# m TRANSMITTA L O F OMAH ALEAD SITE SOI L REMEDIATIO N FILE FOLDE R SAID# : 3338 6 DATE : 1/1 5 ADDRESS : 400 5 N 2 6 A V REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201 ^ 

## SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENTS d PR E AN D POS T VIDE O O F PORPERT Y (DVD ) 3023754 6 

## <

/ EXECUTIV E SUMMAR V HMH I / Superfun d
• EPA-PROVIDE D PROPERT Y SKETC H

• SIGNE D ACCES S AGREEMEN T FOR SUBJEC T PROPERT Y O SIGNE D ACCES S AGREEMENT{S ) FOR ADJACEN T PROPERT Y ^

RESTORATIO N AGREEMEN T D SETTLEMEN T DOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) E l CONFIRMATIO N DAT A d PHOTOGRAPH S [ ^

AS-BUIL T SKETC H H SATISFACTOR Y RESTORATIO N SIGNE D B Y PROPERT Y OWNE R d PROPERT Y CLOSE-OU T CHECKLIS T SIGNE D B Y EP A D DESCRIPTIO N O F AREA S NOT MEETIN G RO D CLEANU P CRITERI A

• UTILIT Y CLEARANCE S

• PROPERT Y INFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E D 

# n D 

# y y" SIGNATUR E DAT E

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 400 5 N2 6 A V 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 : B 2 = 6 3 PP M @ 6" ; E A = 7 4 PP M @ 2 " ATTACHMENT S 1 ) Propert y sketc hprovidedb y EP A pursuan t to 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 video clip/photograph s 5 ) Documentation - CompletedClose-ou t Checklis t 6 ) As-Built sketch
i ) Shal l includ e final lea dlevel s v ) Legen d ii ) Contamination lef t behindarea s vi ) Contracto r identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r items t o be includedi n th e individua l propert y file, i f available , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (ifan y ar e mad e wit hth 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 ) o r SW F(FlashPlayer ) forma t and/o r photograph s iv ) Signedfor mverifying satisfactor y restoration v ) Description of area s not meeting Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC .Fin d Record 

### Backnil :

Sampl e Area : 3338 6 - 400 5 N 2 6 A V Owner :
n Owne rOccupie d Owne rName : jBENE^ GLENNO N J Owne rAddressl : IC/O GEORG E C ANDERSO N J R Owne rAddressZ : 11604 SPRAGU E S T City : State : Zi p Code : jOMAH A IN E 168110 - Owne rPhon e Alternat e Phone :

Contract : i Contractor : PRUDENT201 0 S ! Contrac t Optio n jQPTlG N 2 Remediatio n Quer y Lea d Remainin g Quer y Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Resident : Owne rName : Residen t Name : 

# : 1 ' 1 ^ Owne rAddress : Propert yAddress : 

# r |400 5 N 2 6 A V Zi p Code : 

### J681li City : State : Zi p Code : Residen t Phon e 

## j Owne rPhone : Alternat e Phone : 

## • 1

Assessment : Qualifyin g Grou p 40 0 Assessmen t Ma xXR F Valu e j 492.7 8TECHNOLOGIES , INC . 

# EPA Propert y Clos e Ou t Propert y #: ?5 ^

'^A o 

### Propert y Address : ^c5 " >- ^ • 2 6 Au- C Date/Time : Owner' s Name : ^7* ^ c^ OiySyu \ Quad s Excavated : 9 2 - Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l Ye s No I,

If necessary , wer e the correct quadrant(s ) excavatedandrestored ? / 2,

If necessary , wer e th e correct area s of drip zon e e.xcavate dan drestored ? 

# y Gradin g Sodan dVegetatio n Ye s No 1.Doe s the gradin g aroundth e perimete r of th e hous e in excavatedarea s generall y slop e awa y fro mthe house ? 

# y" Has sodbeen lai d in all area s tha t wer e excavated ? 

# y 3.Doe s the sodappea r to be generally health y andgrowing ? (Onl y evaluate if

inspected at a

30 da

y lim e period) ^ 

# y Ar e soddedarea s generall y fm n andevenl y graded' ! 5.

Ar e tli e joint s between the so dstrip s generall y tiglit ? (Onl y evaluat e if

inspecte d at a

30 da y tim e period) 6.Wa s the propert y grade dsuc htlia t wate r wil l not pool on Ui e property ? 

# -r 1.

Was damag e to landscaping or plan t material s avoided ? 

# y Gates , Fence s an dRetainin g >VaU s Ye s No i.

Do gate s ope n andclos e freely ? (I f apphcable ) / 

### 2.Wer e all gate sor fence s taken dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) / 

### 1.Was damag e to gate sor fence s avoided ? (I f applicable ) Was damag e to retainin g wall s avoided ? (I f applicable ) 

# r Foundation , Sidin g an dGutter s No Ye Yes s Wa s damag e to th e siding or trimavoided ? 2. Wa s damag e to tlie foundation avoided ? 

# r Was damag e to window s avoided ? 

# y 4. Wa s damag e to window sor doo r screen s avoided ? 

# y fl

. Wa s damag e to downspout sor downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Yea
- No 1.Wa s damag e to diivewa y surface s avoided'! ' 

# y 2.

Was damag e to 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 Oa^^J ^ Date : itjisl/ o

### TrnKuuKiihs . \s i OI,S #3338 6 »a( f F.xravati'd : 12/08/201 0 I SEPASigncd-OfTDatc :

Owne rName : GLENNO N J BENE ' Address : 400 5 N 2 6 AV

Phone : H : Sampl e Numbe r RYASCPXA-,3338 6 RYBSCPXA-3338 6 RYCSCPXA-3338 6 RYDSCPXA-3338 6 -F»ZSef%0r-^33e6 ­



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CONTRAC T # : EP-S7-10-0 5 PRUDENTTECHNOLOGIES , INC . 4513 0

## Propert yCompletio n Agreemen t Tlii s agreemen t document s th e completio n o f remova l activitie s performe do n th e belo w liste dpropeity . Th e propert y owner' s signatur e indicate s tha t th e propert y owne r i s satisfie dwit hth 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 (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Propert y ID : Propert y Address : HUO^i A / ^^fl- ^ /X-i. ' Owner : 

## Ck -,- 1 (A.-.^U x Phone : 

## 0 '-iOj-'-/w'-/ ' '-u^( A Restoratio n Item s I n Question :

Item : Item : Item : Item : Item :

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 )



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i lA' ' A ( yy{-^ y np « Sionntiirp- ^ Dat e Owner' s Signatur e IPruden t Technologies , Inc . (Prudent ) I s unde rcontrac l wit h th e U . S . Environmenta l Protectio n Agenc y(EPA ) l o clea n u p lead contaminate d soil s a t a numbe rofpropertie s locate d i n Omaha , Nebraska , includin g th e propert ylocate d at Vrt^f " ^',)rt h ^( i AjiAt/ C . Th e EP Arequests >'ou rpennissio n t o allo wPruden l t o perfor m a soi l cleanu p a t thi s propen yt o remov e lead-contaminate d soil . B ysignin g thi s form, th e propert yowne rgrant s permissio n l o Pruden t t o perfor m activitie s relate d t o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate d soil , an d restoratio n ofth e refaence d property . I f yo u hav e an yquestion s abou t th e soi l cleanu p planne d foryou rproperty , pteas e contac t Pruden t sout h oflic e .fo rth e Omah a Lea d Sit e cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah a Lea d Sit e cleanu p ca n b e directe d t o th e EP APubli cbifotmatio n Centers a t (<I02 ) 731-304 5 (Soul h Omah a office ) o r(402 ) 991-958 3 (Nort h Omah a oflice) . PropertyAcces s Grante d By : /^/'/mi-y i l^iyU/}i> h (Pleas e Pri mName ) Propeit y Owne r Signature : (Signature ) (Dale ) PROPERT YINFORMATIO N (T o b e complete d b yresiden t and/o rproperl yowne r­ pleas e print ) RESIDEN TNAME : Owne r Rente r RESIDEN TADDRESS : _ I F RENT>U, , PROPERT YOWNE D BY : 

### ^ OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : J L WORK : 

### J 1 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 WIT H SIDIN G SINC E 1978 ? _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 NUMBE R O F CHILDRE NUNDE R 7 YEAR S OL D WH O PLAY I NTH 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. )

AUTHORfT YFO R ENVIRONMENTA L RESPONS E ACTIONS ; Th e activitie s t o be implemente d b yEP Aunde rthi s agreemen t arcpursuan t t o Sectio n 10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f access t o th e properl yi s provide d fo ri n Sectio n 104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic h provide s entryfo r"determinin g th e nee d fo rresponse , o rchoosin g o rtakbi g an yrespons e actio n unde rthi s title , o rotherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkvray , Suit e 40 5 660 0 S 1 0 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)822-968 8 Fax:(816)363-370 7 Fax : (402)733-188 3 Fax : (210 ) 679-667 7ENVIRONIVIENTA L & CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m " 1 Address : M O 0 S 

## Date : lo|;2-^tf ^ Phone : BVE) :


# JZ^FCo F

1 4 U 0 \<i ^ Propert y Owne r Pruden t Employ e Signature : Signature : 808 0 War d Parkway , Suit e 40 5 560 0 S 1 0 S t Lcal Drive , Suit e 425 0 KansasCity , M O 6411 4 Omaha , Nebrask a 68107 , a n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 IAnO \ T^J ^ 400 ^ C^v . I-HI W K70JSR7 7

# 3338 6 Owne rName : GLENNO N J BENE ' Addrass : 400 5 N26A V Phone : H : W : 

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### Pag e 1 o f 1

" > Creat e Anothe rTicke t Bac k t o Irt h Interne t Sen d Emai l 

### YOU RTICKE T NUMBE RI S 2629457 . Origina l Cal l Date : 10/29/1 0 Time : 9:1 6 a m Op : SIVA1896 7 Wor k t o Begi n Date : 11/02/1 0 Time : 9:4 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 400 5 Street : N26T H AV E Twp : 15 NRng : 13 E Sect-Qtr : 04-S E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : lea d soi l 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 Compan y: PRUDENT 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 : Y Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phone Nunibe r Utilit y Typ e CXCAT V COX COMMUNICATIONS , INC HEID I 

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

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACOFCITY OFOMAHA-TRAFFICSEWERRICH/TRAFFIC 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLIC POWE RDISTRIC T 

### EL M LOCATIN G Day : 406728934 3

Alt : 406207149 4

Emerg : 888728934 3 QLNN E 1 C QWES T LOCA LNETWOR K 

### EL M LOCATIN G Day : 406728934 3

Alt : 406207149 4

Emerg : 888728934 3
http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT. . . 10/29/201 0

### SOLUTION S 

# jir a SAF*:TY HAZARD ANALY S 

# W
Address : Af M C—K L ?J t 0 ^ Excavatio n Date : Crew : Backfil l Date :

Ite m Conditio n Hazard s Correctiv e Actio n Overhea dLine s C^< ' ^i-^ J /uf~
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# or - Retainin g Wall s Fence s PC£ ^ Tree s cy ^ Structure s a^ ^ Drivewa y o*- ^ Sprinkle r Syste m — — 

## Othe r - 

## Cre w Forema n Sit e Safet y Offic e Date :

108 0 Wuifltariany , Suit o 40 S SSOOSIOS t 424 2 Medica l Drive , Suit e 725 0 (anaa«Ct|yiMa«411 4 Oadlia , NeiMaMB a S810 7 Sa n Antonio , T X 7822 9 ihanKf81«)36»37S 3 Phona : f4a3)733-1ia s Phone : (2t0 ) 822-«58 8 Fax : (402)73»'1«S 3 Fax ; {210)«r9457 7

# . 

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