## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL E FOLDE R SAID# : 7)\l[0l ^ Date : 1 1 ' I O " I U Address : A^Q l M . \[ D S ^ Remediation Contractor : Ppt- , n/Pvii'- f

%.r M N^OC , i^ <i. . Ir^c i Year : <^ U I ( J SOI LREMEDIATIO N PROPERT Y FIL E FOLDE RDOCUMENT S [? f

Video o f

propert y (DVD ) Q

l Executiv e Summar y 

# 4 EPA-providedpropert y sketch SignedAcces s Agreemen t fo r

subject propert y D SignedAcces s Agreement(s ) fo r

adjacen t propert y B ) Restoratio n Agreemen t D Settlemen t doctmients (i.e. , fo r

damage o r

t o replac e plants , etc. ) aConfinnatio n data aPhotograph s s f

As-built sketch o

f

Satisfactor y restoratio n signedby Propert y Owne r aPropert y close-out chec k

Us t signedby EP A D Descriptio n of area s not meeting RO D cleanu p criteri a B Utilit y clearance s y Propert y infonnatio n fromDougla s Count y Assessor' s Office D D D

^ ^ .'*''' ' 

## Signatur e Dat e 3026085 0 Superfun d

### PROPERT Y SUMMAR Y Date : 11/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Novembe r Propert y Address ; 330 1 N 1 6 S T A . EXECUTIV E SUMMAR 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 = 16 3 PP M @ 6" ; B l = 25 8 PP M @ 6" ; B 2 = 19 3 PP M @ 6" ; EA = 24 1 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 othe r propertie s 3 ) Pre-Excavatio n digital 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 fma l 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 di n th e individual property file , i f available , or obtaine dinclude : i ) Pre-excavatio n agreemen 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 n digital vide o i n MPEG , WM V (Window s Medi aVideo ) o r SW F(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 .

TECHNOLOCIES , INC .Fin d Record 

### Backfill :

Sampl e Area : 3116 6 - 330 1 N 1 6 S T Owner : n Owne rOccupie d Owne rName : |FAN TDOROTH YM Owne rAddressl : 

# 1 Owne rAddressZ : )320 7 N 1 6 S T City : State : ZipCode : jOMAH A |N E J68110 - Owne rPhon e Alternate Phone : |f402 ) 341-753 0 

### ' Contract : Contractor : |PRUDENT2010 . 

### . 5 Contrac t Optio n jOPnO N 1 Remediatio n Quer yj Lea d Remainin g Quer yi Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : 

# 1 Owne rAddress : 

# 1 City : 

# 1 State : ZipCode : 

# 1 1 Owne rPhone : 

# 1 Alternat e Phone : 

# 1

Assessment : Qualifyin g Grou p J46 6 Assessmen t Ma xXR F Valu e | ~ 

### 523 Resident : Residen t Name : 

# I Propert yAddress : 

### |330 1 N 1 6 S T Zi

p Code : J68110 - Residen t Phon e 

# I

# JCiMMi J TECHNOLOGIES , INC . 

# -yr^ ^ EP A Propert y Clos e Ou t Propert y# : -3 ^ ^

^ ^' Propert y .Address : 1» 3 C j JV^ - I ^ ^1 " Date/Time : . Owner'sName : {;?c r^* i ^ -tcci^- V Quad s Excavated : r I ( V I , \ $ <^ . Contracto r Group : Fniidlen t Technologies , Inc. , Excavatio n Genera l Ye s N o 1 .I f necessary , wer e (h e correc i quadrant(s ) excavale dan drestored" ; 2 .If necessary , wer e th e correc i area s o f dri p zon e excavate dan drestored ? 

### Gradin g So dan dVegetatio n Ye s N o 1 .

Doe s th e gradin g aroundthe perimete r o

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

## y fro mthe liouse'; ' 2 .Has sodbee n laidi n all area s tlia t wer e excavaled ? 

# y 3 .

Doe s tli e sodappea r t

o b e generall y healtli y an dgrowing ? (Onl y evaluat e i f inspecteda t a3 0 ^ da

y tim e period) 4 .Ar e soddedarea s generally finn an devenl y graded ? 

# y 5 .Ar e th e jomt s between the so dstrip s generall y tight ? (Onl y evaluat e i f inspecteda t a3 0 da y tim e period ) 

# y 6 .

Wa s th e propert y grade dsuc htlia i wate r will not pool o n tii e property ? 

# y 7 . Wa s damag e t o landscaping o r plan t niaterial s avoided ? 

# y Gates , Fence s an dRetainin g Wall s Ye s N o 

### 1 .

Do gate s ope n an dclos e freely ? (I f apphcable ) 

# y 2 .Wer e al l gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) 

# y 3 .

Wa s daniag e lo gate s o r fence s avoided ? (T f applicable ) / 4 . Wa s damag e t o relaining wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye s N o 1 . Wa s dajnag e to th e sidin g o r tri mavoided ? / 2 Wa s damag e to th e foundatio n avoided ? 

# y Wa s damag e l o window s avoided ? 

# y t 4 .

Wa s damag e t o window s o r doo r screen s avoided ? 5 ,

Wa s damag e l o downspout s o r downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Ye s No 1 .Wa s damag e l o drivewa v surface s avoided ? 

# y 1 .Wa s damag e t o walkwa y surface s avoided ?

## Owner s comn aents :

Inspectio n notes :

Remova l an drestoratio n activate s complete includin g th e 30-da y sodwarranty : EP A Representativ e j^^-y/j ^ Date : ir,J±^jiy iKTTODEDGIES , INC . 

## AS - BUIL T DRAWING OL S #3116 6 Dat e Excavated : 9/29/201 0 

## OMAHA LEAD SUPERFUND SIT E I'SEP A Signed-Of T Date : 

## 3116 6

EA = 24 1 PP M @ SCRAP E CONTRAC T# : EP-S7-10-0 5 PRUDENITECHNOLOGIES , INC .

### Thi s agreement documents th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s that th e property owne r i s satisfie dv/it hth e restoratio n ofth e subjec t firoperty , an dtha t n o itein s are in question , now , o r a

t any tim e i n th e future , excludin g any remaining warrant y (3 0 day s total ) excep t thos e item s liste dbelow , if any . Propert j CD : Propert y Address : 

## •33 0 

# ) M \

# t . 

# K S V Owner : 

# T:)or 

# u, ^ pi-au^> — Phone : 

## Ho ^ 

## - • C ^ 

## <^ d Restoratio n litem s iin i Qyestiomi :

Require dcorrection s t o comp>let e th e piropeitjf:

l l 

### agre e restoratio n i s completed , except a s note d abo\/e . 1 I d o no t agre e restoratio n i s complete d

Owner' s Sigmatur e 

### I'.. X

Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clean u p lead contaminate dsoil s a t anumbe r ofpropertie s locate di n Omaha , Nebraska , includin g th e propert y locaie dat ^^ 0 1 N l )f e .^ L . Tli e EP A request s you r permissio n t o allo w Pruden t t o performasoi l cleanu p a t thi s property t o remove lead-coniaminate dsoil . B y signin g thi s form , th e property owne r grant s pennissio n t o Pruden t t o perform activitie s relate dt o th e cleanu p includin g soi ] sampling , remova l oflead-contaminate dsoil , an drestoratio n ofth e reference dproperty . Ifyo u hav e an y question s abou t th e soi l cleanu p planne dfor you r property , pleas e conta aPruden t southoffic e .fo r th e Omah aLea d Site cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informalio n Center s a l (402 ) 731-304 5 (Sout hOmali aoffice ) o r (402 ) 991-958 3 (NorthOmali aoffice) . Property Acces s Grante dBy ; / y< ^ l<CfT . H ^ t/Hit f (Pleas e Prin t Name ) 

# <^lf^l^lo Property Owne r Signature : /tiignature)' ^ (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r — pleas e print ) RESIDEN T NAME : 

### rS-OJ ^ ^Py"^1 ^ Owne r Rente r RESIDEN TADORESS : 

# 3-^^ ( AJj(.S y(r/syh ) I F RENTAL , PROPERT Y OWNE D BY : 

# /t/// - OWNER' S MAILIN G ADDRE S 

## ^p-t?- ? /y > >^^ ^ OWNER' S TELEPHON E NUMBE R - HOM E 

### : lU ^

3 V/^-y^ O WORK : ( 1 ^ATWe . 

## yS ) 

## - AG E O F HOME? : 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 

# i^l k NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OL D 

# •.y NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBER O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , Y GATES , ETC. ]

AtrrHORlT Y FO RENVIRONMENTA LRESPONS EACTIONS ^ Th e activilie s t o b e implemenle db y EP A unde r thi s agreemen t are pursuan t t o Sectio n 10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA'srigh t 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 fo r "detemiinin g th e nee dfo r response , or choosin g or talciii g an y respons e aaio n unde r thi s title , o r olherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkway . Suit e 4-0 5 560 0 S t cS t 424 2 Medica l Drive . Suit e 425 0 Kansa s City.'M O 6411 4 Omaha , Webrask a 631C 7 Sa n Antonio . TX 7822 9 Phone : (816 ) 363-370 3 Phone : i402 . 733-118 8 Phone : (210)822-958 8 Fax : (315 ) 363-370 7 Fax : (402 ) 733-188 3 Fax:,'210 ) 579-657 7ENVfRONMEiVTALiS t 

# IRUDEN ' COiNSTRLCTrO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : 3*3^ ' '^ ^ ' t J"f . Date : 7-/j^/t j BVID : 

## Phone : l^^ ^ 3*^/^^$:? ^ ^./>^ g ^Ar^.to . ni l -l-h x Jjs ^

Pruden t Employe e Signature : 80S 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 6810 7 Sa n Antonio , T X 7322 S Phone : (816 ) 363-370 3 Phone : (402)733-118 3 Phone : (210)822-958 8

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## D Date : /2-7-D 7 RYBSCPXA-3116 6 F 2 

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## D XR F Unit : ^S'-V( D Book : ZCT ^ — 

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### Printed : No v 16.201 0 www.dcgis.org/dogi sPag e 1 o f 1

" > Create Anothe r Ticke t Bac k t o Irt h Inteme t Sen d Emai l

• YOU RTICKE T NUMBE RI S 2591490 . Origina l Cal l Date : 9/14/1 0 Time : 11:0 8 a m Op : SIVA1896 7 Wor k t o Begi n Date : 9/16/1 0 Time : 11:4 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 330 1 Street : N16TH S T Twp : 15 NRng : 13 E Sect-Qtr : 10-NE-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : SOI L LEA D REMEDIATIONPROJEC T Locatio n o f Work : LOCAT E ENTIR E PROPERTY 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 : EPA Dept h o f Excavation : 6 FT Corne r Lot : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V

MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Nuinbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIE S DISTRICT SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACOFCIT Y O FOMAHA-TRAFFIC,SEWE RRICHATRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLIC POWE RDISTRICT EL M LOCATING Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES T LOCA LNETWOR K EL M LOCATIN G Day : 406728934 3

Alt : 406207149 4 Emerg : 888728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/14/201 0

### ENVIRONMENTAL ENGINEERIN GAN D CONSTRUCTIO N TEeHNauttes , mc . 

### SOLUTION S 

## SIT E SAFET Y HAZAR D ANALYSI S Address : —^12^-1-^ - ^ ^ Excavatioi i Date : Crew : Backfil l Date :

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## Sprinkle r Syste m Othe r Cre w Forema n Sit e Safet y Offic e Date :

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