## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R 

# SAID# : ^(fA4 3 Date : 11-15^1 0 Address : I^J ^ Nl l ^t " Remediatio nContractor : fip/.-, ncarM ^ T^/'.f i N^OC , )-? • <^ ^ Ir^.ij i Year : Z^ C J I ( J SOI LREMEDIATIO N PROPERT YFIL EFOLDE RDOCUMENT S 

# ' Zl'ZT ' ^ 

## EPA-provide dpropert y sketc h 

# J Signe dAcces s Agreemen t fo r subjec t propert y D Signe dAcces s Agreement(s ) fo r adja^n t propert y 

# i Restoratio nAgreemen t 

# •• H

D Settlemen t document s (i.e. , fo r damag eo r t o replac eplants , etc. ) ffl Cotifinnatio ndat a 2 1 Photograph s 0 As-buil t sketc h [ / Satisfactor y restoratio nsignedb y Propert y Ovme r B IPropert y close-oir t chec k Us t signe db y EP A D Descriptio no f area s no t meetin g RO D cleanu p criteri a 0 Utilit y clearance s of

Propert y informatio nfromDougla s Count y Assessor' s Offic e D D D 

## Signatur eDat e

### PROPERT Y SUMMAR Y Date : 11/15/201 0 Omah aLea dSit e Remedia l Actio nContrac t #EP-R7-07-0 6 TO# l Mont hof : Novembe r Propert y Address ; 152 2 N1 7 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 NSAMPLIN GDATA/RESULTS : F 2 = 6 6 PP M @ 6" ; N O EASEMEN T 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 dinth e individua l property file, i f available , o r obtainedinclude : i ) Pre-excavatio nagreemen t detail s (ifan y ar e mad e withth e property owner ) ii ) Property Statu s Formsigne db y property owne r iii ) Excavatio ndigita l vide o inMPEG , WM V (Window s Medi aVideo ) o r SWF(Flas hPlayer ) format and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio no f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCiES . INC .Fin d Record 

### Backfill :

Sampl e Area : 2624 3 - 152 2 N 1 7 S T Owner : D Owne rOccupie d Owne rName : jPUSC H JA N E Owne rAddressl : 

# r Owne rAddressZ : | P O BO X 54043 2 City : 

### State : Zi p Code : lOMAH A NE " 16815 4 Owne rPhon e Alternat e Phone : 

# I

Contract : Contractor : |PRUDENT2010_S Contrac t Optio n (OPTIO N 1 Remediatio n QueryI Lea d Remainin g Quer yI Propert yDamag e Query

Use rProvide d Owne rInformatio n Owne rName : Owne rAddress :
City : State : Zi p Code : Owne rPhone : Alternat e Phone : 

# I

Assessment : Qualifyin g Grou p [40 0 Assessmen t MaxXR F Valu e | 507. 7 Resident : Residen t Name : 

# r Propert yAddress : 11522 N 1 7 ST Zi p Code : )68110 - Residen t Phon e 

# IINCBU3GIlS i JNC . 

# yy/yA^iy^ ^ EP APropert y Clos e Ou t IPrwpeirt y # : 2 ^ 2-M- 3 Frojpeirty Aftdlress:'^ ^ v* ? ^ ' - Date/lime : Owner' s Name : " 5 c w v ^ ^V- ^ Qtnad s Excavated : F-2 ^ Contracto r Group : Pruden i TccKniologjieJJ , HMG. , Exiravatio nGenera l ¥e » N o f If necessary , wer e th e correc J quadrant(s ) excavate dan drestored ? 

# A 2 . If necessary- , wer e th e correc t area s o f dri p zon e excavate dan drestored ? 

# A Gradin g So dan dVegetatio m ¥e » Mo 1 . Doe s tl^ e gradin g aioiui dtii e periniete r of th e hous e i nexcavate darea s generall y slop e awa y / fro mth e house ? 2 . Ha s so dbee nlai di nal l area s tliat wer e excavated ? / 3 . Doe s th e sodappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t a3 0 day tim e period ) 

# y 4 . Ar e sodde dajea s generall} - fimi an devenl y graded ? 

# y 5 . Ar e th e joint s betwee ntli e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 day 

## y tim e period ) 6 . Wa s th e propert y grade dsuc htliat wate r wil l no t poo l o ndi e property ? 

# y 7 . Wa s dafliag e t o landscapin g or plan t material s avoided ? 

# y Gales , Fence s an dRetainint g WaM s ¥e s N o 1 .D o gale s ope n;ui dclos e freely ? (I f applicable ) 

# y 2 . Wer e al l gate s o r fence s take ndow ndurin g restoialio nactirvitie s reinstalled ? (I f applicable ) 

# y 1 . Wa s damag e l o gate s o r fence s avoided ? (I f applicable ) 

# y 4 . Wa s damag e to retailin g wall s avoided ? (I f applicable ) 

# y IFomitdlation , Sidin g an dGutter s ¥e 9 N o f . Wa s damag e t o tli e sidfn g o r tri mavoided ? 

# y Z. Wa s damag e t o tli e foundatio navoided ? 

# y Wa s damag e to window s avoided ? 

# y 4 . Wa s damag e t o window s o r doo r screen s avoided ? 

### y 5' . Wa s damag e to downspouts : o r downspou t extension s avoided ? 

## y SidewaUk s an dDriveway s (Concrete ) Ye s N o 

### y ^ 1 -Wa s damag e to drivewa y surface s avoided ? ^ ^ 2 .Wa s damag e t o walkwa y surface s avoided ? -. 1

## Owner s comments :

Inspectio nnotes :

Remova l an drestoratio nactivate s complete includin g th e 30-da y so dw^arranty : EP A Representativ e x^a ^ ^A j Date : (ojislc oECiHNOLO(JIE.S, INC . 

### A S - BUIL T DRAWIN G OI. S # 2624 3 Dat e Excavated : 9/16/201 0 

### OMAH A LEA D SUPERFUN D SIT E IISEP. \ Signed-Of f Date : 

# aae^ d Exterio rPain t Nol h Arro- w Omah a Lea d Sit e Owne rName : (Jaf l ^C/ C Pl/dCA } • Goo d Sit e Sketc h A<!dress : /S2 a / V / 7 <S f • Poo r Phone : » G5'< 9 ' d6G T (3^0 1 pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : T m FCl . C.N * RYASCPXA-<?<S^y j F 1 2 R ^ pp m 

### D Dat eH-M^ V RYBSCPXA-,?(2£V 5 F 2 •50 8 pp m 

### D Time :.Z'. ^ RYCSCPXA-^C^^ J B 1 ; ' 7 3 pp m 

### D Sample s Analyze d RYDSCPXA-<£'<Sc'y J B 2 

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### D D Date . £ -O i • o: ^ RPZraCPXA - £i2£H 3 P ^

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### D D Time : F H Staf f Hs-y ; Numtre ro f Sample s = U Legend : F l = Fron t Left . F 2 • Fron t Right , B l = Bac k Left , B 2 = Bac k Righ t D Z = Dn p Zone , G Z = Garden , P Z = Pla y Ai l Quadrant s ar

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

## Propert yCompletio n Agreemdn t Thi s itgrcemeitt document s di e comptetio no f remova l activJtiB S perfonxte do atb e beio w liste dproperty . Th e propeit y owner' s si^ittur e indicete s tha t th e propeit y owne r i s aetbfie dwitf i th e reatoratioinofth e subjeo t properQ' , an dtlu x n o itAn s ar e i nquestion , now , o r t t an y tim e i ntb e fiiture , excludin g an y remainin g wamrnt y (3 0 d«y 9 total ) exoep t thos e tteto s liste dbelow , ifany . 

### Propert y ID : Properly Addrett : \5as . N 

# liw , ^ y ^^•f - T(XW9..A L Phone ; Restoratio n ttenwt n Question :

Item : ttun: Item :

RMiulra d conoction s t o oorapiet e th s propatiy ;

L J I agr M restoratio n I s comploted , excep t a s note d above . [ U I d o no t agre e restoratto n i s complete d 

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# yA/sA/ d OwaiA' * Sl|Batur < I>at e



### OES LnLna»n/n i eOOfZOCT d d 3 rB6o: u 0 1 9 L P O E d W'69-0Ce-30t ' 

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## -•, . •y Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Enviromnenta l Protectio nAgenc y (EPA ) t o cleanu p lead contaminate dsoil s a t anumbe r ofpropertie s locate dinOmaha , Nebraska , includin g th e propert y locate da t ' ' S ^ 5 WJ . \~ ? ^ "r- ^ Tli e EP Arequest s you r permissio nt o allo w Pruden t t o performasoi l cleanu p a t thi s property t o remov e lead-contaminate dsoil . B y signin g thi s form , th e propert y owne r grant s permissio nt o Pruden t t o perfor m activitie s relate dt o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio nofth 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 for 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 canb e directe dt o th e EP A Publi c Infomiatio n Center s a t (402 ) 731-304 5 (SouthOitiali aoffice ) o r (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Grante dBy : * f P

I eas e Prin t Name ) B Property Oj^uTe r Signature : ^ 

## ^itH|;r>i ^ (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 TNAME : \f<aCrj n V L 6 ^ Owne r Rente r RESIDEN TADDRESS : ^ \ I F RENTAL , PROPERT YOWNE D BY : OWNER' S MAILIN G ADDRESS : 

# M T G ^ AL 5 6 \1 \~t ^ <yw . OWNER' S TELEPHON E NUMBE R - HOME : S^ ^ (g*^" ^ ""^^^^^^" H WORK : AG E O F HOME? : 

# AD O YEARS . HO W LON G HAV E YO U LIVE D HERE ? HA S TH E EXTERIO R BEE N PAINTE D O R COVERE O WIT H SIDIN G SINC E 1978 ? 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 OLDER ' NUMBE R 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 WEE K COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS . ENTR YGATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t are pursuan t t o Sectio n10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f

acces s t o th e propert y i s provide dfor i nSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry for "determinin 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. " 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 Orraha , Nebrask a6S1C ? Sa n Antonio . T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402 s 733-118 8 Phone : (210)822-958 8 Fax ; (816 ) 363-370 7 Fax : (402 ) 733-188 3 Fax : (210 ) 576-667 7ENV[RO.MVlENT.'\L & CONSTRUCT[O N 

### TECHNOLOGIES , INC . SERVICE S 

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## Pruden t Employe e Signature : Signature : 808 0 War d Parkway , Suit e 40 S 560 0 S 1 0 S t 424 2 Medica l Drive , Suit e 425 0 KansasCity , M O 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)822-968 8 /o-«e ^ '%c t iTrt ^ C^ v l-)M\ \«7«JS«7 7

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# n Date : 4|2fJ0 v RYBSCPXA-^G^^'J ? F2 pp m 

## D Time : 'I , '• 3> & RiCSQPy-.^-SQB^ S B l pp m 

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## D Tim.e : ,f'','*' t 

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" > Creat e Anothe r Ticke t Bac k t o Irt h Ir^teme t Sen d Emai l 

## YOURTICKE T NUMBERI S 2592067 . Origina l Ca-l l Date : 9/14/1 0 Time : 5:1 6 p m Op : SIVA1896 7 Wor k t o Begi n Date : 9/16/1 0 Time : 5:4 5 p m State : N E County : DOUGLA S Place : OMAH A Address : 152 2 Street : N17T H S T Twp : 15 NRng : 13 E Sect-Qtr : 15-NW 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 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 : 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 CXCAT V LEVEL 3 MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C 

### Servic e Are a Contac t Phon e Number Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL S COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4 MUDO l METROPOLITA NUTILITIES DISTRICT SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE R RICH/TRAFFI C 

### Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0 

### Day : 406728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/14/201 0

## Page 2 o f

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OPPDGPR 5 OMAH A PUBLI C POWE RDISTRICT EL M LOCATIN G 

## Alt : 406207149 4 Emerg : 888728934 3 QLNNEIC 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

### ENVIRONMENTA L ENGINEERIN GAN D CONSTRUCTKW isoiwALaanB , mc . SOLUTION S



## Address : —Z.^*? ^ Crew :

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