### TRANSMITTA L o f OMAH A LEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R 

# SAI D #: JH^^i j Date : lOJ\tl^\ ^ Address : 2(^ 3 /Vvf. S ^ / Remediatio n Contractor : PPf-^nPn- f 7»/'-f4Na6;>C|ift<4^/Ai(i. ^ Year : ^-OlO ^ SOILREMEDUTIO N PROPERT Y FIL E FOLDE RDOCUMENT S E Vide o of propeit y (DVD ) 9 f -g . /Po^4 ­ 'H Executiv e Summar y M EPA-provide dpropert y sketch 5 r

SignedAcces s Agreemen t fo r

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

adjacen t propert y • M Restoratio n Agreemen t 0 Settlemen t document s (i.e. , fo r

damag e o r

to replac e plants , etc. ) \S

7 Confinnatio n data aPhotograph s _ . ' e ^ As-built sketc h & / Satisfiactor y restoratio n signedb y Propert y Owne r B ^ Propert y close-out check lis t signedby EP A D Descriptio n o f area s no t meeting RO D cleanu p criteri a S ^ Utilit y clearance s 53 ^ Propert y information firomDougla s Count y Assessor' s Office D D 

# m ^
3026240 9 

# liiinHHiii i Superfun d

### PROPERT Y SUMMAR Y Date : 10/15/201 0 Oinah aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont h of : Octobe r Propert y Address ; 212 2 AME S AV E 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 Infonnation : NON E CONFIRMATIO N SAMPLIN G DATA/RESULTS : B 2 = 247 PP M @ 10" ; D Z = 26 6 PP M @ 9" ; N O EASEMENT CONTAMINATIO N LEF T BEHIND PE RP.O . REQUEST : DZ/L S (5'X9' ) = 44 0 PP M @ SCRAPE

ATTACHMENT S 1 ) Propert y sketch providedb y EP A pursuan t t o contract specification s 2 ) Signe dAcces s Agreemen t including acces s agreement s requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l video clip/photograph s 4 ) Post-Excavation digita l vide o clip/photograph s 5 ) Documentation - CompletedClose-out Checklis t 6 ) As-Buil t sketc h ­ i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contamination lef t behin darea s vi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r items to b e includedi n th e individua l propert y file , i f available , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (i f an y ar e mad e wit h th e propert y owner ) ii ) Propert y Statu s For msignedb y propert y owne r iii ) Excavation digita l vide o i n MPEG , WM V (Window s Medi aVideo ) or SW F(Flash Player ) forma t and/or photograph s iv ) Signedfor mverifying satisfactor y restoration v ) Description o f area s not meeting Interi mRO D cleanu p criteria .

TECHNOLOGIES . INC ,Fin d Record Backfill :

Sampl e Area : 3452 6 - 212 2 AME S A V Owner : n Owne rOccupie d Owne rName : [POLSLE Y GREGOR Y S Owne rAddressl : 

# I Owne rAddress2 : (699 6 COUNT Y ROA D #3 2 City : State : Zi p Code : FOR T CALHOU N [NE " 168023 - Owne rPhon e Alternat e Phone :

Contract : Contractor : |PRUDENT_2010_S Contrac t Optio n BAS E 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 : 

# i dty : 

# 1 State : 

# 1 Zi p Code : 

# 1 Owne rPhone : 

# 1 " Alternat e Phone : 

# 1

Assessment : Qualifyin g Grou p 1400 Assessmen t l^axXR F Valu e P 439.2 1 Resident : Residen t Name : IKIMBROUG H KIRB Y Propert yAddress : I212 2 AME S A V Zi p Code : 168110 - Residen t Phon e7jr TECHNOLOGIES , INC . . e 

# EP A Propert y Clos e Ou t Propert y #:'^^^' ^ Propert y Address ^ Z\' ^ f Y^ > '^ ^ ^ Date/Time : v^/ ^ Owner' s Name : Gni'^fb'^'^ ^ Quad s Excavated : 'O^ i ^ ^ Contracto r Group : Pruden t Technologies , Inc , Excavatio n Genera l Ye s N o 1 .

I f necessary , wer e th e correc t quadiant(s ) excavate dan drestored ? 

## y 2 . I f necessary , were th e correc t area s o f dri p zone excavate dan drestored ? / Gradin g Sodan dVegetatio n Ye s N o I .Doe s th e gradin g aroun dth e perimete r of th e hous e i n excavate darea s generally slop e awa y / fro mth e house ? 2 .

Ha s so dbeen lai di n al l area s tha t wer e excavated ? 

# y 3 .

Doe s th e so dappea r to b e generally health y an dgrowing ? (Onl y evaluate if inspecte da t a3 0 da

y time period ) / 4 .Ar e sodde darea s generally fir man devenl y graded ? / S .Ar e th e joint s between th e sodsbip s generally tight ? (Only evaluate i f inspecte da t a3 0 da y / time period ) 6 .

Was th e propert y grade dsuch tha t wate r will no t poo l o n th e propeity ? 

# y -7 . Was damag e t o landscapin g or plan t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s N o 1 .

D o gate s open andclos e freely? (Ifapplicable ) 

# y 2 .

Wer e al l gate s or fence s take n down durin g restoratio n activitie s reinstalled ? (I f applicable ) 

# y 3 .

Was damag e l o gate s o r fence s avoided ? (Ifapplicable ) / 4 .

Was damag e to retaining wall s avoided ? (Ifapplicable ) / Foundation , Sidin g an dGutter s Ye s N o I .Was damag e to tli e sidin g or tri mavoided ? 

### y 2 .Was damag e t o th e foundatio n avoided ? 

# y 3 .

Was damag e to window s avoided ? 

# y 4 .. Wa s damag e t o window s o r door screen s avoided ? 3 .

Was damag e l o downspout s or dowuspuul exieusion s avoided ? ^ Sidewalk s an dDriveway s (Concrete ) Ye s N o I . Was damag e to drivewa y surface s avoided ? 

### y 2 . Wa s damag e t o wallcwa y surface s avoided ? 

# y

### Owner s comments :

Inspectio n notes :

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e Ba* , &- , Date : fllzji Q

# mM CHNOLOGIES . INC 

### AS - BUIL T DRAWIN G OL S #3452 6 Dat e Excavated : 08/05/201 0 I'SEPASigned-OITDate : 

### OMAHA LEAD SUPERFUND SIT E

Name : k-rbvU..,< ^ iV.-j'u ^ Omah a Lea d Sit e Address : 217 2 A..^ ^ .'kt - Sit e Sketc h Phone : </(4%'^'/ ^ Tea m %lli r /l-l:.,.-...-^ UxCi. O BVID#_3i^£Z ^ Sampl e Numbe r Lea d Concentratio n 2,7 3 pp m pp m pp m pp m pp m pp m La

b RYCSCPLA-3452 6 pp m -Resul t 39 5 pp m 

## '" " j [" \I pg\i^\^i ^ rtfe ^ Date : Nort h Arro w \ Time : 1 1 XR F Cod e ^^^ ^ Conflmwtio n Sample(g/ - <:!p ^ •^lYe s jiYe C3 ^ ^ O- ' N o O (jiYe s a No cr v*Ye s Cl No O -

Ye s 1^ No CD Ye s n No D Ye s a No CD Ye s a No •



## /CP'-6l / (S ) > ' i ,-1 . J..„ .

CONTAMINATIO N LEF T BEHIN D PE R P.O . REQUEST ; DZ/L S (5'X9' ) = 44 0 PP M (A SCRAP E 

# Fi '! *

NO EASEMEN T j" " ^^j;;::" ^ ^^^ .



### ^. U H ^r9- ^ OmahaLea dSit e 4613 0 CONTRAC T #: EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# EP A Propert yCompletio n Agreemen t Thi s agreement document s th e completio n o f remova l activitie s performe do n th e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e propert y owne r i s satisfie dwith th 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 a t an y tim e i n th e future , excludin g an y remainin g warrant y (30 , day s total ) excep t thos e item s Uste dbelow , ifany . Propert y ID : Propert y Addniss : ^ { ^ ^ ^ ­ ^ ^^/: ^ O^er ; \^ ^

jL{?, ^ r^^/rcL^r ^ Phon e Restoratio n Item s i n Question :

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

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 )



# \^^^ : D.AAI ; lo ^ )wner' s Signatur e Date

# iicffsfti^rn'M T Pruden t Technologies , Inc . (Prudent )is under contrac t withth e U. S. Environmental Protectio n Agenc y (EPA ) to cleanu p lead
contaminate dsoil s at anumbe r of

propertie s locate d in Omaha , Nebraska , includin g th e property locate d at *• 12 ^ fw\.tJ k ftiie^ • Th e EPA request s you r pennissio n to allo w Pruden t to perfor masoi l cleanu pat thi s property to remov e lead-contaminate dsoil . By signin g thi s form, tli e property owne r grant s permissio n to Prudentto perfor m activitie s relate d to th e cleanu p includin g soi l sampling , removalof lead-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 dfo r you r property , pleas e contac t Prudent Sout hOmah aOffic e fo r th e Omah a LeadSit e cleanup,.at (402 ) 733-1188 ; 733-1455 . General question s abou t th e Omah aLea dSit e cleanu p can be directe dto th e EP A Publi c Infonnatio n Center s at (402 ) 73 1 -304 5 (Sout hOmah aoffice) . Property Acces s Grante dBy : C^T H <~ ^ OK 2 L^ ? ^ ^ H ^ (Pleas e Prin t Name ) Piopert y Owne r Signature : -^pj ^ P<y-g<»^A ^ "T) H | X^ I *- ' / i I (Sig0»uie ) (Date ) PROPERT Y INFORMATIO N T co n (T oo b b e cmplete d byresiden t and/o rpropert yowne r—pleas e print ) RESIDEN T NAME : \flK^ii>\ ^ Owne r Rente r RESIDEN T ADDRESS : 

## 9^\^ i ^m£. £^£ 1 c3Tv\a-V ^ Li^ E Cg U O IF RENTAL , PROPERT Y OWNE D BY : 

# GOWNER' ; . - 19. , n er j HVNER' S S

MAILIN MAILIN G G ADDRESS

ADDRESS : y-\tl, i ,.f A OWNER' S TELEPHON E NUMBE R - HOME : ( ) WORK : AG E OF HOME? : \>(P\ 7 YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WIT H SIDIN G SINC E 1978 ? _YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R 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 Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMEIMTA LRESPONS E ACTIONS ; Th e activitie s to be implemente d by EP A unde r thi s agreemen t ar e pursuan tto Sectio n 10 4 of CERCLA , 42 U.S.C . 9604 . EPA' s righ t of

acces s to th e propertyis provide dfo r in Sectio n 104(e ) of CERCLA , 42 U.S . C 960S(e) , whic hprovide s entry for "determinin g th e nee dfo r response , or choosin g or takin g any response actio n unde r thi s title , or otherwis e enforcin g th e provision s ofth e title. "

808 0 War d Parkway , Suit e 40 5 560 0 S. 10' " Stree t 424 2 Medica l Drive , Suit e 425 0 Kansa s City , MO 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-145 5 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7ENVIRONMENTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^\A^ . /Wv>e ^ AVA- C 

### Date : *^| H I ^ ^ Phone : BVID : H0Z ~ ^-7g - \\7^ V ^^B^v/oQ . p^np ^ B7_ j h-Z- , 

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808 0 War d Parkwav . Suit e 40 S 250 5 N . 24* ^ Street . Suit e 30 8 424 2 Medica l Drive . Suit e 425 0Name ; ]Lirhyl^.iA'W.aJ^ U Omah a Lea d Sit e Date ; U-Z/'CJ- } Nort h Arro w —1 * Address ; VlA ^ .5^^ ' Sit e Sketc h Time ; (^ 0 ' ] Phone ; 

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SEPTEMBE R 200 8 -DOUGLA S COUNT Y ASSESSO i 

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### Ticke t Tex t andMa p displa y fo r

Ticket : #255556 5 Pag e 1 of 2 

### Origina l Cal l Date : Wor k t o Begi n Date : 7/29/1 0 8/02/1 0 Time : Time : 8:1 6 a m 8:4 5 a m Op :

, 

### SIVA1896 7 State : N E Address : 212 2 County : Street : DOUGLA S AME S AV E Place : OMAH A Twp : 15 NRng : 13 E •Sect-Qtr: . 03-NW-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : SOI L LEA D REMEDIATIO NPROJEC 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 Being Don e For : EPA Dept h o f Excavation : 6 F T Corne r Lot : N Involve s Tunnelin g o r Horizonta l Borin g : NFront : Y Explosives : N Rear ; GXCAT V

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### Day : 402444719 7

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### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNE l C QWES T LOCA L NETWOR K EL M LOCATIN G 

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## Emerg : 888728934 3

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### ENVIRONMENTAL ENGINEERIN G AN D CONSTRUCTIO N lECHNOLOaiES , INC . 

### SOLUTION S 

## SIT E SAFET Y HAZAR D ANALYSI S Address : Crew: -

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 

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Hazard s Correctiv e Actio n

Sit e Safet y Offic e Date :

S600S108 t 424 2 Medica l Drive , Suite-725 0 ) Ctty . M O 6411 4 Omaha , Nebiaifc a 6810 7 Sa n Antonio , T X 7822 9 PtKMw : (816 ) 36^370 3 Fax:(816)863-370 7 Phone : (402)733-118 8 Fax : (402)733-188 3 Plione : (210)822-988 8 Fax : (210)-«79-657 7

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