## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FDL E FOLDE R SAID * /^4'n3S l Date : 11-15-1 0 Adtoss : I m l M .5 5 ^ Remediatio n Contractor : Pi?, , r>PrM" 7 7^/^4 1 NOtLoc , l< ^ q. ^ ir\ic.> i Year : SOI LREMEDIATIO N PROPERT Y FIL E FOLDE RDOCUMENT S H

^ Vide o o f propert y (DVD ) 3023751 4 ^ I2

r EKecuUveS.. ^

EPA-provide dpropert y sketch 11111 Superfun d 

### 1
/ 

### Signe dAcces s Agreemen t fo r

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

adjaipen t propert y B Restoratio n Agreemen t D Settlemen t document s (i.e. , fo r

damag e or to replac e plants , etc. ) aConfirmation data / 

### Photograph s / 

### As-built sketch Satisfactor y restoratio n signedb y Propert y Owne r aPropert y close-out check lis t signe dby EP A D Descriptio n of area s not meeting RO D cleanu p criteri a B Utilit y clearance s aPropert y infonnatio n fromDougla s Count y Assessor' s Office Q 

### D D ^Vytiitli i 

### Signatur e Dat ePROPERT Y SUMMAR Y Date : 11/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Novembe r Propert y Address ; 101 7 N 3 3 S T 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 Information : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : F l = 10 4 PP M @ 9" ; F 2 = 9 8 PP M @ 9" ; B l = 35 1 PP M @ 9" ; D Z = 11 5 PP M @ 10" ; E A = 21 1 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 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 ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include din th e individua l property file, i f available , o r obtainedinclude : i ) Pre-excavatio n agreement detail s (ifan y ar e mad e withth e property owner ) ii ) Propert y Statu s Formsigne db y property owne r iii ) Excavatio n digita l vide o i n MPEG , 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 n o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES . INC .Fin d Record Backfill :

Sampl e Area : 2483 2 - 101 7 N 3 3 S T Owner :
n Owne rOccupie d Owne rName : IGOKI E DANIE L Owne rAddressl : 

# I Owne rAddress2 : 1101 7 N 33 S T City : state : Zi p Code : JOMAH A ~ [N E |68131 - Owne rPhon e Alternat e Phone : 

# r
Contract : Contractor : jPRUDEriT2010_ S Contrac t Optio n |BAS E Remediatio n QueryI Lea d Remainin g QueryI Propert yDamag e Query
Use rProvide d Owne rInformatio n Owne rName : 

# 1 . Owne rAddress : 

# 1 City : 

# 1 State : 

# 1 Zi p Code : 

# 1 Owne rPhone : Altemat e Phone : 

# 1 " 1

Assessment : Qualifyin g Grou p |400/CHIL D Assessment Ma xXRF Valu e \ 591.3 6 Resident : Residen t Name : (RESIDEN T Propert yAddress : 1101 7 N 3 3 S T Zi p code : |68131 - Residen t Phon e 

### I — •..... I •-•l^'K'^.il.^lry : \ u TECHNOLOGIBS , INC . Propert y # : ^"^^^Z
- Date/Time : Quad. s Excavated : p [ p2_iD2
- ^ 1 

# EP A Propert y Clos e Ou t Propert y Address : {Ol y h"S"? 9-^ . Owner' s Name : -yTo-U. ^ f^u.?j^a^ftr v Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l I I f necessary , wer e tli e correct quadrant(s ) excavate dandrestored ? 2 .

I f necessary , wer e th e correct area s o f drip zone e.xcavate dandrestored ? Gradin g Sodan dVegetatio n 1 .

Doe s th e gradin g aroundth e perimete r o

f th e hous e in excavatedarea s generally slop e awa y fro mthe house ? 2 .

Has sodbeen lai din all area s tha t wer e excavated ? 3 .

Doe s the sodappea r to b e generall y health y andgrowing ? (Onl y evaluat e i f inspecte da t a3 0 da

y time period) 4 .

Ar e soddedarea s generally fir man devenl y graded ? 5 .Ar e the joint s between th e sodstrip s generall y tight ? (Onl y evaluat e if inspecteda t a3 0 da y tim e period ) 6 .Wa s the propert y grade dsuc htlia t wate r wil l no t pool on^th e property ? 7 .

Wa s damag e to landscapin g o r plan t material s avoided ? Gates , Fence s an dRetainin g Wail s 1 .

Do gate s open andclos e freely ? (I f applicable ) 2 . Wer e all gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) 3 , Wa s damag e lo gate s o r fence s avoided ? (I f applicable ) 4 .

Wa s damag e t o retainin g wall s avoided ? (I f applicable ) Foundation , Sidin g an dGutter s 1 .

Wa s damag e t o the sidin g o r trimavoided ? 2 .

Wa s damag e t o the foundation avoided ? 3 .

Wa s damag e t o window s avoided ? 4 .

Wa s damag e t o window s or doo r screen s avoided ? 5 .Was damag e f o downspout s o r downspou t extension s avoided ? Sidewalk s an dDriveway s (Concrete ) 1 Was damag e to drivewa y surface s avoided ? 2 .

Was damag e t o walkwa y surface s avoided ? Ye s N o / / Ye s N o / / / / / / / Ye s N o 

# y ' 

# y / 

# y Yes , N o / 

# y 

# y y A Yes , N o / r

### 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 Qp ^ j ^ Date : \(i\\i\ ^

# M CHNOLOGIES , INC . 

### AS - BUIL T DRAWIN G OLS #2483 2 Dat e Excavated : 09/03/201 0 

### OMAH A LEA D SUPERFUN D SIT E lISEPASigned-OfTDate :

Name : P/l^' ~ /-//f/OOJE''- ' Address : / ^ f ? K J V ^ ^ r Phone : Omah a Lea d Sit e Sit e Sketc h Date : Time : ihj/o- i Nort h Arro w^

Te«T i C'^£^/.LA^J:C//i-^<^ ' BVID #'?M33S
- XRFCode 9^0 H Sampl e Numbe r Lea d Concentratio n Confirmatio n Sampl e P-rA^dPXA--^M-?l 7 B.yg<cPxA--XM-73'2
­ pp m pp m RYe s a riYe s Q ftfYes CD OiVe s n

Ye s • Ye s •

s n pp pp m

m I Ye Ye s LJ Bl Landscap e = 21 PP M aScrape ; 2'x30 ' No C3 No 0 No 0 No

E3 No a No

CD o • N N o U •;=:.• - ( ^ , k ^ _

Omah aLea dSit e 4613 0 EA=2I 1 PP M

raScrap e CONTRA a #: EP-S7-10-0 5 PRUDEN T TECHNOLOGIES , INC .

## Propert yCompSetio n Agreemen t Thi s agreement document s th e completio n o f remova l activitie s perfonne do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e propert y owne r i s satisfie dwit hth e restoratio n ofth e subjec t property , an dtha t n o item s ar e in question , now , o r at an y tim e i n th e fiiture , excludin g an y remaining warrant y (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Propert y Wi : Propert y Address : 

### \0\ 1 M ^'h<( ^ Owner : ^^^4,, ^ M IAAJ ^ ^o^f ^ Phon e Restoratio n item s i mQuestion : item : item : Itern : item : Item : item : Require d correction s t o complet e th e property : C3<J - <2_/ 

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[ 2 AI agre e restoratio n i s completed , excep t a s note d above . L J I d o no t agre e restoratio n i s complete d 

# Tmr^^^— ^ <^'2l-l O Owia<ef' s Signatu n Date\ T5C1-i'^':^ICXi3?^'"JV: : i^rudent Technologies , In c (Prudent ) i s unde r contrac t witti th e U S Environmenta i Protectio n Agenc y (,£PA ) t o clea n up Icad
coniammate dsoil s a l anumbe r o f

propertie s locate di n Omaha , Nebraska , includin g th e property locate da t ^Ot* ^ K l ^ J ^ ^ * ^ ^ ^ f ^ request s you r permissio n t o allo w Pruden t t o peTt'or masoi l cleanu p al ihi s properl y t o remov e lead-contaminate dsoi l B y signin g thi s form , th e property owne r grant s permissio n t o Prtiden l t o perfor m activitie s relate dt o th e cleanu p includm g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio n o f :h e lelerence dpioperty I f yo u hav e an y question s abou t th e soi l cleanu p plarme dfor you r property , pleas e contac t Pruden t • • ' ••'•..• • . : n . ibr th e Omah a LeadSit e cleanup , a t (402 ) 733-1188 ; 733-1455 . Genera l question s abou t th e Omah aLeadSit e cleanu p can b ; diiecte dl o the EP A Publi c Informatio n Center s at (402 ) 731-304 5 (SouthOmah aoffice) . Propert y Acces s Grante dB y 

### Uar-^'t. } CpolC.'-t ^ (Pleas e Prin t Name ) Propert y Owne r Signatur e A/O/rluA i yjiyjice ^ ^'^^ ' 'C > (Signature ) (Dale ) PROPERT Y INFORMATIO N (T o be.complete d b yresiden t and/o rpropert yowne r— pleas e print ) RESIDEN T NAME : A/Onu / yjryHea . (jOwn^L ^ Rente r RESIDEN T ADDRESS : 

## /a/ n A/ori ^ '32r J ^/ . CD^K/IC , 

## Aye ' ^a/? / I F RENTAL , PROPERT Y OWNE D BY :
OWNER' S MAILIN G ADDRESS ; , ^ .
OWNER' S TELEPHON E NUMBE R - HOME : (VCQ \ SS & ' ^S'SCs . WORK :
AG E O F HOME? : /O S 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 WIT H SIDIN G SINC E 1978 ? _i__YE S N O 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 OLDE R



# a NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y I 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 Y GATES , ETC. )

AUTHORIT Y l-O RENVIRONMENTA LRESPONS E ACTIONS : Th e activitie s t o b e implemente db y EPA .mder thi s agrecmc-n t ar e pursuan t t o Sectio n 10 4 ofCERCLA , 4 2 U S C 960 4 EPA' s righ t o f

acces s t o th e propert y i s provide df c i n Sectio n 104(c ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry for "determinin g th e nee dfor response , o r choosin g o r talving any lespons e actio n unde r this title , o r otherwis e enforcin g th e provision s ofth e title, "

808 0 War o P.-i;Kw.;,- , r.- • ' ••/•.-.1.... 1 '•••.•: . ^\::iv^ Z Kansa s Cltv . M C 64'-'• : • • ' ^^:v•..••- . •"••,•';••;^ ' ^'hoiif . fP-i« : ib i .."• ' ' • • ' • " •';•• • •- ?ENVIRONMENTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : Date : Phone : BVID : 

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### gef?^.^g^ » YOURTICKE T NUMBERI S 2580210 . Origina l Cal l Date : 8/30/1 0 Time : 2:5 9 p m Op : SIVA1 8 96 7 Wor k t o Begi n Date : 9/01/1 0 Time : 3:3 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 101 7 Street : N33R D S T Twp : 15 NRng : 13 E Sect-Qtr : 16-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 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 : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V LEVEL 3 MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Plion e Numbe r Utilit y Typ e 

### Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , IN C HEIDI 

### Alt : 402934046 9 Etnerg : 402932975 7 Day : 8773668344 LEVEL S LEVEL S COMMUNICATIONS , LL C N A 

### Alt : Emerg : 8773668344 Day : 402504782 3 MUDO l METROPOLITA N UTILITIE S DISTRICT SAND Y 

### Alt : 

### Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE RRICH/TRAFFI C Alt : 402444516 1 

### Emerg : 402444516 0 Day : 406728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 8/30/201 0

### Pag e 2 of 2

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 :

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### 406728934 3 406207149 4 

### Emerg : 888728934 3

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### ENVIRONMENTAL ENGINEERIN GAN D CONSTRUCTIO N SOLUTION S 

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