DATA 

01 PHOTOGRAPHS 

m AS-BUILT SKETCH 

[ ] SATISFACTORY RESTORATION SIGNED BY PROPERTY OWNER 

m PROPERTY CLOSE-OUT CHECK LIST SIGNED BY EPA 

D DESCRIPTION OF AREAS NOT MEETING ROD CLEANUP CRITERIA 

• UTILITY CLEARANCES 

db PROPERTY INFORMATION FROM DOUGLAS COUNTY ASSESSOR'S OFFICE 

D 

D 

D ^ 

^ ^ ^V^V' 

SIGNATURE DATE 

30218281 

Superfund 
PROPERTY SUMMARY 

Date: /15/2010 Omaha Lead Site Remedial Action Contract # EP-R7-07-06 TO#l Month of: 

Property Address: 1032 S 23 ST 

A. EXECUTIVE SUMMARY 

A.l Issues Encountered: MONE 

A.2 Issues Resolved: NONE 

A 3 Unique Findings: NONE 

A.4 Other Relevant Infonnation: NONE 

CONFIRMATION SAMPLING DATA/RESULTS: 

Bl = 364 PPM @ 6"; B2 = 381 PPM @ 8"; EA = 201 PPM @ SCRAPE (~1") 

ATTACHMENTS 

1) Property sketch provided by EPA pursuant to contract specifications 

2) Signed Access Agreement including access agreements required for crossing other properties 

3) Pre-Excavation digital video clip/photographs 

4) Post-Excavation digital video clip/photographs 

5) Documentation - Completed Close-out Checklist 

6) As-Built sketch ­

i) Shall include final lead levels v) Legend 

ii) Contamination left behind areas vi) Contractor identification 

iii) Property address vii) Date 

iv) BVID number 

7) Other items to be included in the individual property file, if available, or obtained include: 

i) Pre-excavation agreement details (if any are made with the property owner) 

ii) Property Status Form signed by property owner 

iii) Excavation digital video in MPEG, WMV (Windows Media Video) or SWF (Flash Player) format and/or 

photographs 

iv) Signed form verifying satisfactory restoration 

v) Description ofareas not meeting Interim ROD cleanup criteria. 

TECHNOLOGIES, INC. 
Find Record 

Backfill: 

Sample Area: 21599 - 1032 S 23 ST 

Owner: 

n Owner Occupied 

Owner Name: 

IBENITEZ AVELINO 

Owner Addressl: 

Owner Address2: 

11034 S 23 ST 

City: State: Zip Code: 

lOMAHA ~ |NE 168108-

Owner Phone Alternate Phone: 

1(402) 345-1663 

Contract: 

Contractor: PRUDENT2010 S 

Contract Option |BASE 

Remediation Query Lead Remaining Query Property Damage Query 

User Provided Owner Information 

Owner Name: 

Owner Address: 

City: State: Zip Code: 

" I I 

Owner Phone: Alternate Phone: 

Assessment: 

Qualifying Group 400 

Assessment Max XRF Value 

483.59 

Resident: 

Resident Name: 

Property Address: 

11032 S 23 ST 

Zip Code: 

168108-

Resident Phone 
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Owners comments: 

Inspection notes: 

Removal and restoration activates complete including the 30-day sod warranty. 

EPA Representative .^"^ ^ Date: /^/^//^ 
rnNnrrsniEs. INC 

AS - BUILT DRAWING 

OL.S# 21599 

Date Excavated: II/I8/20I0 

I SEPA Signed-Ofr Date: OMAHA LEAD SUPERFUND SITE 

Owner Natne: AVEUNO BENITEZ

Address: 1032 s 23 ST

Phone: H 402-345-1663

Sample Number 

RYASCPXA-21599 

RYBSCPXA-21599 

RYCSCPXA-21599 

RYDSCPXA-21599 

RDZSCPXA 21600-

RGZGCrXA 21000 

Fl 

F2 

B1 

B2 

RP^scp.Y.^ 21600 -PZ-

 Omah a Lead Site 

 Site Sketch 

 W: 

Lead Sample LAB Concentration Collected 

Z.'^H ppm 

D 

Z°[Q> ppm W D 

W3I ppm D 

^ & ^ ppm D 

ppm D D 

" ppm D D 

" ppm D D 

Number of Samples = ' *-| 

21599 

Extenor Paint North Atrow 

• Good 

• Poof 

g^ t paint 

Samples Collected 

Firm: Pc i A\ T -4 (ri^ -

Date OS-\'-KO'^ i 

Time p. . <4-T A'V^. 

Samples Analyzed 

XRF Unit: IOl? l Book; I^ Z 

Date <i-Z.9'e>^ 

Time: P m 

Staff: i^A 

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 Ihe street, facing propeity 

ENTSKSp 

CONTRACT #: EP-S7-10-05 PRUDENTTECHNOLOGIES, INC. 
«EF^ 

Property Completion Agreement 

This agreement documents the completion of removal activities performed on the below listed property. 

The property owner's signature indicates that the property owner is satisfied with the restoration ofthe 

subject property, and that no items are in question, now, or at any time in the future, excluding any 

remaining warranty (30 days total) except those items listed below, ifany. 

Property ID: 

Property Address: ?3 5 

Owner: Ai^A^ J'^'-O 

Phone: 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Required corrections to complete the property: 

^E ] I agree restoration is completed. 

L J I do not agree restoration is completed at (noted deficiencies above) 

1^-3^- 10 

Owner's Signature Date 
Prudent Technologies, Inc. (Prudent) is under contract with the L). S. Environmental Protection Agency (EPA) to clean up leadcontaminated soils at a number of properties located in Omaha, Nebraska, including the property located at 

. The EPA requests your permission to allow Prudent to perform a soil cleanup at this 

property to remove lead-contaminated soil. By signing this form, the property owner grants permission to Prudent to perform 

activities related to the cleanup including soil sampling, removal of lead-contaminated soil, and restoration ofthe referenced property. 

If you have any questions about the soil cleanup planned for your property, please contact Prudent south office .for the Omaha Lead 

Site cleanup-at (402) 733-1188. General questions about the Omaha Lead Site cleanup can be directed to the EPA Public Information 

Centers at (402) 731 -3045 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Property Access Granted By: 

(Please Print Name) 

Property Owner Signature: 

(Signature) (Date) 

PROPERTY INFORMATION 

A^ i(To

o b htt complete completedd bbyy residen residentt and/o and/orr pi property owner — please print)

RESIDENT NAME Owner Renter 

RESIDENT ADDRESS: 

\Q2> ^ S '2^Zr4. -St 

IF RENTAL, PROPERTY OWNED BY: 

OWNER' WNt:K'SS MAILIN MAILINQG ADDK^SS ADDRESS: 1 1 ^ f\ / ^ 

r 

OWNER'S TELEPHONE NUMBER - HOME: ( ) WORK: 

AGE OF HOME?: YEARS. HOW LONG HAVE YOU LIVED HERE? YEARS. 

HAS THE EXTERIOR BEEN PAINTED OR COVERED WITH SIDING SINCE 1978? YES NO 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: . NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER 


NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 


COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 


AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement 

are pursuant to Section 104 of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property is provided for in Section 104(e) of 

CERCLA, 42 U.S. C 9605(e), which provides entry for "determining the need for response, or choosing or taking any response action 

under this title, or otherwise enforcing the provisions ofthe title." 

8080 Ward Parlcway, Suite 405 5600 SIO St 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68107 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)733-1188 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)733-1883 Fax: (210) 579-6577 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: /^32 _ s 2a ^ ^ Date: 

Phone: BVID: 

Property Owner Prudent Em 

Signature: Signature: 

8080 Ward ParkwayrSuite 405 5600 S 10 St 4242 Medical Drive, Suite 4250 

KansasCity, MO 64114 Omaha, Nebraska 6 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)733-1188 Phone: (210)822-9688 

Ci v f>M\\ K7CtJili77 
21599 

Omah Exterior Paint North Anow Owne a Lead Site r Name; AVELINO BENITEZ 

Sit • Good e SIcetch Address: 1032 8 23 ST .z:^ • Poor 

Phone: ": 402-345-1663 W: 

Q'^o t paint 

Sample Number Lead Sample Samples Collected 

Concentration Collected LAB Fimi: P E mT4G/2^ 

RYASCPXA-21599 Fl ppm D Date: OS- V'A 0 5 

RYBSCPXA-21599 F2 ppm W D Time: fiiO^A/VV

RYCSCPXA-21599 Bl ppm D 

Samples Analyzed 

RYDSCPXA-21599 B2 ppm D 

RDZOOPXA 21600 Bi - ppm D D XRF Unit: Ipy i Book: f^ Z 

ROnOCPXA 21600 6Z- ppm D Date: _ q-zq-as' RPZSCPXA 31600 P2- ppm n D Time: pjyi 

Staff: i^A Number of Samples = *-{ 

Legend: Fl = Front Left, F2 = Front Right B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

Ilev4- (M614I.0I23 
LEGA

L DIMENSIONS: 55 X 145 

A Printed

: Nov 17,2010 *is 

www.dcgis.org/dogis 
Page 1 of2 

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Create Another Ticket Back to Irth Intemet Send Email 

• YOUR TICKET NUMBER IS 2643174. 

Original Call Date: 11/16/10

Work to Begin Date: 11/18/10

 Time:

 Time:

 5:15 pm 

 5:45 pm 

Op: SIVA18967 

State: NE 

Address: 1032 

County: DOUGLAS 

Street: S 23RD ST 

Place: OMAHA 

Twp: 15N Rng: 13E 

Twp: Rng: 

Legal Given: C 

Sect-Qtr: 22-SW,27-NW 

Sect-Qtr: 

Type of Work: SOIL LEAD REMEDIATION PROJECT 

Location of Work: LOCATE ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: UNSURE CORNERS 

Company : PRUDENT TECHNOLOGIES 

Contact Name: SIVA JAMPAMA Phone: (402)733-1188 

Work Being Done For: EPA 

Depth of Excavation: 6 FT Corner Lot: N 

Involves Tunneling or Horizontal Boring : N 

Front: Y

Explosives: N 

 Rear: 

CXCATV DOCOINFS LEVEL3 METHODIS MUDOl MUD02 OMAHACOF 


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Service Area Contact Phone Number Utility 

Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

DOCOINFS DOUGLAS COUNTY 

INFORMATION SERVICES ALLAN 

Day: 4025107242 

Alt: 4024447188 

Emerg: 4025107242 

LEVELS LEVELS COMMUNICATIONS, 

LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

METHODIS METHODIST HEALTH 

SYSTEMS 

CONSOLIDATED 

UTILITY SERVICES 

Day:

Alt: 

 8888474757 

Emerg: 8888474757 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT... 11/16/2010 
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METROPOLITAN UTILITIES 

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METROPOLITAN UTILITIES 

DISTRICT 

CITY OF OMAHATRAFFIC,SEWER 

OMAHA PUBLIC POWER 

DISTRICT 

OMAHA PUBLIC POWER 

DISTRICT 

 QWEST LOCAL NETWORK

 QWEST LOCAL NETWORK

SANDY 

SANDY 

RICH/TRAFFIC 

ELM LOCATING 

ELM LOCATING 

 ELM LOCATING 

 ELM LOCATING 

Day: 4025047823 


Alt: 


Emerg: 4025047970 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

Day: 4024447197 

Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret-<RESULT... 11/16/2010 
TEOHN CONSTRUCTION i lOUMMKi

, , mc. SOLUTIONS 

SITE SABtTY HAZARD ANALYSIS 

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Address: Excavation Date: 

Crew: Backfill Date: — 

Item 

Overhead Lines 

Gas Line 

Water Line 

Sewer Line 

Septic/Leech 

Field 

Propane/Butane 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Structures 

Driveway 

Sprinkler System 

Other 

Crew Foreman 

Condition Hazards Corrective Action 

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Site Safety Office 

Date: 

m o VtMifPmlamaf. Suite 405 SSOOSIOSt 4242 Medical Drive, Suite 7260 

(flnaa«City/Ma«41l4 Omata, NaboAfca 08107 San Antonio, TX 78229 

•bona: fSW) 38^3703 Pttoaa: (402)733-1180 Phone: (2t0)82Z«688 

^ax: fSW) 363'3707 FK C fl02) 733^1083 Fax: (210)6T»-6577 
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