TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: ^(fA43 Date: 11-15^1 0 

Address: I^J ^ N l l ^t " 

Remediation Contractor: fip/.-, ncarM^ T^/'.fi N^OC, )-?• <^^ Ir^.iji Year: Z^C J I ( J 

SOIL REMEDIATION 

PROPERT Y FILE FOLDER DOCUMENTS 

' Zl'ZT'

^ 

EPA-provided property sketch J Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adja^nt property i Restoration Agreement 

 ••H 

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

ffl Cotifinnation data 

21 Photographs 

0 As-built sketch 

[/ Satisfactory restoration signed by Property Ovmer 

BI Property close-oirt check Ust signed by EPA 

D Description of areas not meeting ROD cleanup criteria 

0 Utility clearances 

of Property information from Douglas County Assessor's Office 

D 

D 

D 

Signature Date 
PROPERTY SUMMARY 

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

Property Address; 1522 N 17 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: 

F2 = 66 PPM @ 6"; NO EASEMENT 

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 (ifany 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: 26243 - 1522 N 17 ST 

Owner: 

D Owner Occupied 

Owner Name: 

jPUSCH JAN E 

Owner Addressl: 

r 

Owner AddressZ: 

|P O BOX 540432 

City: State: Zip Code: 

lOMAHA NE" 168154 

Owner Phone Alternate Phone: 

I 

Contract: 

Contractor: |PRUDENT2010_S 

Contract Option (OPTION 1 

Remediation Query I Lead Remaining Query I Property Damage Query 

User Provided Owner Information 

Owner Name: 

Owner Address: 

City: State: Zip Code: 

Owner Phone: Alternate Phone: 

I 

Assessment: 

Qualifying Group [400 

Assessment Max XRF Value | 507.7 

Resident: 

Resident Name: 

r 

Property Address: 

11522 N 17 ST 

Zip Code: 

)68110-

Resident Phone 

I 
INCBU3GIlSi JNC. yy/yA^iy^^ 

EPA Property Close Out 

IPrwpeirty #: 2 ^ 2-M-3 Frojpeirty Aftdlress:'^^ v*? ^ ' -

Date/lime: Owner's Name: "5 c w v ^ ^V-^ 

Qtnads Excavated: F -2 ^ Contractor Group: Prudeni TccKniologjieJJ, HMG., 

Exiravation General ¥e» No 

f If necessary, were the correcJ quadrant(s) excavated and restored? A 

2. If necessary-, were the correct areas of drip zone excavated and restored? A 

Grading Sod and Vegetatiom ¥e» Mo 

1. Does tl^e grading aioiuid tiie perinieter of the house in excavated areas generally slope away / from the house? 

2. Has sod been laid in all areas tliat were excavated? / 

3. 

Does the sod appear to be generally healthy and growing? (Only evaluate if inspected at a 30 

day time period) y 

4. 

Are sodded ajeas generall}- fimi and evenly graded? y 

5. 

Are the joints between tlie sod strips generally tight? (Only evaluate if inspected at a 30 day y time period) 

6. Was the property graded such tliat water will not pool on die property? 

y 

7. Was dafliage to landscaping or plant materials avoided? 

y 

Gales, Fences and Retainintg WaMs 

¥es No 

1. Do gales open ;uid close freely? (If applicable) y 

2. 

Were all gates or fences taken down during restoialion actirvities reinstalled? (If applicable) y 

1. Was damage lo gates or fences avoided? (If applicable) y 

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

IFomitdlation, Siding and Gutters ¥e9 No 

f. Was damage to tlie sidfng or trim avoided? y 

Z. Was damage to tlie foundation avoided? 

y 

Was damage to windows avoided? 

y 

4. Was damage to windows or door screens avoided? 

y 

5'. Was damage to downspouts: or downspout extensions avoided? 

y 

SidewaUks and Driveways (Concrete) 

Yes No 

y ^ 1 -

 Was damage to driveway surfaces avoided? 

^ ^ 

2. Was damage to walkway surfaces avoided? 

-.1 
Owners comments: 

Inspection notes: 

Removal and restoration activates complete including the 30-day sod w^arranty: 

EPA Representative x^a^ ^Aj Date: (ojislco 
ECiHNOLO(JIE.S, INC. 

AS - BUILT DRAWING 

OI.S # 26243 

Date Excavated: 9/16/2010 OMAHA LEAD SUPERFUND SITE IISEP.\ Signed-Off Date: 

aae^d 

Omah a Exterior Paint Nolh Arro-w Lea d Sit e Owner Name: (Jaf l ^C/ C Pl/dCA } • Good Sit e Sketc h A<!dress: /S2 a / V / 7 <Sf • Poor 

Phone: » G5'<9 ' d6G T (3^0 1 paint 

Sampl Lead Sample 

Samples Collected e Number LAB Concentration Collected Firm: T m FCl. C.N* 

RYASCPXA-<?<S^yj F1 2 R ^ ppm D Date

 H-M^ V 

RYBSCPXA-,?(2£V5 F2 •50 8 ppm D Time:

 .Z'. ^ 

RYCSCPXA-^C^^ J B1 ;' 7 3 ppm D Samples Analyzed 

RYDSCPXA-<£'<Sc'yJ B2 l i U _ ppm D 

RDZSCPXurt, gQSV S OZ _ ppm D O XRF Unit ^0 1 Book: /; g 

RGHOOPXA tJC^-VJC g _ ppm D D Date. £ -O i • o: ^ 

RPZraCPXA- £i2£H 3 P^ _ ppm D D 

Time: F H 

Staff Hs-y ; Numtrer of Samples = U 

Legend: Fl = Front Left. F2 • Front Right, Bl = Back Left, B2 = Back Right DZ = Dnp Zone, GZ = Garden, PZ = Play 

Ail Quadrants are as viewed figm the street, facing properly 

CONTRACT #: EP-S7-10-05 PRUDENTTECHNOLOGIES, INC. 
Property Completion Agreemdnt 

This itgrcemeitt documents die comptetion of removal activJtiBS perfonxted oa tbe beiow listed property. 

The propeity owner's si^itture indicetes that the propeity owner is aetbfied witfi the reatoratioin ofthe 

subjeot properQ', and tlux no itAns are in question, now, or tt any time in tbe fiiture, excluding any 

remaining wamrnty (30 d«y9 total) exoept those ttetos listed below, ifany. 

Property ID: 

Properly Addrett: \5as . N 

liw, ^ y 

^^•f- T(XW 9..A L 

Phone; 

Restoration ttenw tn Question: 

Item: 

ttun: 

Item: 

RMiulrad conoctions to oorapiete ths propatiy; 

L J I agr M restoration Is comploted, except as noted above. 

[ U I do not agree restoratton is completed 

X<\ii. \ iLXV yA/sA/d 

OwaiA'* Sl|Batur< I>ate 

OESL nLna»n/ni eOOfZOCTd 

d 3 r B6o:u 01 9L PO Ed W'69-0Ce-30t' 

fr»6S OeC Z0» 01:1L 0 LOZ/S L/0L aui|i/9)eQ)Ri eoo'd 
-•,.• y 

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

' ' S ^ 5 WJ. \~? ^ "r- ^ Tlie 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 Infomiation 

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

Property Access Granted By: 

* f PI ease Print Name) B 

Property Oj^uTer Signature: ^ ^itH|;r>i^ 

(Date) 

PROPERTY INFORMATION 

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

RESIDENT NAME: \f<aCrjn V L6 ^ Owner Renter 

RESIDENT ADDRESS: ^ 

\ 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS: 

AL MT G^ 5 6 \1 \ ~t^ 

<yw. OWNER'S TELEPHONE NUMBER - HOME: S^ ^ (g*^" ^ ""^^^^^^"H WORK: 

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

HAS THE EXTERIOR BEEN PAINTED OR COVEREO WITH SIDING SINCE 1978? 

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 ofCERCLA, 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 Parkway. Suite 405 5600 S 10 St 4242 Medical Drive. Suite 4250 

Kansas City. MO 64114 Orraha, Nebraska 6S1C? San Antonio. TX 78229 

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

Fax; (816) 363-3707 Fax: (402) 733-1883 Fax: (210) 576-6677 
ENV[RO.MVlENT.'\L& 

CONSTRUCT[ON 

TECHNOLOGIES, INC. SERVICES 

Property Status Form ^ , 

XMress: |i5£ ^ . ( j .\ n ^ ^ ?> i ' ""' " H | 1 4 I I O 

Phone BVID: : n^-^-A-^p^L^ 

\f^acc^\ L(SY 

'' ^ )rv^{<-f-^y^ Ah^ua^ . 

Property Owner SfV\ B^I C OM.'S^ H Prudent Employee 

Signature: Signature: 

8080 Ward Parkway, Suite 40S 5600 S 10 St 4242 Medical Drive, Suite 4250 

KansasCity, MO 64114 Omaha, Nebraska 68107 San Antonio, TX 78229 

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

/o-«e^ '%ct iTrt^ C^ v l-)M\\ «7«JS«77 
0- : i ^ > -^ '••t> 

C- W.' £c:,5^ 

Exterior Paint North A.i'i'OW.'": '••" Owner Name; cAsy} 6r/ Q PudCA ) Oniaha Lead Site [""] Gooci 

A<idress: /f"<?£ 4 ' / J d f ^ite Sketch • Poor Phone: H:<i:5-c5.-/jaa.r „ \^''%A patnt 

Samples Coiiected Sample Number Lead bampie LAB 

Concentration Coiiected Firmi: ±xa. ySM. RYASCP.K.A- eCe^ B F1 n Date: 4|2fJ0v 

RYBSCPXA-^G^^'J? F2 ppm D Time : 'I, '• 3>& 

RiCSQPy-.^-SQB^S Bl ppm & n 

Samples Analyzed RYDSCPXA•^(S<?V^J B2 Ppm D 

ppm D n XRF Unit: 4D 1 Book: // g 

RG-ZBCPX.'-'i. QCQti.yZl. ppm D n Date- j^ : - D; - .: ,,­

pprn n D Tim.e: ,f'','*'t 

Staff: \-I -".V!.;, N u m be r of S a m p! es = l\ 

Legenci: F1 = Front Lett. F2 = Front Right, 31 = Back Left, B2 = Back Right DZ = Drip Zone. GZ = Garden, PZ = Play 

Ah quadrants are as viewed from me sireet, facing property 

< • 

f 
H 152

2 N 17 St 

A Printed

: Oct 18.2010 

www.dcgi.s.org/dogis 
Page 1 of2 

"> 

Create Another Ticket Back to Irth Ir^temet Send Email 

YOUR TICKET NUMBER IS 2592067. 

Original Ca-ll Date: 9/14/10 Time: 5:16 pm Op: SIVA18967 


Work to Begin Date: 9/16/10 Time: 5:45 pm 


State: NE County: DOUGLAS Place: OMAHA 


Address: 1522 Street: N 17TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 15-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 LEVEL3 MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number Utility Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day: 4029340469 

Alt: 4029340469 

Emerg: 4029329757 

LEVELS LEVELS COMMUNICATIONS, LLC NA 

Day: 8773668344 

Alt: 

Emerg: 8773668344 

MUDOl METROPOLITAN UTILITIES DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC.SEWER RICH/TRAFFIC

Day: 4024447197 

 Alt: 4024445161 

Emerg: 4024445160 

Day: 4067289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/14/2010 
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OPPDGPR5 OMAHA PUBLIC POWER DISTRICT ELM LOCATING 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 

CONSTRUCTKW isoiwALaanB, mc. SOLUTIONS 

Address: —Z.^*?^

Crew: 

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 

SITE SAFETY HAZARD ANALYSIS 

 .^^"7 

Excavation Date: 

BackfiU Date: 

Condition Hazards Corrective Action 

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Site Safety Office 

Date: 

9600 8108 1 4242 Medical Drive, Sutts 7250 

iG«yilK>«4114 168107 San Antonio, TX 78229 

Plwne: fStS) 3634703 (402) 733-1188 Phone: (210)822^9588 

Faac (816)3634707 rax : (402)733«1683 Fax: (210) 679-6577 
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