TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 7)\l[0l ^ Date: 1 1 ' I O " I U 

Address: A^Q l M . \[ D S ^ 

Remediation Contractor: Ppt-, n/Pvii'-f %.rM N^OC, i^ <i.. Ir^ci Year: <^U I (J 

SOIL REMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

[?f Video of property (DVD) 

Ql Executive Summary 

4 EPA-provided property sketch 

Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adjacent property 

B) Restoration Agreement 

D Settlement doctmients (i.e., for damage or to replace plants, etc.) 

a Confinnation data 

a Photographs 

sf As-built sketch 

of Satisfactory restoration signed by Property Owner 

a Property close-out check Ust signed by EPA 

D Description of areas not meeting ROD cleanup criteria 

B Utility clearances 

y Property infonnation from Douglas County Assessor's Office 

D 

D 

D 

^ ^ .'*'''' 

Signature Date 

30260850 

Superfund 
PROPERTY SUMMARY 

Date: 11/15/2010 Omaha Lead Site Remedial Action Contract # EP-R7-07-06 TO#l Month of: November 

Property Address; 3301 N 16 ST 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE 

A.2 Issues Resolved: NONE 

A.3 Unique Findings: NONE 

A.4 Other Relevant Information: NONE 

CONFIRMATION SAMPLING DATA/RESULTS: 

Fl = 163 PPM @ 6"; Bl = 258 PPM @ 6"; B2 = 193 PPM @ 6"; EA= 241 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 fmal 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 of areas not meeting Interim ROD cleanup criteria. 

TECHNOLOCIES, INC. 
Find Record 

Backfill: 

Sample Area: 31166 - 3301 N 16 ST 

Owner: 

n Owner Occupied 

Owner Name: 

|FANT DOROTHY M 

Owner Addressl: 

1 

Owner AddressZ: 

)3207 N 16 ST 

City: State: ZipCode: 

jOMAHA |N E J68110-

Owner Phone Alternate Phone: 

|f402) 341-7530 

' 

Contract: 

Contractor: |PRUDENT2010. .5 

Contract Option jOPnON 1 

Remediation Query j Lead Remaining Query i Property Damage Query 

User Provided Owner Information 

Owner Name: 

1 

Owner Address: 

1 

City: 

1 

State: ZipCode: 

1 1 

Owner Phone: 

1 

Alternate Phone: 

1 

Assessment: 

Qualifying Group J466 

Assessment Max XRF Value | ~ 523 

Resident: 

Resident Name: 

I 

Property Address: 

|3301 N 16 ST 

Zip Code: 

J68110-

Resident Phone 

I 
JCiMMiJ 

TECHNOLOGIES, INC. -yr^^ 

EPA Property Close Out 

Property #: -3 ^ ^ ^ ^' Property .Address: 1» 3 C j JV^- I ^ ^1 " 

Date/Time: . Owner'sName: {;?c r^*i ^ -tcci^-V 

Quads Excavated: r I ( V I, \$ <^. Contractor Group: Fniidlent Technologies, Inc., 

Excavation General Yes No 

1. If necessary, were (he correci quadrant(s) excavaled and restored"; 

2. If necessary, were the correci areas of drip zone excavated and restored? 

Grading Sod and Vegetation Yes No 

1. Does the grading around the perimeter of the house in excavated areas generally slope away y from the liouse';' 

2. Has sod been laid in all areas tliat were excavaled? y 

3. Does tlie sod appear to be generally healtliy and growing? (Only evaluate if inspected at a 30 ^ day time period) 

4. Are sodded areas generally finn and evenly graded? y 

5. Are the jomts between the sod strips generally tight? (Only evaluate if inspected at a 30 day 

time period) y 

6. Was the property graded such tliai water will not pool on tiie property? y 

7. Was damage to landscaping or plant niaterials avoided? 

y 

Gates, Fences and Retaining Walls 

Yes No 

1. Do gates open and close freely? (If apphcable) y 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) y 

3. Was daniage lo gates or fences avoided? (Tf applicable) / 

4. Was damage to relaining walls avoided? (If applicable) 

/ 

Foundation, Siding and Gutters 

Yes No 

1. Was dajnage to the siding or trim avoided? 

/ 

2 Was damage to the foundation avoided? 

y 

Was damage lo windows avoided? 

y t 4.

 Was damage to windows or door screens avoided? 

5, Was damage lo downspouts or downspout extensions avoided? y 

Sidewalks and Driveways (Concrete) 

Yes No 

1. Was damage lo drivewav surfaces avoided? 

y 1.

 Was damage to walkway surfaces avoided? 
Owners com na ents: 

Inspection notes: 

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

EPA Representative j^^-y/j^ Date: ir,J±^jiyi 
KTTODEDGIES, INC. AS - BUILT DRAWING 

OLS #31166 

Date Excavated: 9/29/2010 OMAHA LEAD SUPERFUND SITE I'SEPA Signed-OfT Date: 

31166 

EA= 241 PPM @ SCRAPE 

CONTRACT #: EP-S7-10-05 PRUDENITECHNOLOGIES, INC. 
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 v/ith the restoration ofthe 

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

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

Propertj CD: 

Property Address: •33 0 ) M \ t. K SV 

Owner: T:)or u,^ pi-au^>— Phone: Ho^ - • C^ <^d 

Restoration litems iini Qyestiomi: 

Required corrections to comp>lete the piropeitjf: 

ll 

agree restoration is completed, except as noted abo\/e. 

 1 I do not agree restoration is completed 

Owner's Sigmature 

I
'..X 

Prudent Technologies, Inc. (Prudent) is under contract with the U. S. Environmental Protection Agency (EPA) to clean up leadcontaminated soils at a number ofproperties located in Omaha, Nebraska, including the property locaied at 

^^ 0 1 Nl )fe .^L . Tlie EPA requests your permission to allow Prudent to perform a soil cleanup at this 

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

activities related to the cleanup including soi] sampling, removal oflead-contaminated soil, and restoration ofthe referenced property. 

Ifyou have any questions about the soil cleanup planned for your property, please contaa 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 Informalion 

Centers al (402) 731-3045 (South Omalia office) or (402) 991-9583 (North Omalia office). 

Property Access Granted By; / y<^ l<CfT. H ^ t/Hit f 

(Please Print Name) 

<^lf^l^lo Property Owner Signature: 

/tiignature)'^ (Date) 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner — please print) 

RESIDENT NAME: rS-OJ^ ^P y "^1 ^ Owner Renter 

RESIDENT ADORESS: 

3-^^( AJj(.Sy (r/syh) 

IF RENTAL, PROPERTY OWNED BY: 

/t///-

OWNER'S MAILING ADDRES 

^p-t?- ? /y> >^^ ^ 

OWNER'S TELEPHONE NUMBER - HOME : lU ^ 3 V/^-y^ O WORK: 

( 1 ^ATWe . 

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

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

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD •. y 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, Y GATES, ETC.] 

AtrrHORlTY FOR ENVIRONMENTAL RESPONSE ACTIONS^ The activilies to be implemenled by EPA under this agreement 

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

CERCLA, 42 U.S. C 9605(e), which provides entry for "detemiining the need for response, or choosing or talciiig any response aaion 

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

8080 Ward Parkway. Suite 4-05 5600 S tc St 4242 Medical Drive. Suite 4250 

Kansas City.'MO 64114 Omaha, Webraska 631C7 San Antonio. TX 78229 

Phone: (816) 363-3703 Phone: i402. 733-1188 Phone: (210)822-9588 

Fax: (315) 363-3707 Fax: (402) 733-1883 Fax:,'210) 579-6577 
ENVfRONMEiVTALiSt IRUDEN' COiNSTRLCTrON 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: 3*3^ ' '^^ ' t J"f. Date: 7-/j^/t j 

BVID: Phone: l^^^ 3*^/^^$:? ^ 

^./>^g ^Ar^.to. ni l -l-hx Jjs ^ 

Prudent Employee 

Signature: 

80S0 Ward Parkway, Suite 405 5600 S 10 St 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68107 San Antonio, TX 7322S 

Phone: (816) 363-3703 Phone: (402)733-1183 Phone: (210)822-9588 

. . /04ev oe i i7rt ? i*n^ \ -rtf ioo-> C-.V­ ("3-lftV B70J!S7 7 
• • 

H I IIIIIIIIII 31166 

Omah Exterior Paint North Antw a Lead Site 

Sit • Good e Sketch • Poor 

Sampling Address: 3301 N 16 ST 0 Not paint 

Sample Lead Sample Samples Collected Number U\B Concentration Collected Firm: F M CC-W L 

RYASCPXA-31166 F1 

ppm D Date: /2-7-D 7 

RYBSCPXA-31166 F2 2Q f ppm D Time:

 / / •' / 7 <i/H 

RYCSCPXA-31166 Bl ^2. 3 ppm D 

Samples Analyzed 

RyDSCPXA-31166 82 HH T ppm I D

nDZSCPXA 31166 SZ ppm D XRF Unit: ^S'-V(D Book: ZCT^ 

nOZCCPXA 31166 8£ — ppm D D Date: I 2 - IP, - 0 7 

nrgconxA'31166—pz — ppm D Time: 

D =3. Bn. I • I Staff: i/^'^iy Number of Samples = | ^ ; [ Q I 

Legend: Fl = Front Left, F2 = Front Right, Bl = Back Left, B2 = Back Rigtit DZ = Drip Zone, GZ = Garden, PZ = Piay 

All quadrants are as viewed from the street, facing property 

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Created: :8-Nav-i)7 (>46141.0123 

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A 415_ Printed: Nov 16.2010 

www.dcgis.org/dogis 
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• YOUR TICKET NUMBER IS 2591490. 

Original Call Date: 9/14/10 Time: 11:08 am Op: SIVA18967 


Work to Begin Date: 9/16/10 Time: 11:45 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 3301 Street: N 16TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 10-NE-NW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


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 Front: Y Rear: 


Involves Tunneling or Horizontal Boring : N Explosives: N 


CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Nuinber Utility Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RICHATRAFFIC

Day: 4024447197 

 Alt: 4024445161 

Emerg: 4024445160 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT ELM LOCATING

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

QLNNEIC QWEST LOCAL NETWORK ELM LOCATING

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/14/2010 
ENVIRONMENTAL 

ENGINEERING AND 

CONSTRUCTION TEeHNauttes, mc. SOLUTIONS 

SITE SAFETY HAZARD ANALYSIS 

Address: —^12^-1-^ - ^ ^ Excavatioii Date: 

Crew: Backfill Date: 

Item Condition Hazards Corrective Action 

Overhead Lines t-gfe- y^^ ^ 

Gas Line 

Wate r Line 

Sewe r Line - ^ 

Ty ^ y 

Septic/Leech 

Field 

Propane/Butan e 

Sidewalk ...#v. ^yf ^ / ^ a. 

^*^^ ^ 

Foundation 

Retaining Walls 

Fences 

Trees 

Structures 

Driveway .» ^ t-^&^ . ^^^£^ey&^>*y -

Sprinkler System 

Other 

Crew Foreman Site Safety Office 

Date: 

8080 WaRf«arioKay. Sute 405 5600 SIO St 4242 Medica! Drive, Suite 7250 

Kansas Cily;aiO«4114 Omaba, Netaaska 68107 San Antonio, TX 78229 

Phone: |8f6) 362^3703 Phone: (402)733-1188 Phone: (2t0) 822ri9588 

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