### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 2159 9 DATE : 1/1 5 ADDRESS : 103 2 S 2 3 S T REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201 < 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S a PRE AN D POS TVIDE O O F PORPERT Y(DVD )

• EXECUTIV E SUMMAR Y 

## 1 ^ 

# 2 EPA-PROVIDE D PROPERT YSKETC H SIGNE D ACCES S AGREEMEN TFOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT{S ) FOR ADJACEN TPROPERT Y I D RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. )

• CONFIRMATIO N DAT A 0 1 PHOTOGRAPH S m AS-BUIL TSKETC H [ ] SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R m PROPERT YCLOSE-OU TCHECKLIS TSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A

• UTILIT YCLEARANCE S db PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E 

## D D D ^ 

# ^ ^ ^V^V ' SIGNATUR E DAT E 

### 3021828 1 Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLea dSit e Remedia l Actio nContrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 103 2 S 2 3 S T A . EXECUTIV ESUMMAR Y A. l Issue s Encountered : MON E A. 2 Issue s Resolved : NON E A 3 Uniqu e Findings : NON E A. 4 Othe r Relevan t Infonnation : NON E CONFIRMATIO NSAMPLIN GDATA/RESULTS : B l = 36 4 PP M @ 6" ; B 2 = 38 1 PP M @ 8" ; E A = 20 1 PP M @ SCRAP E(~1" ) ATTACHMENT S 1 ) Property sketc hprovide db y EP A pursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfor crossin g othe r propertie s 3 ) Pre-Excavatio ndigita l vide o clip/photograph s 4 ) Post-Excavatio ndigita l vide o clip/photograph s 5 ) Documentatio n- Complete dClose-ou t Checklis t 6 ) As-Buil t sketc h­ i ) Shal l includ e final lea dlevel s v ) Legen d ii ) Contaminatio nlef 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 obtainedinclude : i ) Pre-excavatio nagreemen t detail s (i f any ar e mad e wit hth e property owner ) ii ) Property Statu s For msigne db y property owne r iii ) Excavatio ndigita l vide o inMPEG , 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 nofarea s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES , INC .Fin d Record 

### Backfill :

Sampl e Area : 2159 9 - 103 2 S 2 3 S T Owner :
n Owne rOccupie d Owne rName : IBENITE Z AVELIN O Owne rAddressl : Owne rAddress2 : 1103 4 S 2 3 ST City : State : Zi p Code : lOMAH A ~ |N E 168108 - Owne rPhon e Alternat e Phone : 1(402 ) 345-166 3
Contract : Contractor : PRUDENT201 0 S Contrac t Optio n |BAS E Remediatio n Quer y Lea d Remainin g QueryPropert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : Owne rAddress :
City : State : Zi p Code : 

# " I I Owne rPhone : Alternat e Phone :

Assessment : Qualifyin g Grou p 40 0 Assessmen t Ma xXR F Valu e 

### 483.5 9 Resident : Residen t Name : Propert yAddress : 1103 2 S 2 3 ST Zi p Code : 168108 - Residen t Phon e

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# in o 3S0 O ^Jsdoj j Vci a ON I 'saiooioNHoax .

## Owner s comments :

Inspectio nnotes :

Remova l andrestoratio nactivate s complete includin g th e 30-da y so dwarranty . EP A Representativ e .^"^ ^ Date : /^/^// ^rnNnrrsniEs . IN C A S - BUIL T DRAWIN G OL.S # 2159 9 Dat e Excavated : II/I8/20I 0 I SEPASigned-Of rDate : OMAH A LEA D SUPERFUN D SIT E

Owne rNatne : AVEUN O BENITE Z Address : 103 2 s 2 3 S T Phone : H 402-345-166 3 Sampl e Numbe r RYASCPXA-2159 9 RYBSCPXA-2159 9 RYCSCPXA-2159 9 RYDSCPXA-2159 9 RDZSCPX A21600 - RGZGCrX A2100 0 F l F 2 B 1 B 2 RP^scp.Y.^ 2160 0 -PZ
- Omah a Lea d Sit e Sit e Sketc h W : Lea d Sampl e LA B Concentratio n Collecte d Z.'^ H pp m D Z°[Q > pp m 

## W D W3 I pp m D ^ & ^ pp m D pp m D D " pp m D D
" pp m D D Numbe ro f Sample s = ' *- | 2159 9 Exteno rPain t Nort h Atro w • Goo d • Poo f g^t pain t Sample s Collecte d Firm : Pc i A\ T - 4 (ri^ - Dat e OS-\'-KO'^ i Tim e p. . <4- TA'V^ . Sample s Analyze d XR F Unit : IOl? l Book ; I^ Z

Dat e <i-Z.9'e> ^ Time : P m Staff : i^ A Legend : F l = Fron t Left , F 2 = Fron t Right , 8 1 = Bac k Left . B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a

s viewe d fro m Ih e street , facing propeit y 

# ENTSKS p

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

# «EF ^ Propert yCompletio n Agreemen t Thi s agreement document s th e completiono f remova l activitie s performe do nth e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth e restoratio nofth e subjec t property , an dtha t n o item s ar e inquestion , now , o r at any tim e inth e future , excludin g any remaining warranty (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Property ID : Property Address : 

# ? 3 5 Owner : 

### Ai^A ^ J'^'- O 

### Phone : Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item : Require d correction s t o complet e th e property :

^E ] I agre e restoratio n i s completed .

LJ I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above ) 

# 1^-3^
- 1 0 Owner' s Signatur e Dat ePruden t Technologies , Inc . (Prudent ) is unde r contrac t wit hth e L) . S. Environmenta l Protectio nAgenc y (EPA ) to cleanup lead
contaminate dsoil s at anumbe r of

propertie s locate d inOmaha , Nebraska , includin g th e property locate d at

. Th e EPA request s you r permissio nto allo w Pruden tto perfor masoi l cleanu pat thi s property to remove lead-contaminate dsoil . By signin g thi s form , th e property owne r grant s permissio n to Pruden tto perfor m activitie s relate d to th e cleanu p includin g soi l sampling , removal of lead-contaminate dsoil , an drestoratio nofth 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 southoffic e .fo r th e Omah aLead Sit e cleanup-a t (402 ) 733-1188 . General question s abou t th e Omah aLea dSit e cleanu p can be directe dto th e EPA Publi c Informatio n Center s at (402 ) 73 1 -304 5 (Sout hOmah aoffice ) or (402 ) 991-9583 (NorthOmah aoffice) . Property Acces s Grante dBy : (Pleas e Prin t Name ) Property Owne r Signature : (Signature ) (Date ) PROPERT YINFORMATIO N i(T h propert yowne r—pleas e print ) A^ o

o b t t complete

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residen t t and/o

and/o r rpi RESIDEN TNAM E Owne rRente r RESIDEN TADDRESS :



## \Q2> ^ S '2^Zr4. 

# -S t IF RENTAL , PROPERT YOWNE D BY :
OWNER' G ADDRES S

WNt:K' S S MAILIN

MAILIN Q ADDK^SS : 1 1 ^f\ / ^ 

# r OWNER' S TELEPHON E NUMBE R - HOME : ( ) WORK :
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 WIT 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 CHILDREN 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 : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s to be implemente d by EP A unde r thi s agreemen t ar e pursuan tto Sectio n10 4 of CERCLA , 42 U.S.C . 9604 . EPA' s righ t of

acces s to th e propertyis provide dfo r inSectio n104(e ) of CERCLA , 42 U.S . C 9605(e) , whic hprovide s entry for "determinin g th e nee dfo r response , or choosin g or takin g an y respons e actio n under thi s title , or otherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parlcway , Suit e 40 5 560 0 SI O St 424 2 Medica l Drive , Suit e 425 0 Kansa s City , MO 6411 4 Omaha , 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 ) 579-657 7ENVIRONMENTA L& CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : /^32 _ 

# s 

# 2 a ^ ^ Date : Phone : BVID :

Propert y Owne r Pruden t Em Signature : Signature : 808 0 War d ParkwayrSuit e 40 5 560 0 S 1 0 S t 424 2 Medica l Drive , Suit e 425 0 KansasCity , M O 6411 4 Omaha , Nebrask a 6 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-968 8 Ci v f>M\ \K7CtJili7 7

# 2159 9 Exterio rPain t Nort h Ano w 

### Omah a Lea d Sit e Owne rName ; AVELIN O BENITE Z • Goo d 

### Sit e SIcetc h Address : 103 2 8 2 3 S T 

# .z: ^
• Poo r Phone : ": 402-345-166 3 W : Q'^o t pain t Sampl e Numbe r Lea d Sampl e Sample s Collecte d Concentratio n Collecte d LA B 

## Fimi : P E mT4G/2 ^ RYASCPXA-2159 9 F l pp m 

# D Date : OS - V' A0 5 RYBSCPXA-2159 9 F2 pp m 

# D Time : fiiO^A/VV 

# W RYCSCPXA-2159 9 B l pp m 

# D Sample s Analyze d RYDSCPXA-2159 9 B 2 pp m 

# D RDZOOPX A2160 0 Bi - pp m 

# D XR F Unit : Ipy i Book : f^ Z 

# D ROnOCPX A2160 0 6Z - pp m 

# D Date : _ 

# q-zq-as ' RPZSCPXA3160 0 P2 - pp m 

# n D Time : 

### pjy i Staff : 

### i^ A Numbe ro f Sample s = *- { Legend : F l = Fron t Left , F2 = Fron t Righ t B 1 = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewe d fro m th e street , facin g propert y

Ilev4
- (M614I.0I2 3

# LEGALDIMENSIONS : 5 5 X 145 

# A Printed : No v 17,201 0 *i s www.dcgis.org/dogi s

## Page 1 of 2

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



## • YOURTICKE T NUMBERI S 2643174 . Origina l Cal l Date : 11/16/1 0 Wor k t o Begi n Date : 11/18/1 0 Time : Time : 5:1 5 p m 5:4 5 p m Op : SIVA1896 7 State : N E Address : 103 2 County : DOUGLA S Street : S 23R D S T Place : OMAH A Twp : 15 NRng : 13 E Twp : Rng : Lega l Given : C Sect-Qtr : 22-SW,27-N W Sect-Qtr : 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 Contac t 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 : N Involve s Tunnelin g o r Horizonta l Borin g : N Front : Y Explosives : N Rear : CXCAT V DOCOINF S LEVEL 3 METHODI S MUDO l MUD0 2 OMAHACO F 0PPDGPR 5 0PPDGPR 6 QLNNEI C QLNNEI F
Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7
DOCOINF S DOUGLA S COUNT Y INFORMATIO NSERVICE S ALLA N 

### Day : 402510724 2 Alt : 402444718 8 Emerg : 402510724 2
LEVEL S LEVEL S COMMUNICATIONS , LL C N A 

### Day : 877366834 4 Alt : Emerg : 877366834 4
METHODI S METHODIS T HEALT H SYSTEM S 

### CONSOLIDATE D UTILIT Y SERVICE S 

### Day : Alt : 888847475 7 

## Emerg : 888847475 7 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT.. . 11/16/201 0

### Pag e 2 of 2

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### CONSTRUCTIO N TEOHN i lOUMMK , 

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### SOLUTION S 

## SIT ESABtT Y HAZAR D ANALYSI S 

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## Othe r Cre w Forema n Conditio n Hazard s Correctiv e Actio n cpr<~ A=^ j Lj~ . ^ i« " /T ? f<if/ S 

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## Sit e Safet y Offic e Date :

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