### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 4477 3 DATE : 1/1 5 ADDRESS : 251 2 MONRO E S T REMEDIATIO N CONTRACTOR : PRUDEN TTECHNOLOGIES . INC . YEAR : 20l f 

### SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENT S Q PR E AN D POS T VIDE O O F PORPERT Y(DVD ) EXECUTIV E SUMMAR Y EPA-PROVIDE D PROPERT YSKETC H m SIGNE D ACCES S AGREEMEN T FOR SUBJEC T PROPERT Y D SIGNE D ACC:ESSAGREEMENT(S ) FOR ADJACEN TPROPERT Y m RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) EZ

i CONFIRMATIO N DAT A 0 PHOTOGRAPH S 0 AS-BUIL T SKETC H m SATISFACTOR YRESTORATIO N SIGNE D B Y PROPERT Y OWNE R [ ^

PROPERT YCLOSE-OU T CHECKLIS T SIGNE D B Y EP A D DESCRIPTIO N O F AREA S NO T MEETIN G RO D CLEANU P CRITERI A Q ' UTILIT YCLEARANCE S G

J PROPERT YINFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E D 

## D D

SIGNAl^R E DAT E 

### 3021758 6 

# m m Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLeadSit e Reinedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 251 2 MONRO ES T A . EXECUTIV E SUMMAR Y A. l 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 :

B l = 38 1 PP M @ 3" ; E A = 7 6 PP M @ SCRAP E (~1" ) ATTACHMENT S 1 ) Propert y 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 digita 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 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 individua l property file, ifavailable , o r obtaine dinclude : i ) Pre-excavatio n agreemen 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 n digita l vide o in 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 .

TECHNOLOGIES , INC .Fin d Record Remediatio n Quer yI Lea d Remainin g Quer yI Propert yDamag e Quer y 

### Backfill :

Sampl e Area : 4477 3 - 251 2 MONRO E S T Owner : n Owne rOccupie d Owne rName : jSVOBODAJOSEP H A Owne rAddressi : 

# 1 Owne rAddress2 : )251 4 MONRO E S T City : State : Zi p Code : lOMAH A )N E |68107 - Owne rPhon e Alternat e Phone : 1(402 ) 731-547 3 

# 1

Contract : Contractor : )PRUDENT2010_ S Contrac t Optio n |OPnO N 1 Use rProvide d Owne rInformatio n Owne rName : 

# 1 Owne rAddress : 

# 1 City : 

# 1 State : 

# 1 Zi p Code : 

# 1 Owne rPhone : 

# 1 " Alternat e Phone : 

# 1

Assessment : Qualifyin g Grou p |40 0 Assessmen t Ma xXR F Valu e [ 528.4 7 Resident : Residen t Name : 

# r Propert yAddress : |251 2 MONRO E S T Zi p Code : |68107 - Residen t Phon e 

# I

### 3 TECHNOUXJIBS , INC . 

# SE m EP A Propert y Clos e Ou t Propert y # : U ^ 77 3 Propert y Address : '^'^(^Moi^^cx ^ Date/Time : ^ Owner' s Name : ^«fi3^*a n ^^c^rZ'^i A Quad s Excavated : v^ ^ Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l Ye s N o 1 .

I f necessary , wer e th e correct quadrant(s ) excavatedandrestored ? 

# y 2 .

I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? / 

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

Doe s the grading aroundth e perimete r o

f the hous e i n excavatedarea s generally slop e awa y fro mthe house ? / 2 .

Ha s sodbeen laidin al l area s tha t wer e excavated ? / 3 .

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

y lim e period) / 4 .

Ar e sodde darea s generall y fim i andevenl y graded ? / 5 .Ar e tlie joint s betwee n the sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da t a3 0 da y tim e period) / 6 .Wa s the propert y gradedsuc hdia t wate r wil l not pool on the property ? / 7 .

Wa s damag e lo landscaping o r plan t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s N o 1 .

D o gate s ope n andclos e freely ? (I f apphcable ) / 2 . Wer e all gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) / Wa s damag e t o gate s o r fence s avoided ? (Ifapplicable ) / 4 .Was damag e to retainin g wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye ^ N o 1 . Wa s damag e t o the siding o r trimavoided ? 

## A 2 . Wa s damag e t o the fomidation avoided ? 

# A 3 . Wa s dainag e to window s avoided ? 

# A 4 .

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

# A 5 .Wa s damag e t o downspout s o r downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e l o diivewa v surface s avoided' ? /



# - A Wa s damag e t o walkwa y surface s avoided ?

## 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 Q^^^r^JL . ^Date: ipji^ftnUHNOLOGIES , INC , 

### A S - BUIL T DRAWIN G OL S #4477 3 Dat e Excavated : 11/15/201 0 

### OMAH A LEA D SUPERFUN D SIT E I'SEP A Signed-Of f Date : ll . miiummt^imttmmuwi^mMsamiwmttttmtr'immmmmmStmmMlflfaB' f 

### 4477 3 J»«n> 1 UJe^rziA/ s Exterio rPaint htort h Arro w Omah a Lea d Sit e Owne r Name:t<e9ePf l A SVOBOO A • • Goo d Sit e Sketc h Address : 251 2 MONROE S T 

# 4 • Poo r Phorw : H : W : ^Aio X paint Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Ccllecte d RYASCPXA-4477 3 F 1 _Jji5_PP" n 

### D Date : 

### 0^\i U OJ! : RYBSCPXA-4477 3 F 2 ^ 7 pp m 

### D Time : <T.-3 6 A.- w RYCSCPXA-4477 3 RYDSCPXA-4477 3 ROZSCPX A^1177 3 ReZSCPXA.1'177 a 8 1 B2 -O Z 5Z. & pp m 3 I (f i pp m

~ pp m pp m "" " pp m Numlje r o

f Sample s • 

### B ^ D D 

## a 

# q " D D D D D Sample s Analyze d XR F Unit : /63 1 Book : /5 2

Date : /0-£)^-OS ~ Time : Staff : PAT ) 

### L A

.^^-t^'^-"l'»lfN'i ' I I ij^^'^' t • ^ 

# EUT E EE D 'i:!ir i 

# fi > 31 6 B l =38 1 PP M 3 " 

# H (S L

<a5'iA^:'^^''^.^'^ ' ^


## f; / 

# u F-' H 19 5 

## \ ^ 8 7 ±—-A.—^—^—)i c 

# :_w^^._- ^ MoMj^H T;^ ! Omah aLeadSit e 4613( 1 E

A = 7 6 PP M aSCIUP Et~l" ) CONTRA a # : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# «ERI V Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f remova l 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 dwithth 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 fiiture , excludin g an y remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Propert y ID : Propert y Address ; ;g^5- ; ^ ^^^^^ ^ 5^ ^ Owner : 

# S o oiy\ l

AIhta y Phone : 

## ^0^ ^ f.^ ^ Restoratio n Item s i n Question :

item : Item : Item : item : Item : item : Require d correction s t o complet e th e property :

Elagr e 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 )

(yiA^yyfyCy ^ / ^ A^ . y^LyLytyty^ — 

# m 

# h^ L J 6 Owner' s Signatur e Dat ePruden t Technologies , In c (l-'iudent )is under contrac t withth e U. S. Environmenta l Protectio n Agenc y (EPA ) to clea n up lencl
coijUminate dsoil s at anumbe rof propertie s locate d in Omaha , Nebraska , includin g th e property locate d at aiS l a l f^ 0/lf" Q P,,, , •^"TTh e EPA request s you r permissio nto allo w Pruden t to perlbr masoi l cleanu p at

thi s propert y to rerriov e lead-contaminaie dsoi l By signin g this form , th e property owne r grant s permissio n to Pru.len l to perfor m activitie s relate d lo th e cleanu p includin g soi l sampling , remova l of lead-contaminate dsoil , an drestoratio n of

he reference dpropeit y If

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 Prudent . • • •' . • .fo r th e Omah a Lea dSit e cleanup , at (402)733-1188 ; 733-1455 . General question s abou t th e Omah aLeadSil e cleanu p can b ; du-ecta 1 to the EP A Publi c Informatio n Center s af

(402 ) 731-304 5 (Sout hOmah aoffice) . Propert yAccess Grante d ByJ'o^M W f - [X^-gC ? /"^"g-V/| ^ (Pleas e PnnVSJame) / Propert y Owne r Signature>^. , CAfTi^Myy L ^ . , vlA(24AlAYyiA A jjl^ l '/ O / /

(Signature ) O Q^ y (Date l PROPERT YINFORMATIO N (T o be complete dbyresiden t and/o rpropert yowne r —pleas e print ) RESIDEN TNAiVlE ; jTc ? g| n ») ^ \X ) €.0 . Y" ^V] Owne rRente r RESIDEN TADDRESS :
IF RENTAL , PROPERT Y0\WNE D BY : OWNER' S MAILIN G ADDRESS ; 

# XS]" ^ l^pysrof: 5+
- OWNER' S TELEPHON E NUIWBE R - HOME : ^7 1 ) '73 7 -.$"^^ 3 WORK : AG E O \ \ f f )) YEA f HO W LON G HAV E YO U LIVE D HERE ? 7 3 YEARS . D

FF

HOME? : RS . 0 Y \ HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WIT H SIDIN G SINC E 1978 ? YE S /y ^ NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : 0 NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R 

### _JL _ NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y IN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. ) 'X^\CL^ . 

### oeUL L UxJ^nr.^. . gjl-a.r4- i •-^ AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS , Th e activitie s tobe implemente d by EP A .indei thi s agreemen t are pursuan tto Sectiorr 104 of

CERCLA , 42 U SC . 9604 . EPA' s righ t of

acces s to th e propertyis provide d tb

in Sectio n 104(e)o r CERCLA , 42 U.S . C 9605(e) , whic hprovide s entry for "detenninin g th e nee dfo r response , or choosin gor takin g any respons e actio n unde r thi s title , or otherwis e enforcin g th e provision s ofth e title. "

,-<ansa. s "ity . •'W C '-." 'E^VIROMiV1E^\TAL & 

# IRUDR N CONSTRLCTIO N 

### TECHNOLOGIES , INC . SERVrCE S 

# Propert y Statu s For m Address : SLSI5 - K|oAr<D<,= 5 7—Date : | (-Os^—^ O BVID :
I^J'A\yV^<A. ^ IA Y ^y>^it ^ 

# JS/ .

Prooer ^ Owne r Pruden t Emplo)re e Si^ure : /%-aynAiyL , £ . , \Xj.^yiyiyMyi AJ Signature : t^ay . Suit e 40 5 808 0 War d Park ' < 7 ^ ^ 560 0 S 1 0 S t 4^ 2 Medica l Drtve , £ Suit e 425 0 Kansa s City , 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)822-958 8 C^"
- I'i.itWB70.*<7 7

## 4477 3 Exterio rPab < 

### Nort hAm w Omah aLea dSH B Owne rNameri*09EP i I A CVOPeBA * 

### • Goo d Sit e Sketc h Address : 251 2 MONRO E S T 

# A • Poo r Phone : H ; w 

### B ^ pain t Sampl e Number Lea d 

### Stsnpi e LA B 

### C<riiecte d Concentratio n 

### CoBected Ftrm : RYASCPXA-4477 3 F 1 

# n DSHB C RYBSCPXA-4477 3 F 2 

# n Ttme : RYCSCPXA-4477 3 B 1 pp m 

# n Saniple s An^yzed RYDSCPXA4477 3 B 2 

# n RPZSCPX A <1<I77 3 D Z 

# D 

# n XR FUni t Id3 1 Book . /3 2 RGZSCnX A <I177 3 

## -e z 

# D 

# n Date : yg-T^V-i^S " RPZSCJ'XA-44y/' 8 -pg - 

# • Time : ^/» ? 

## i^/ 4 Number o

f Sam;ri« '

**^- ^ 

## SE P 1 5 208 5 

# b 3I & 

# .C L S.3. . 

# r

F. I 

# ^i f % 

# li s r z 0 .; . mL 

# m y/? • 

## A^oi^ffu^ t ;^ t Omah aLea dSit e 4613( 1

# 251 2 Monro e S t 40x13 0 

# A Printed : No v 04 , 201 0 www.dcgis.org/dogi s

## Pag e 1 of 2

" > Creat e Anotiie rTicl<e t Baci t t o irtl i Interne t Sen d Emai l



## • YOURTICKE T NUMBERI S 2634543 . Origina l Cal l Date : 11/04/1 0 Time : 10:0 8 a m Op : SIVA1896 7 Wor k t o Begi n Date : 11/08/1 0 Time : 10:4 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 251 2 Street : MONRO E S T Twp : 14 NRng : 13 E Sect-Qtr : 09-SE,10-S W 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 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 ATTNEBR l CXCAT V LEVEL S MUD0 2 OMAHACO F 0PPDGPR 6 PAETE C QLNNEI F SPRINTN E

Servic e Are a Contac t Phon e Numbe r Utilit y Typ e ATTNEBR l ATT/T 

### Day : 8002413624 9 Alt : Emerg : 8002413624 9 CXCAT V CO X COMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL 3 LEVEL S COMMUNICATIONS , LL C N A 

### Day : 877366834 4 Alt : Emerg : 877366834 4 MUD0 2 METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 

## http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 11/4/201 0

## Pag e 2 of 2

CIT Y O FOMAHA
- OMAHACO F RICH/TRAFFI C TRAFFIC.SEWE R
OMAH A PUBLI C POWE R 0PPDGPR 6 EL M LOCATIN G DISTRIC T
N O NEE D T O CAL LOU T PAETE C PAETE C COMMUNICATION S EMERGENC Y QLNN E I FQWES T LOCALNETWOR K EL M LOCATIN G



### SPRIN T COMMUNICATION S SPRINTNE C O Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 Day : 800289190 1 Alt : Emerg : 800289190 1 Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 Day : 800521057 9 Alt : 

## Emerg : 800521057 9

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 11/4/201 0

### ENVIRGNMENTAL ENGINEERIN GAN D CONSTRUCTIO N iBeMwoLOttiES , mc . 

### SOLUTION S 

## SIT E SAFfeT Y HAZAR D ANALYSI S 

# :i M 1 0 

## Address : Excavatio n Dat e Crew : 

# B.ckf,nD.te:-^:^itZ£ .

Ite m Overhea dLine s Ga s Lin e Wate r Lin e Sewe r Lin e Septic/Leec h Fiel d Propane/Butan e Sidewal k Foundatio n Retainin g Wall s Fence s Tree s Structure s Drivewa y Sprinkle r Syste m Othe r Cre w Forema n Conditio n ^ v ^ 

# gc-v j l^^y ^ '^\y^y~ry J



# hy/ ^ 

# r^ H ^e>e? r ^ic^^v^v


# rv M pHU/ ^ 

### f«>*«-v
1/^ ^ 

### po^?N r 

# A^ M Hazard s Correctiv e Actio n

Sit e Safet y Offic e Date : > ^ ^

808 0 WanHJaftasay . SuilE r40 6 

### seoosios t 424 2 Medica l Drive , Suit e 725 0 K»s»G«y;Ha6411 4 Omaha , Netaa^k a €810 7 Sa n Antonio , T X 7822 9 Phone : (8t6)36S'370 3 Ptntne : (403)733-118 8 Phone : (210)822^958 8 Fax : (St« ) 363-370 7 Fax : (402)733^188 3 Fax : (210 ) 579-657 7