### TRANSiVIITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 

### 2937 6 DATE : 12/15/201 0 ADDRESS : 261 6 N 1 9 A V REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . IN C YEAR : 

### 201 0 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S [Z

fPR E AN D POSTVIDE O O F PORPERT Y(DVD ) a EXECUTIV E SUMMAR Y S ( EPA-PROVIDE D PROPERT YSKETC H SIGNE D ACCES S AGREEMEN TFO R SUBJECTPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FO R ADJACEN TPROPERT Y 0 RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENT S (I.E. , FO R DAMAG E O R T O REPLAC E PLANTS , ETC. ) 0 CONFIRMATIO N DATA ffl PHOTOGRAPH S AS-BUIL TSKETC H a SATISFACTORYRESTORATIO N SIGNE D B YPROPERT YOWNE R 0 PROPERT YCLOSE-OU TCHEC KLISTSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A a UTILITYCLEARANCE S

• PROPERT YINFORMATIO N FRO M DOUGLA S COUNTYASSESSOR' S OFFIC E 

## D D D ^ ^ 

### <\V' ^ 

## >V ' SIGNATUR E DAT E 3026075 4 Superfun dFin d Record Remediatio n Quer yi Lea d Remainin g Quer y Propert yDamag e Quer y 

# i J Backfill :

Sampi e Area : 2937 6 - 261 6 N 1 9 A V Owner : n Owne rOccupie d Owne rName : JAC E WELDIN G AND^PM l INC^ Owne rAddressi : 

# 1 ^ ' Owne rAddress2 : |261 1 FLORENC E BLV D ^ City : State : Zi p Code : [OMAH A " JN E J68110 - Owne rPhon e Alternat e Phone :

Contract : Contractor : jPRUDENTTOlO " Contrac t Optio n JOPTIO N 2 Use rProvide d Owne rInforniatio n Owne rName : 

### 1 • " Owne rAddress : City : State : ZipCode : 

# 1 j Owne rPhone : Alternat e Phone : ' Assessment : Qualifyin g Grou p 40 0 Assessmen t Ma xXR F Valu e f 48 0 Resident : Residen t Name : 

# I Propert yAddress : 1261 6 N 1 9 A V Zi p Code : J68110 - Residen t Phon e

### PROPERT Y SUMMAR Y Date : 12/15/201 0 Omah aLea dSit e Remedia l Actioi i Contrac t #EP-R7-07-0 6 TO# l Mont hof : Decembe r Propert y Address : 2616N19A V 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 : B 2 = 33 3 PP M @ 6" ; E A = 27 9 PP M @ SCRAP E(~1" ) 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-Bui hsketch 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 din th e individual property file , i f available , o r obtaine dinclude : 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 n digita l vide o in MPEG , WM V (Window s Medi aVideo ) o r SWF(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio n ofarea s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES . INC .TECHNOLOGIKS , INC . 

# EP A Propert y Clos e Ou t Propert y # : 'L°<1>7( D 

### Propert y Address : "2^^' ^ " ^ l^^^vtf , Date/Time : Owner'sName : "S^iwvPr-'Jt- ^ Quad s Excavated : \/L — Contracto r Group : Pruden t Technologies , Inc. , Excavatio nGenera l Ye s N o 1 .I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 

## y 2 .If necessary , wer e th e correc t area s o f dri p zon e e.\cavate dan drestored ? y Gradin g So dan dVegetatio n Ye s N o 1 .Doe s th e gradin g aroun dth e perimete r o f th e hous e i nexcavate darea s generall y slop e away fromth e house ? y 2 .Ha s so dbee nlai di nal l area s tha t wer e excavated ? 

## y 3 .

Doe s th e so dappea 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 . Are sodde darea s generall y firn i an devenl y graded ? 

# y 5 , Ar c di e joint s betwee ndi e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 day ^ tim e period ) 6 .Wa s th e property grade dsuc hdiat wate r wil l no t poo l o nth e property ? 

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

## y Gates , Fence s ao dRetainin g WalS s Yeg N o 1 .D o gate s ope nan dclos e freely ? (If applicable ) 

## y y 2 .Wer e al ! gate s o r fence s lalcendow ndurin g restoratio nactivitie s reinstalled ? (If applicable ) 3 .

Wa s damag e t o gate s o r fence s avoided ? (If applicable ) 

### y 4 . Wasdamag e t o retainin g wall s avoided ? (If applicable ) 

## y Foundation , Sidin g an dGutter s Ye s N o 1 .Wa s damag e t o di e sidin g o r tri mavoided ? 

# y 2Wa s damag e t o th e foundatio navoided ? 

### y 3 .

Wa s damag e t o window s avoided ? 

### y

. ^ 4 .Wa s damag e t o window s o r doo r screen s avoided ? 5 ,

Wa s damag e l o downspout s o r downspou t extension s avoided ? y Sidewalk. s an dDriveway s (Concrete ) Ye s N o 1 Wa s damag e t o drivewa y surface s avoided ? y

. Jf.. . • 2 .Wa s damag e t o walkwa y surface s avoided ?

## Owner s comments :

Inspectio nnotes :

Remova l an drestoratio nactivate s complete includin g th e 30-da y so dwarranty . EP A Representativ e ^' ^ "^ ^Date: iiff/' o:CHNOLOGIES , INC . 

## A S - BUIL T DRAWIN G OL S #2937 6 Dat e Excavated : 10/28/201 0 

## OMAHA LEA D SUPERFUND SIT E I'SEP ASigncd-Of TDate : 

# liiiii i 2937 6 Exterio rPaint Nort h Am w SanqMn g AddiOT K^16NJ9AV ^ Sit e Sketc h • Goo d Omah a Lea d Sit e

• Poo r ALT: Q'No t paint Lea d Sampl e Sample s Collecte d Sampl e Numtw r LA B Concentratio n Collecte d Firm : l\ir l Nf/I f RYASCPXA-2937 6 F 1 

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### D Date : ^•ll-Q l RPZSCPX A3037 6 P2 - — pp m 

### D 

### D Time : 

# M . Staff : Numbe ro f Sample s = W 

# n^ w Legend : F l = Fron t Left , F2 = Fron t Right , B l = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Play A O quadrant s ar e a

s vievte d tro m th e stieet , facing propeit y 

# ENTER ED

CONTRA a # : EP-S7-10-0 5 PRUDENTTECHNOLOGIES , INC .

# SEPA Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f removal activitie s performe don th e belo w liste dproperty . Th e property owner' s signatur e indicate s that th e property owne r i s satisfie dwit hth e restoratio n ofth e subjec t property , an dtha t n o item s are i nquestion , now , or at any tim e i n th e future , excludin g any remaining warranty (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Property ID : Propert yAddress : 

# M U M ­ ^^H \.gwp ^ Owner : A 

# l i y^^ v 

# pii^\^e ^ Phone : Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item : Reqiiire d correction s t o complet e th e property :

L J I agre e restoratio n i s completed . I I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above ) 

# \v\o--\ o (Jvwier^ Signatur e Dat e IPnidai t Techiwlogies , Inc . (Prud^nL) i s un.der.'ConIract . withtii e U.S . Environmenta l Proiectio nAgenc y (EPA ) t o clea nu p lead contamiiiated'soils.a t anunibe r o f

propertie s locaie dinOniaha , Nebraska , includin g th e propert y located.a t ' ' . . ! Tli e EP A request s you r permissio n t o allo w Pruden t t o performasoi l cleanu p atthi s property t o remov e lead-contaminate dsoil : B y signin g thi s fonn,.th e property owne r grant s pennissio'n.t o Pruden t t o perform activitie s relate dt o th e cleanu p includin g soi l sarnpling , remova l o f lead-cohtaminate dsoil, - an drestoratio nofth e reference dproperty . Ifyo u hav e aii y question s aboutth e soi l cleanup , planne dfor you r propeity , pleas e contac t Pruden i southoffic e for th e Orhah aLea d Site cleaiaip7a t (402 ) 733-1188:..Genera l question s abou t th e Ornaha.Lea dSit e cleanup.ca n b e directe dt o th e EP A Publi c Informatio n Center s a t (402 ) 7 3 U304 5 (SouthOiiuli aoffice).o r (402/^5T^58 3 (]>Jort hOniah aoffice) . Property - Acceis s Grante dB y Property Ownva ' Signature ; y / . (Date ) PROPERT Y INFPRMATIO N , (T o b e complete db y residen t and/o r propert c owne r —pleas e print ) RESipEN TNAME : V j XX^CJ^X^—rJ': ^ \

O l ^ Owne r Rente r RESIDEN TADDRESS : I F RENTAL , PROPERT YOWNE D B ^ 

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# ..^p ^ J L ^ OWNER' S MAILIN G ADDRESS ; ' 

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# ^ f^ ^ kVyi- ^ OWNER' S TELEPHON E NUMBE R - HOME : ( ) WORK : AG E O F HOME? : YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WPr H SIDIN G SINC E 1978 ? YE S N O NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBERO F OCCUPANT S 7 YEAR S OL D AN D OLDE R 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 WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES . ETC. )

AirrHORIT Y FOR.EMVIRONMENTA LRESPONS EACTIONS : Th e aaivitie s t o b e implemente db y EP A unde r this.agreemerrt are pureuan t t o Sectio n10 4 o f CERCLA , 4 2 U.S.C : 9604 . EPA!sriglito f acces s t o di e propert y i s provided , for.i nSectio n 104(e ) o f CERCLA , 4 2 UvS . C 9605(e) . whic hprovide s entry fo r "determinin g th e nee dfor response , or choosin g or talkin g an y respons e actio n • imderthisUtle,.o r otherwis e emfprcing th e provisio'n s ofth e title.- " - ' 808 0 War d Parkway , Suit e 40 5 •560 0 S 1 0 S t 424 2 MedicalOrive , Suit e 42S 0 Karisa s City , 'M O 6411 4 Omaha . Tvebrask a 6210 7 Sa n Antonio , TX 7822 9

. Phone : (81S ) 363-370 3 -Phone : ;402 ) 733-118 8 Phone : (210 ) 822-958 8

Fax : (815 ) 363-370 7 , Fat ! (402 5 733-188 3 .Fax : «210 ) 579.657 7ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^^\^ 

## 1 0 \qH ^ A^L ^

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808 0 War d Pa i 560 0 SI O S t 424 2 Medica l Drive , Suit e 425 0 Kansa s City . M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio.T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7

# 2937 6 Omah a Lea d Sit e Exterio rPain t Nort h Arro w SampUn g Address : 2616N19A V 

## Sit e Sketc h Q Goo d [[ ] Poo r Phone : H^ ALT : Q ' No t pain t Sampl e Numbe r Lea d Sampl e Sampie s Coiiecte d U B Concentratior t Collecte d Firm : As W i^fll f RYASCPXA-2937 6 F l 

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## D Date : 0-7- 2 7-zo o • » RYBSCPXA-2937 6 F2 

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## D Time : "^'-O o P' A RYCSCPXA-2937 6 B l 

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### YOURTICKE T NUMBERI S 2622430 . Origina l Cal l Date : 10/20/1 0 Time : 5:2 6 pm Op : SIVA1896 7 Wor k t o Begi n Date : 10/22/1 0 Time : 6:0 0 pm State : N E County : DOUGLA S Place : OMAH A Address : 2 61 6 Street : N19T H AV E Twp : 15 NRng : 13 E Sect-Qtr : 10-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lead 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: PRUDENT TECHNOLOGIE S Contac t Name : SIV AJAMPAM A Phone : (402)733-118 8 Wor k Bein g Don e For : EPA Dept h o f Excavation : 6 F T Corne r Lot : NFront : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V

MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA NUTILITIE S DISTRIC T SANDY 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y OFOMAHA-TRAFFICSEWERRICH/TRAFFIC 

### Day : 402444719 7 Alt : 402444516 1 

### Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLIC POWE RDISTRICT EL M LOCATING 

### Day : 406728934 3 Alt : 406207149 4 

### Emerg : 888728934 3 QLNNEI C QWES T LOCA LNETWOR K EL M LOCATING 

### Day : 406728934 3 Alt : 406207149 4 

### Emerg : 888728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT. . . 10/20/201 0

### CONSTRUCTIO N SOLUTION S 

## SIT ESAFET Y HAZAR D ANALYSI S Address : f^^l AH I I (^ ^ Excavatio nDate : 'Q/^^^' ^ 

## Crew : BackfiU Date : l o 12-^ 1 ( 9

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