TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID #: JH^^i j Date: lOJ\tl^\^ 

Address: 2(^ 3 /Vvf. S ^ / 

Remediation Contractor: PPf-^nPn-f 7»/'-f4Na6;>C|ift<4^/Ai(i.^ Year: ^-OlO^ 

SOILREMEDUTION 

PROPERTY FILE FOLDER DOCUMENTS 

E Video of propeity (DVD) 9f -g. /Po^4 ­

'H Executive Summary 

M EPA-provided property sketch 

5r Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adjacent property 

•M Restoration Agreement 

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

\S7 Confinnation data 

a Photographs _ . ' 

e ^ As-built sketch 

&/ Satisfiactory restoration signed by Property Owner 

B^ Property close-out check list signed by EPA 

D Description of areas not meeting ROD cleanup criteria 

S ^ Utility clearances 

53^ Property informationfirom Douglas County Assessor's Office 

D 

D 

m^ 

30262409 

liiinHHiiii 

Superfund 
PROPERTY SUMMARY 

Date: 10/15/2010 Oinaha Lead Site Remedial Action Contract # EP-R7-07-06 TO#l Month of: October 

Property Address; 2122 AMES AVE 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE 

A.2 Issues Resolved: NONE 

A.3 Unique Findings: NONE 

A.4 Other Relevant Infonnation: NONE 

CONFIRMATION SAMPLING DATA/RESULTS: 

B2 = 247 PPM @ 10"; DZ = 266 PPM @ 9"; NO EASEMENT 

CONTAMINATION LEFT BEHIND PER P.O. REQUEST: DZ/LS (5'X9') = 440 PPM @ SCRAPE 

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 (if any 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. 

TECHNOLOGIES. INC, 
Find Record 

Backfill: 

Sample Area: 34526 - 2122 AMES AV 

Owner: 

n Owner Occupied 

Owner Name: 

[POLSLEY GREGORY S 

Owner Addressl: 

I 

Owner Address2: 

(6996 COUNTY ROAD #32 

City: State: Zip Code: 

FORT CALHOUN [NE" 168023-

Owner Phone Alternate Phone: 

Contract: 

Contractor: |PRUDENT_2010_S 

Contract Option BASE 

Remediation Query j Lead Remaining Query I Property Damage Query 

User Provided Owner Information 

Owner Name: 

1 

Owner Address: 

i 

dty: 

1 

State:

1

 Zip Code: 

1 

Owner Phone: 

1 "

Alternate Phone: 

1 

Assessment: 

Qualifying Group 1400 

Assessment l^ax XRF Value P 439.21 

Resident: 

Resident Name: 

IKIMBROUGH KIRBY 

Property Address: 

I2122 AMES AV 

Zip Code: 

168110-

Resident Phone 
7j r TECHNOLOGIES, INC. 

.e 

EPA Property Close Out 

Property #:'^^^' ^ Property Address^ Z\' ^ f Y^ > '^ ^ ^ 

Date/Time: v^/^ Owner's Name: Gni'^fb'^'^ ^ 

Quads Excavated: 'O^ i ^ ^ Contractor Group: Prudent Technologies, Inc, 

Excavation General 

Yes No 

1. If necessary, were the correct quadiant(s) excavated and restored? y 

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

/ 

Grading Sod and Vegetation 

Yes No 

I. Does the grading around the perimeter of the house in excavated areas generally slope away / from the house? 

2. Has sod been laid in all areas that were excavated? y 

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

day time period) / 

4. Are sodded areas generally firm and evenly graded? / 

S. Are the joints between the sod sbips generally tight? (Only evaluate if inspected at a 30 day / time period) 

6. Was the property graded such that water will not pool on the propeity? y 

-7. Was damage to landscaping or plant materials avoided? 

/ 

Gates, Fences and Retaining Walls Yes No 

1. Do gates open andclose freely? (Ifapplicable) y 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) y 

3. Was damage lo gates or fences avoided? (Ifapplicable) / 

4. Was damage toretaining walls avoided? (Ifapplicable) / 

Foundation, Siding and Gutters 

Yes No 

I. Was damage to tlie siding or trim avoided? y 

2. Was damage to the foundation avoided? y 

3. Was damage to windows avoided? y 

4. . Was damage to windows or door screens avoided? 

3. Was damage lo downspouts or dowuspuul exieusions avoided? ^ 

Sidewalks and Driveways (Concrete) 

Yes No 

I. Was damage to driveway surfaces avoided? 

y 

2. Was damage to wallcway surfaces avoided? 

y 
Owners comments: 

Inspection notes: 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA Representative Ba*, &-, Date: fllzjiQ 
mM CHNOLOGIES. INC 

AS - BUILT DRAWING 

OLS # 34526 

Date Excavated: 08/05/2010 

I'SEPASigned-OITDate: OMAHA LEAD SUPERFUND SITE 

Name: k-rb v U..,<^ iV.-j'u^ Omaha Lead Site 

Address: 2172 A..^^ .'kt- Site Sketch 

Phone: </(4%'^'/^ 

Team %llir /l-l:.,.-...-^ UxCi.O BVID#_3i^£Z^ 

Sample Number Lead Concentration 

2,73 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm Lab RYCSCPLA-34526 ppm -Result 395 ppm 

'"" j [" \ I pg\i^\^i^ rtfe ^ 

Date: North Arrow \ 

Time: 

1 1 

XRF Code ^^^ ^ 

Conflmwtion Sample(g/- <:!p^ 

•^lYe jiYes C3 ^^ No O O-'

(jiYes a No cr 

v*Yes Cl No O -

Yes 1^ No CD 

Yes n No D 

Yes a No CD 

Yes a No • 

/CP'-6l/ (S ) 

> ' i 

,-1. J..„. 

CONTAMINATION LEFT BEHIND PER 

P.O. REQUEST; DZ/LS (5'X9') = 440 

PPM (A SCRAPE Fi 

'! * 

NO EASEMENT j" " ^^j;;::" ^ ^^^ . 

^.U H ^r 9-^ 

Omaha Lead Site 46130 

CONTRACT #: EP-S7-10-05 PRUDENT TECHNOLOGIES, INC. 
EPA 

Property Completion Agreement 

This agreement documents the completion of removal activities performed on the below listed property. 

The property owner's signature indicates that the property owner is satisfied with the restoration of the 

subject property, and that no items are in question, now, or at any time in the future, excluding any 

remaining warranty (30, days total) except those items Usted below, ifany. 

Property ID: 

Property Addniss: ^ { ^ ^ ^ ­ ^ ^^/: ^ 

O^er; \^ ^ jL{?,^ r^^/rcL^r ^ 

Phone 

Restoration Items in Question: 

Item: 

Hem: 

Item: 

Item: 

Hem: 

Item: 

Required corrections to complete the property: 

agree restoration is completed. 

L J I do not agree restoration is completed at (noted deficiencies above) 

\^^^ : D.AAI; lo^ 

)wner's Signature Date 
iicffsfti^rn'MT 

Prudent Technologies, Inc. (Prudent) is under contract with the U. S. Environmental Protection Agency (EPA) to cleanup leadcontaminated soils at a number of properties located in Omaha, Nebraska, including the property located at 

*• 12 ^ fw\.tJk ftiie^ • The EPA requests your pennission to allow Prudent to perform a soil cleanup at this 

property to remove lead-contaminated soil. By signing this form, tlie 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. 

Ifyou have any questions about the soil cleanup planned for your property, please contact Prudent South Omaha Office for the Omaha 

Lead Site cleanup,.at (402) 733-1188; 733-1455. General questions about the Omaha Lead Site cleanup can be directed to the EPA 

Public Infonnation Centers at (402) 731 -3045 (South Omaha office). 

Property Access Granted By: C^TH <~ ^ OK2 L^ ? ^ ^ H 

^ (Please Print Name) 

Pioperty Owner Signature: -^pj ^ P<y-g<»^A ^ "T) H | X^ I *-' 

/ i I (Sig0»uie) (Date) 

PROPERTY INFORMATION 

(TToo bbe cocmplete nd by resident and/or property owner — please print) 

RESIDENT NAME: \flK^ii>\ ^ Owner Renter 

RESIDENT ADDRESS: 

9^\^i ^m£.£ ^£1 c3Tv\a-V^ Li^E CgU O 

IF RENTAL, PROPERTY OWNED BY: 

GOWNER' HVNER'SS MAILIN MAILINGG ADDRESS ADDRESS:; y-\tl, i . ,.f- A 19., n erj

OWNER'S TELEPHONE NUMBER - HOME: ( ) WORK: 

AGE OF HOME?: \>(P\7 YEARS. HOW LONG HAVE YOU LIVED HERE? YEARS. 

HAS THE EXTERIOR BEEN PAINTED OR COVERED WITH SIDING SINCE 1978? _YES NO 

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 ENVIRONMEIMTAL RESPONSE ACTIONS; The activities to be implemented by EPA under this agreement 

are pursuant to Section 104 of CERCLA, 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 960S(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'" Street 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68107 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)733-1455 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)733-1883 Fax: (210) 579-6577 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: ^ \ A^. /Wv>e^ AVA-C Date: *^| H I ^ ^ 

Phone: BVID: H0Z ~ ^-7g - \\7^V 

^^B^v/oQ. p^np^ B7_ j h-Z-, 

g 7 Ma pla.H(rt 

AJ-D /^^JL £PAp f 

.JL2 - ^J^iki PUA..UJ- k>r^ L ft-^J o r fup-t: 

Tk ^ ^>Jol&Kv^^ Q>-(X\vA^y "5 

loA^ ^ Lvxgi? g<J- I^»vC- ^ruA.gJU>aA.. 

BG*a'ft>oog^L^J?-v 

^ vVk j • 

Property-Owner Prudent Employee 

Signature : . Alp e p oJLU^ Signature: ^ L^^QULA-^S-u 

8080 Ward Parkwav. Suite 40S 2505 N. 24*^ Street. Suite 308 4242 Medical Drive. Suite 4250 
Name; ]Lirh y l^.iA'W.aJ^U Omaha Lead Site Date; U-Z/'CJ- } North Arrow —1 

* Address; VlA ^ .5^^ ' Site Sketch Time; (^0 '] 

Phone; T 

Team ^id r /iJ,,^^ ^ (U^JCIKS) BVID# 3^'^Z6 ' XRF Code j ^ 5'' ^ • / 

Sample Number 

Lab RYCSCPLA-34526 

•Result 395 ppm 

t

Lead Concentration 

^7 3 

J ^ 

./^/ i: ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

ppm 

 peTy^S "^yC^ " 

Confirmation Sample( ^ 

7,1 Yes Q ^ 

(i^Yes a 

o2Yes n 

Yes n 

Yes n 

Yes • 

Yes • 

No C K 

No Q ^ 

No O ^ 

No 1^ 

No n 

No Q 

No • 

./£gZg.. )r 

• cA 

.i .ii. U7i5 

fci 

4^^ 7 

> • 

- 1

Ot 

y -

\ i V 

P2ir;/4/^ 

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^^0 H c^r ? 'T. 

46130 
Page 1 of 1 

SEPTEMBER 2008 -DOUGLAS COUNTY ASSESSOi 

2.IZZ Amis A/. 

http://douglasne.mapping-online.com/assessdoc/Photos/03/R0201960000000Ljpg 6/11/2010 
Print Preview Page 1 of2 

( ) y ) 

Douglas County-Omaha, NE 

Parcel ID 

Owner 

Name 

Property 

Address 

City 

Zip 

Owner 

Address 

Owner 

Address 

Owner 

City 

Owner 

State 

Owner 

Zip 

Sec-TwnRng 

0201960000 

POLSLEY 

GREGORY S 

2122 AMES 

AV 

OIVIAHA 

68110 

6996 

COUNTY 

ROAD #32 

FORT 

CALHOUN 

NE 

68023 

Addition 

Block 

Lot 

Legal 1 

Legal 2 

Legal 3 

Legal 4 

Acres 

Treasurer 

Website 

Link 

Assessor 

Website 

Link 

LANDS 

W31 E66S110FTTAXLT17 

31X110 

0.08 

http;//webapps.dotcomm.org;8080/TreasTax/faces/pages/taxinfo.jsp? 

parc=0201960000 

http;//douglasne.mappingonline.com/DouglasCoNe/static/accountinfo.jsp? 

accountno=R0201960000 

http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Douglas County-... 6/10/2010 

2 
Ticket Text and Map display for Ticket: # 2555565 Page 1 of2 

Original Call Date: 

Work to Begin Date: 

7/29/10 

8/02/10 

Time:

Time:

 8:16 am 

 8:45 am 

Op: 

, 

SIVA18967 

State: NE 

Address: 2122 

County: 

Street: 

DOUGLAS 

AMES AVE 

Place: OMAHA 

Twp: 15N Rng: 13E •Sect-Qtr:. 03-NW-SW 


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

Involves Tunneling or Horizontal Boring : N

 Front: Y

 Explosives: N 

 Rear; 

GXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area Contact Phone Number 

utility 

Type 

CXCATV COX COMMUNICATIONS, INC HEIDI 

Day:

Alt:

 4029340469 

 4029340469 

Emerg: 4029329757 

MUDOl METROPOLITAN UTILITIES 

DISTRICT SANDY 

Day: 4025047823 

Alt: 

Emerg: 4025047970 

OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RICH/TRAFFIC

Day: 4024447197 

 Alt: 402444516 1 

Emerg: 4024445160 

0PPDGPR5 OMAHA PUBLIC POWER DISTRICT ELM 

LOCATING 

Day: 4067289343 

Alt: 4062071494 

Emerg: 8887289343 

QLNNEl C QWEST LOCAL NETWORK ELM 

LOCATING 

Day:

Alt:

 4067289343 

 4062071494 

http://www.dhon.org/irthintemet/MessageText/MessageTextAndMap.asp?NoticeID=DH... 10/19/2010 
Ticket Text and Map display for Ticket: # 2555565 Page 2 of2 

Emerg: 8887289343 

View Map Close Map 

http://www.dhon.org/irthintemet/MessageText/MessageTextAndMap.asp?NoticeID=DH... 10/19/2010 
ENVIRONMENTAL 

ENGINEERING AND 

CONSTRUCTION lECHNOLOaiES, INC. 

SOLUTIONS 

SITE SAFETY HAZARD ANALYSIS 

Address: 

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 

Condition 

Qh^J 

Q>n&X 

C^ (W 

"A/M 

HIk 

Nik 

r 1 

f^ao<7 

H /(i 

N/A 

(honJ 

(be?&-/ 

(hrrirl 

f\l A 

A,^,/ ),7^ 

Excavation Date: 

Backfill Date: — 

Hazards Corrective Action 

Site Safety Office 

Date: 

S600S108t 4242 Medical Drive, Suite-7250 

) Ctty. MO 64114 Omaha, Nebiaifca 68107 San Antonio, TX 78229 

PtKMw: (816) 36^3703 

Fax:(816)863-3707 

Phone: (402)733-1188 

Fax: (402)733-1883 

Plione: (210)822-9888 

Fax: (210)-«79-6577 
i 

/\(r\tS St 

1/\rf\t

L ­

1 

1