### TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL EFOLDE R SAID# ; '^^lyS ' Date : 

# I1H5-I 0 Address : .-^^^ir . Flor&)Ce . Pr O Remediatio n Contractor : Pp c nPfMT f

Wr^l ^ Nfldoc, \^ q. ^ i(^^>i Year : SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 

# d Video of propert y (DVD ) Executiv e Summar y 

# d EPA-providedpropert y sketch SignedAcces s Agreemen t fo r

subject propert y D 

### SignedAcces s Agreement(s ) fo r

adjaipen t propert y / 

### Restoratio n Agreemen t D Settlemen t documents (i.e. , fo r

damag e or t

o replac e plants , etc. ) Confirmation data 

# d Photograph s As-built sketch 

# d Satisfector y restoratio n signedb y Propert y Owne r Propert y close-out chec k

hs t signedby EP A D 

# d Descriptio n ofarea s not meeting RO D cleanu p criteri a Utilit y clearance s Propert y information fromDougla s Count y Assessor' s Office D D D 

# 3y^y \ Signatur e Dat e Superfun dPROPERT Y SUMMAR Y Date : 11/15/201 0 Oniah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Novembe r Propert y Address ; 393 6 FLORENC EBLV D 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 N SAMPLIN GDATA/RESULTS : B l = 16 5 PP M @ 6" ; D Z= 25 1 PP M @ 13" ; E A = 26 8 PP M @ 2 " ATTACHMENT S 1 ) Property sketc hprovide db y EPA 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 sketch
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 ) Property addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include di n th e individua l property file, i f available , o r obtaine dinclude : i ) Pre-excavatio n agreement detail s (i f an 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 i n 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 .

TECHNOLOCIES , INC .Fin d Record Remediatio n Quer y Lea d Remainin g QueryI Propert yDamag e Query Backfill :

Sampl e Area : 3363 5 ­ 393 6 FLORENC E B D Owner : Use rProvide d Owne rInformatio n Resident : D Owne rOcriiple d Owne rName : Owne rName : Residen t Name : | N AN D L PROPERT YMANAGEMEm " L 

# 1 |TENA?fTS Owne rAddressl : Owne rAddress : Propert yAddress : 

# 1 |393 6 FLORENC E B D Owne rAddress2 : Zi p Code : |10016S13S T |68110 - City : State : Zi p Code : City : State : Zi p Code : Residen t Phon e IBELLEVU E |N E |68123 ­ 

# 1 1 1 I Owne rPhon e Alternat e Phone : Owne rPhone : Alternat e Phone : 

# " 1 1 " 1

Contract : Assessment : Contractor : |PRUDENT2010_S Qualifyin g Grou p |4o 6 contrac t Opti (an jOPnO N 1 Assessmen t Ma xXR F Valu e | 44 7INCSLpGnS , BMC . 

# EP A .Property Clos e Ou t Propert y Address : p%'^(oP\(nt^~cji.^^'^^ ^ Pate/Time : Owner' s Name : y j ^tVv . XXaSjot. . ^ &/\J Qinadl. * Excavated : S^ 7 (5 1 Contiractoi r Group : Pruden t TwfcuMttogJes , Jnc , Esciivatio n Genera l Ye * N o J . I f necessar>- . wer e the correct quadrant(s ) excavatedandrestored ? 

### y 2 . I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? 

### y Gradin g So dan dVegetatiom Ye s N o 1 . Doe s th e gradin g aroun dtii e perimete r o

f the hous e in excavate darea s generall y slop e awa y y ^ fro mthe house ? y 3 Doe s th e sodappea r to be generally health y andgrowing ? (Onl y evaluat e i f inspecteda t a3 0 da

y time period ) 

# y 4 Ar e soddedarea s generally fir mandevenl y graded ? 

## y 2 . Has sodbeen laidi n all area s tha t wer e e.Kcavated?

5 . Ar e the joint s between tli e sodstrip s generall y tight ? (Only evaluat e if inspecte da t a3 0 da y ^ time period ) 6 . Wa s th e propert y grade dsuc htlia l wate r wil l not pool o n th e property ? 

# y 7 . Wa s dainag e t o landscapin g o r plan t material s avoided ? 

## y Gates , Fence s am dMetainimaWaJ5 s Ye s N o 1 . D o gate s ope n iuidclos e freely ? (I f applicable ) 

### y 2 . Wer e all gate s o r fence s taken down during restoratio n activitie s reinstalled ? (I f aj^licable ) 

# y 3 . Wa s damag e t o gate s or fence s avoided ? (I f applicable ) 

# y 4 . Wa s damag e t o retainin g wall s avoided ? (I f applicable ) 

# y FoMwdalion , Sidin g an dGutter s Ye s N o ! . Was damag e to th e sidin g o r trimavoided ? «<^ 2 . Wa s damag e t o tli e foundation avoided ? 3 . Wa s damag e t o window s avoided ? 

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

### l y y . Wa s damag e t o downspout s o r downspou t extension s avoided ? Sidewallks an dDriveway g (Concrete ) Ye s N o y ^ 1 . Wa s damag e lo drivewa y surface s avoided ? 2 . Wa s damaige t o walkwa y surface s avoided ?

### 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 ^s ^ ^Date: /a/^t/t o

# ffiun CHNOLOGIES . IN C 

### A S - BUIL T DRAWIN G OL S #iihi S Dal e Excavated : 09/21/201 0 

### OMAH A LEA D SUPERFUN D SIT E I'SEP A Signed-OffDate :

Name : Address ; liu-jc. ' iJi,. - ^ t^ . J-?nt . ///=//,w , .^-'^ . Omah a Lea d Sit e Sit e Sketc h Date : / 3-c V Time : //• / * / Nort h Arro w _--

^ [-
Team3t//r>//4y.>«> ^ /".^^PS ) BV1D # '??(^.?5 " XR FCod e f/^<^^ - Sampl e Numbe r Lea d Concentratio n Confirmatio n Sampl e 3 4 5 6 f^Y^^Sci-PXA ­ ^"^^ ^ Lab RYASCPLA-3363 5 29 2 pp m Result TfiyT ~ PP" ^ —y^'^^ ^

pp' " 1^^< ^ pp m pp m pp m ^ Ye s -t'iYe s 5 ' Ye s 56 Ye s *.Ye s

Ye s Ye s S - • • O n • • N o C3 . N o C Z N o IS " N o S N o ca " N o C D N o O

£.4 = 26 8 PP\ I a2 " OinahaL.ea dSite 4613 0 CONTRAC T# : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

## 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 dproperry Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth e restoratio n ofth 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 any remainin g warrant^ ' (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Propert y JH) : Propert y Address : 3^3 ^ Pl o re ^ c_i5
- B O Owner : U ^ jyy ^ fef fs.)/y<^c^y ^ Phone : 

# rts - Restoratso n Item s i n Qoestioin :

hy i i agre e restoratio n i s completed , excep t a s note d abov e L J I d o no t agre e restoratio n i s complete d

Owner' s Siguatur e

## y'-'-'-'-^' y

Pruden t Technologies , Inc . (Prudent ) is unde r contrac t withth eU. S. Environmenta l Protectio n Agenc y (EPA ) to clea n up lead
contamiimte dsoil s at anumbe r of

Kpp^tie s locate d in Omaha , Nebraska , includin g th e propert y locate dat ^°13 o TiO'C^Y^tJL-
- ^5C3l . Tli e EP A request s you r permissio n to allo w Pruden t to performasoi l cleanu pat thi s property to remov e lead-contaminate dsoil . By signin g thi s form , th e propert y owne r grant s permissio n to Pruden t to perfor m activitie s relate d to th e cleanu p includin g soi l sampling , remova l of 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 plaime dfor you r property , pleas e contac t Pruden t southoffic e _fo r th e Omah aLea d Site cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLead.Sit e cleanu p ca n be directe d to th e EP A Publi c Infonnatio n Center s at (402 ) 731-304 5 aoffice ) or h aoffice) . 5 (Sout (Sout h h Omah Omah aottice ) or (402 (402 ) )991-958

991-958 3 3 (Nort

(Nort h Omah Omah aottice ) Property Acces s Grante d /^ ^ " ^ (Pleas e Prin t Nanje ) Property Owne r Signatu n (Date ) >PERT Y INFORMATIO N (T o be complete d by residen t and/o r propert y owne r —pleas e print ) RESIDEN TNAME : Owne r Rente r RESIDEN TADDRESS : 

# K. D ^K^g ^ h)-e . Q z 1-2 ) IF RENTAL , PROPERT YOWNE D BY : 

# W^-^^—QAyq^-^v OWNER' S MAILIN G ADDRESS ; 

# p e G'^i^ ^ OWNER' S TELEPHON E NUMBE R - HOME : _ L WORK : AG E OF HOME? : 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 YGATES , ETC. ]

ALHTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS i Th e activitie s to be implemente d by EP A unde r thi s agreemen t ar e pursuan t to Sectio n 10 4 ofCERCLA , 42 U.S.C . 9604 . EPA' s righ t ofacces s to th e propert yis provide dfo r in Sectio n 104(e ) of CERCLA , 42 U.S . C 9605(e) , whic hprovide s entr y for "detenninin g th e nee dfor response , or choosin g or takin g an y respons e 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 S10 St 424 2 Medica l Drive , Suit e 425 0 Kansa s City.'M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio . TX 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)579-667 7

### Address : Phone :



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### Propert y Owne r Signature : 808 0 War d Parkway . Suit e 40 5 Kansa s City , M O 6411 4 Phone : (816 ) 363-370 3 

### TECHNOLOGIES , INC . 

# Propert y Statu s For m Date : BVID : ENVtRONMENTAL A CONSTRUCTIOI N SERVICE S

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### (2jy^ ^ ^ 

## Jl—OLP 

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### Pniden t Employe e Signature : 560 0 S 1 0 S t 424 2 Medica l Drive , Suit e 425 0 Omaha , Nebrask a 6S10 7 Sa n Antonio , TX 7822 9 Phone : (402)733-118 8 Phone : (210)822-958 8 i4AO V Ti l 'ieO- 1Name : Cytc . lL,x.ly . Oniah a Lea d Sit e Date : Nort h Arro w Address : J-^»? C Ay//.. . J/y' . Sit e SIcetc h Time : 

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# M : Phone : Team&//r>^//^r/M. ^ /^-^^S ) BVID#JI2^l5 l XR F Cod e 

# (t^^ 4 Sampl e Numbe r Lea d Concentratio n Confirmatio n Sampl e p p m -/'Ye s N o O pp m -five s a N o ^ pp m ijlYe s t n N o E T 

## U^S . e^Ye s C D N o 1 3 

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### N o • Resul t 29 2 pp m

Oniah aLea dSit e 4613 0

### Pag e 1 o f 1 

# 399 t f t

http://douglasne.mapping-online.com/assessdoc/Photos/03/R20130300000001.jp g 9/15/201 0

# A Printed : No v 16,201 0 www.dcgis.org/dogi s

### Pag e 1 o f 1

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

### YOURTICKE T NUMBERI S 2592095 . Origina l Cal l Date : 9/14/1 0 Time : 5:3 3 p m Op : SIVA1896 7 Wor k t o Begi n Date : 9/16/1 0 Time : 6:0 0 p m State : N E County : DOUGLA S Place : O M Address : 393 6 Street : FLORENC E BLV D Twp : 15 NRng : 13 E Sect-Qtr : 03-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lea d 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: 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

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 HEID I 

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

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE R 

### RICHA-RAFFI C Day : 402444719 7



### Alt : 402444516 1 Emerg : 402444516 0
OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T EL M LOCATIN G 

### Day : 406728934 3 Alt : 4062071494 

### Emerg : 888728934 3 QLNN EI 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=<RESULTS. . . 9/14/201 0

### ENVIRONMENTA L ENGINEERIN GAN D CONSTRUCTIO N ISOHNOUKMSB , mc . 

### SOLUTION S 

## SIT ESAFtiT Y HAZAR D ANALYSI S Address : —J?^J^—tUfXfn r d Q Excavatio n Date : Crew : Backfil l Date :

Ite m Conditioi i Hazard s Correctiv e Actio n Overhea dLine s \yS e /^^/ ^ 

## Ga s Lin e Wate r Lin e 

# ySewe r Lin e 

# M Septic/Leec h Fiel d Propane/Bntan e Sidewal k lySc ^ y>fuA.e^^' 7 

# 7 ^ Foundatio n y 9 ^ 

## Retainin g Wall s Fence s Tree s Stmcture s Driveway ^PiS ^ 

## Jt^ - joU^Atyx^t- y 

## Sprinkle r Syste m Othe r Cre w Forema n Sit e Safet y Oflic e Date :

80 M WmfBartDway . SiBto4< B 980 0 8108 1 424 2 Medica l Drive , Suit e 726 0 Kansa s ia)ly;llO«411 4 BbiaM a 4810 7 Sa n Antonio , T X 7822 9 Pbone : (8f6 ) 3^^370 3 nwne : (402)733-118 8 Phone : (2t0 ) 822.858 8 Fao c|8ffi ) 383>470 7 Fao c(4Q2)73»'1«8 3 Fax : (210 ) ers-es n

# BUZ .