### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# ; 2488 5 DATE ; 1/1 5 ADDRESS : 281 7 NICHOLfli S S T REMEDIATIO N CONTRACTOR : PRUDEN TTECHNOLOGIES . IN C YEAR : 201( ^ 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S .^^^^ ^ d i PR E AN D POS TVIDE O O F PORPERT Y(DVD ) AAVS^iwq fle€-Nxo*o ]»-» ­ m EXECUTIV E SUMMAR Y Q l EPA-PROVIDE D PROPERT YSKETC H Q SIGNE D ACCES S AGREEMEN TFOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FOR ADJACEN TPROPERT Y m RESTORATIO N AGREEMEN T n SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R TO REPLACE PLANTS , ETC. ) d

6 CONFIRMATIO N DAT A C D PHOTOGRAPH S AS-BUIL TSKETC H SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R Q PROPERT YCLOSE-OU TCHEC KLIS TSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A [f l UTILIT YCLEARANCE S b PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E D D D 9y ^ VN ( ^NlA^ ^ SIGNATUR E DAT E 3021857 6 Superfun dPROPERT Y SUMMAR Y Date : /15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 281 7 NICHOLA S S T A . EXECUTIV ESUMMAR 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 l = 33 5 PP M @ 4" ; F 2 = 35 0 PP M @ 4" ; B l = 24 9 PP M @ 6" ; N O EASEMEN T 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 othe r propertie s 3 ) Pre-Excavatio n digita l vide o clip/photograph s 4 ) Post-Excavatio n digital 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 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 individual 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 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 o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES , INC .Fin d Record Remediatio n Quer y1 Ijea d Remainin g Quer y Propert yDamag e Query Backfill :

Sampl e Area : 2488 5 - 281 7 NICHOLA S S T Owner : D Owne rOccupie d Owne rName : fMOBEC O INDUSTRIE S Owne rAddressl : Owne rAddress2 : j 1141 3 HICKOR YR D City ; State : Zi p Code : OMAH AJN E i68144 - Owne rPhon e Alternat e Phone : [(402 ) 342-282 0 f

Contract : Contractor : JPRUDENT2010_ S Contrac t Optio n |0Fn0 N 1 Use rProvide d Owne rInformatio n Resident : Owne rName : Residen t Name : Owne rAddress : Propert yAddress : 1281 7 NICHOLA S S T 

# 1 Zi p Code : j|68131 - State : Zi p Code : Residen t Phon e City : 

# j r ^' 

# r^ Owne rPhone : Alternat e Phone : 

# r

Assessment : Qualifyin g Grou p |40 0 Assessment Ma xXRF Valu e f 51 64 ' TECHNOLOGIfiS , INC . 

# EP A Propert y Clos e Ou t Propert y#:ZH^' 7 Propert y Address : •2-<?-/ 7 MJOVJVL ^ >-f- ^ Date/Time : Owner' s Name : ^iSo€c o "X*vA. ~ Quad s Excavated : ^ \f^Z| ^ ^ Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l Ye s N o 1 .I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 

# y 2 .I f necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? / Gradin g So dan dVegetatio n Ye s N o 1 .

Doe s the gradin g aroundthe perimete r o

f the hous e i n excavatedarea s generally slop e awa y 

# y fro mlhe house ? 2 .

Has sodbeen laidin al l area s tha t wer e excavated ? 

# y 3 .

Doe s tlie sodappea r to be generall y health y andgrowing ? (Onl y evaluat e i f inspecteda t a3 0 da

y lim e period) 

# y Ar e sodde darea s generalh ' fir mandevenl y graded ? / 5 .Ar e tli e joint s between the sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da t a3 0 da y lim e penod ) / 6 .Wa s the propert y grade dsuc htlia t wate r wil l not pool on tlie property ? / 7 .Wa s damag e l o landscaping o r plan t material s avoided ?

. / Gates , Fence s an dRetainin g Wall s Ye s N o 1 Do gate s ope n an dclos e freely ? (Ifapplicable ) 

# y 2 .

Wer e all gale s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) 

# y 3 .

Wa s damag e to gate s o r fence s avoided ? (I f applicable ) / 4 .

Was damag e t o retainin g wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye s N o 1 Was damag e t o tli e siding o r trimavoided ? / 2 .Wa s damag e lo the foundation avoided ? / 3 .

Was damag e t o window s avoided ? / 4 .

Wa s damag e to window s o r doo r screen s avoided ? / 5 .Was damag e l o downspout s or downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s No 1 . Wa s damag e l o drivewa y surface s avoided ? 

## y 2 . Wa s damag e t o walkwa y surface s avoided ? 

### y

### Owner s comments :

Inspectio n notes :

Remova l andrestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e Qcor , /^A ^ Date : f^-lifi fKt'llNOLOUlES . INC . 

### AS - BUIL T DRAWIN G OL S tf

2488 5 Dat e Excavated : 10/05/201 0 ISEPASigned-OITDatc : 

### OMAHA LEAD SUPERFUND SIT E 2^88 5 Name : lYlebec o X^ndvsine s Omali a Lea d Sit e Date : Nort h Arro w Address : ^S/ ? A^rc/jcxtt s t i Sit e Sketc h Time : Phone : ^\- a.PF!t.P i D<KH' . ID-S'-oe ^ Timeip m Tea mc&/^<y i ASi ^ BVID # 

# ^^gg g XR F Cod e 105 1 Bool ^ •• I5 Z Sampl e Numbe r Lea d Concentratio n Confinmatlo n Sampl e 

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OmahaLea dSit e 4613 0 CONTRAC T #: EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# SEP A Propert yCompietio n Agreemen t Thi s agreemen t documents th e completion o f removal activitie s performe do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwit hth e restoratio n o f th e subjec t property , an dtha t n o item s ar e i n question , now , o r at an y tim e i n th e future , excludin g any remaining warranty (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Property ID : Propert y Address : ^ ^ < 3 \" ^ 

### lOiC^vjctaV S ^ -h- Owner : 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 :

I M I agre e restoratio n i s completed . L J I d o no t agre e restoratio n I s complete d a t (note d deficiencie s above )



# Vh^c o XJ^d.'^ ^ { / 

# /^^// o O^u^er' s Signatu n Date 

# a u ^• ' X 

## V \

- - . . • ^ . ^ - . ^ Pniden 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

nunate dsoil s ^ t anumbe r o f

proaprtie s locate di n Omaha , Nebraska , includin g th e propert y locate dat ^' ' MICVVPIOL. ^ ^'^Th c EP A request s you r permissio n t o allo w Pruden t t o perfor masoi l cleanu p at thi s propen y t o remove lead-contaminate dsoil . 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 activitie s relate dt o th e cleanu p includin g soi l sampUng , remova l o f lead-contaminate dsoil , an drestoratio n ofth e reference dproperty . 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 Sit e cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p can b e directe dt o th e EP A Publi c Informatio n Center s a t (402 ) 73 1 -304 5 (SouthOitiali aoffice ) o r (402 ) 991-958 3 (Nort hOmah aoffice) . 

# /3^r z f^A/^ ^

r^ot^^^LLy ^ Property Acces s Grante dBy : 

### • C o 

# '^,^L</xX^ (Pleas e Prin t Name ) j ^ /Ko(ff ^ - Property Owne r Signatu n (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r —plessMimt ) RESIDEN TNAME : V^C-O-r v\ ~ L o V ' C^^Ownet / Rente r RESIDEN TADDRESS : 

# ^4^ ' cl\n\a ^ iJ L I F RENTAL , PROPERT YOWNE D B Y 

### g>'€^rvo.,-^ i Y UorQ^Lt o OWNER' S MAILIN G ADDRESS ; 

## 6g) M M SLSx . Q^AQty ^ Jsl- ^ ^ OWNER' S TELEPHON E NUMBE R - HOME : 

## r^cX . -^"IZ-XS^^ ^ WORK : J J : 

# /O/ A AG E O F HOME ? 

# -.iTlA . 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 1978 ? 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 

## h)/A r NUMBE R O F CHILDRE NUNDE 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 WEE K COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. ) 

# /^/A AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS ; Th e activitie s t o b e implemente db y EP A unde r thi s agreemen l ar e pursuan t t o Sectio n 10 4 o f CERCLA , 4 2 U.S.C . 9604 . EPA' s right 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 "detenninin g th e nee dfor response , or 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 title. " S08 0 War d Parkway , Suit e 40 5 560 0 S 1 0 S t 424 2 Medica l Drive , Suit e 426 0 Kansa s City , M O 6411 4 Onrtaha , Nebrask a 6810 7 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Pbone : (402 ) 733-118 8 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402 ) 733-188 3 Fax:(210)579-667 7ENVfRONMEP^TAL A CONSTRUCTIO N SERVICE S 

# Propert y Statu s For m Address : ; ^ *5 ? 1 1 N ^ • dU ( , o_ A ^ Date: ^[z^ff O 

## Phone : 4^;^ ^ 3^^ ^ ^^^ ^ BVID : 

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### Propert y Owne r Pruden t Employe e Signature : Signature : 

# MH i 808 0 War d Parkway , 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 Omaha , Nebrask a 6S10 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 

# ^/2 # C-.V - l'^^f) ^ STOJS^T ? 

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# 2¥e8 S Name : MakeC Q XA^VfiriA S Omah a Lea d Sit e Date : fAUs - NorthAno w Address : d - 8/" ? ^^reMoot s * t Sit e Sicetc h Time : //.'5- 3 Phone : 

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# 281 7 Nichola s S t 5 1 x 125 

# A Printed : No v 30 , 201 0 www.dcgis.org/dogi shttp://www.(lhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=%3CRESU. , Creat e Anothe rTicke t Bac k t o Irt h Interne t Sein d Erfiai l



### • YOURTICKE T NUMBE RI S  2605475 . Origina l Cal l Date : 9/30/1 0 Time : 12:3 3 p m Op : SIVA1896 7 Wor k t o Begi n Date : 10/04/1 0 Time : 1:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 281 7 Street : NICHOLA S S T Twp : 15 NRng : 13 E Sect-Qtr : 16-S E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lea d remediatio n projec 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 AJAMPAMA 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 CXCATV LEVEL 3 MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C 

### Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL3 LEVEL3 COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : 

### Emerg : 877366834 4

lo f 2 9/30/201 0 12:3 3 P Mhttp://www.(ihon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=%3CRESU. .


### MUDO l METROPOLITA N UTILITIES DISTRICT SAND Y Day : 402504782 3 Alt : 

### Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 4024445160 0PPDGPR 5 OMAH A PUBLI C POWE RDISTRICT EL M LOCATIN G Day : 406728934 3

Alt : 406207149 4 Emerg : 888728934 3 QLNNEl C QWES T LOCA LNETWOR K EL M LOCATIN G Day : 406728934 3



### Alt : 4062071494 Emerg : 888728934 3

2 o f 2 9/30/201 0 12:3 3 P MTEDHN t MC . 

### CONSTRUCTIO N SOLUTION S 

## SIT ESA^T Y HAZAR D ANALYSI S 

# :ZLLXJ^LsiA:,.^^i:l . Address : Excavatio n Date : Crew : Backfil l Date :

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# h^' f ^ 

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## Sit e Safet y Offic e Date :

o n WanfVarfemy , SnibsMt S SMOSIOa t 424 2 Madica l Drivs , Stdt e 726 0 :«nsasO)ly/Ma««11 4 OiirtlMi , MabrKl m BfrtO ? Sa n Antonio , T X 7822 9 hone : (SW ) S^i^ra s Ptwos : (402 ) 733-111 8 Phone : (210)82Z«68 8 B C (916 ) 363f370 7 f=ax : (402)73»'in 3 Fax ; (210 ) 6T9-S57 7" y k 

# mii > /tHOZA S 

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