SAID# : 2837 6 

### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R DATE ; 12/15/201 0 ADDRESS : 240 6 N 2 1 S T REMEDIATIO N CONTRACTOR : PRUDENT TECHNOLOGIES . INC . YEAR : 201 0 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S d \

PR E AN D POS T VIDE O O F PORPERT Y (DVD ) Q EXECUTIV E SUMMARY m EPA-PROVIDE D PROPERT YSKETCH Q

] SIGNE D ACCES S AGREEMEN TFO R SUBJEC T PROPERTi ' D SIGNE D ACCES S AGREEMENT(S) FO R ADJACENT PROPERT Y m RESTORATIO N AGREEMEN T n SETTLEMEN T DOCUMENT S (I.E. , FO R DAMAG E OR T O REPLACE PLANTS , ETC. ) C l CONFIRMATIO N DAT A l i PHOTOGRAPH S m AS-BUIL T SKETCH 0 1 SATISFACTOR YRESTORATIO N SIGNE D B Y PROPERT Y OWNE R \ h PROPERT YCLOSE-OUT CHEC KLIS TSIGNE D B YEP A D DESCRIPTiO N O F AREA S NO T MEETIN G RO D CLEANU P CRITERI A II I UTILIT YCLEARANCE S

• PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E 

### D D D jy ^ SIGNATUR E DAT E 3026083 4 Superfun dFin d Record Remediatio n Quer y Lea d Remainin g Quer y Propert yDamag e Quer y 

# d Backfill :

Sampl e Area : 2837 6 - 240 6 N 2 1 S T Owner : Use rProvide d Owne rInformatio n Resident :

• Owne rOccupie d Owne rName : Owne rName : Residen t Name : JHARRINGTO N JEFFER f 1 

### j Owne rAddressl : Owne rAddress : Propert yAddress :

1 • I2406N21S T Owne rAddressZ : Zi p Code : |232 2 N 2 1 S T 

## llesuo ^ City : State : ZipCode : 

### aty : state : ZipCode : Residen t Phon e lOMAH A | N Y^68110 - 

### ! " " 

# ; 1 Owne rPhon e Alternat e Phone : Owne rPhone : Alternat e Phone : i 

# ' r "'

Contract : 

### Assessment : Contractor : PRUDENT201 0 S I I Qualifyin g Grou p J400 Contrac t Optio n OPTIO N 1 Assessmen t Ma xXR F Valu e 504.6 1PROPERT Y SUMMAR Y Date : 12/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 T0# 1 Mont hof : Decembe r Propert y Address : 240 6 N 2 1 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 : B l = 37 4 PP M @ 12" ; B 2 = 39 1 PP M @ 10" ; N O EASEMEN T ATTACHMENT S 1 ) Property sketc hprovide dby 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 digital 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 leadlevel 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 di n th e individua l property file, i f available , o r obtaine dinclude : i ) Pre-excavatio n agreemen t detail s (i f an y ar e mad e wit hth e property owner ) ii ) Property Statu s For msigne 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 o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC .TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Propert y # : Propert y Address : 2-*4 0 ( > ts l 2 . I S - H Date/Time : {" ^ [ ^ Owner' s Name : iZTc^ ^ HOLY V i" n J -H ? ) ^ Quad s Excavated : Contracto r Group : Pruden t Technolo^fei , Inc. , Excavatio n Genera l Ye s N o 1 . I f necessary , wer e th e correct quadiant(s ) excavatedan drestored ? / 2 . I f necessary , wer e th e correc t arp^i s o f drip zone excavatedandrestored ? 

# y Gradin g So dan dVegetatio nYe s N o 1 .

Doe s th e gradin g aroundthe perimete r o

f th e hous e in excavatedarea s generally slop e awa y 

### y fro

mthe Itouse ? 2 .Has sodbeen lai di n all area s tha t wer e excavated ? 

### y 3 .

Doe s tli e sodappea r to b e generall y health y andgrowing ? (Onl y evaluat e i

f inspecte da t a3 0 

# y da

y lim e period) 4 .

Ar e soddedarea s generally fir man devenl y graded ? 

### y 5 .Ar e llie joint s between th e sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da t a3 0 da y tim e period) y 6 .

Wa s tlie propert y grade dsuc htlia t wate r wil l not pool on tlie property ? 

# y 7 .

Wa s dainag e t o landscapin g o r plan t material s avoided ? y ^ Gates , Fence s an dRetainin g WaU sYe s N o 1 . Do gate s ope n andclos e freely ? (I f applicable ) 

# y 2 . Wer e all gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f apphcable ) 

# y 3 . Wa s damag e t o gate s or fence s avoided ? (I f applicable ) x y 4 . Wa s damag e t o retaining wall s avoided ? (I f applicable ) • ^ Foundation , Sidin g an dGutter s Ye s N o ^ 1 .

Wa s damag e t o the siding o r tri mavoided ? ' 2 .

Wa s damag e t o the foundation avoided ? y ^ *" y 3 .

Was damag e to window s avoided ? " 4 .

Wa s damag e t o window s o r doo r screen s avoided ? y *' 5 .Wa s daniag e t o downspout s or dovkaispou t extension s avoided ? y Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e 1 0 drivewa y surface s avoided ? 

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

# y

### Owner s comments :

Inspectio n notes :

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwairanty : EP A Representativ e 9<^^ ^ ^Date: IO/D-I/' O

# M C'HNOLOtilES , INC . 

### A S - BUIL T DRAWIN G OL S #2837 6 Dat e Excavated : I0/7/20I 0 

### OMAH A LEA D SUPERFUN D SIT E USEP A Signed-Of T Date : 

### 2837 6 Exterio rPain l NoiViAmi w Omah a Lea d Sit e Owne rName : JEFFER Y HARRINGTO N • Goo d Sit e Sketc h Address : Z«» N 2 1 S T • Poo r Phone : "• • 402-684-507 3 W: 402-813-118 4 [T f Notpain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r Concentratio n Collecte d LAS Firm : A^^^ ' AjF/yl J RYASCPXA-2837 6 F i 3lti O pp m 

### D Date : o^/yi/o t RYBSCPX A2837 6 F Z 

### D Time : >^-.» o ^ ^ RYCSCPXA-2837 6 B l ^ d S pp m 

## 0 " D Sample s Analyze d RT'P5ePXA-2837fr - 8 2 _iLU___PP" i 

## E " D 'RDZOCPXA'20J7 0 -BZ
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## D D XR F Uni t IDQTBoofcl^ G RCZCCrXA-2g376 - -G2
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## n D Date : 

## 1-n-c ^ RPZSCPXA-^ajT C • pp m 

### D Time : 

## -ivx v Staff : JSJiS ^ Numbe ro f Sample s = H i Legend : F 1 = Fron t Lef t F 2 = Fnsnt Right , B l = Bac k Lef t B 2 = Bac k Righ t 0 2 = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewe d fro m Ih e street , facing propert y



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## Au^ y ': i m2 t ) 203 6 B t =37 4 PP M 

## @'^ " L^ : B 2 = 39 1 PP M @ 10 " 

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M614I.0I2 3 N O EASEMEN T CONTRAC Ttt : EP-S7-10-0 5 PRUDEN T TECHNOLOGIES , INC .

# JlEF A Propert yCompletio n Agreemen t Thi s agreemen t documents the completion of remova l activitie s performe do n the below listedproperty . Th e propert y owner' s signatur e indicate s tha t the propert y owne r i s satisfiedwit hth e restoratio n of the subject property , an dtha t no items ar e i n question , now , o r a

t an y tim e i n th e future , excluding an y remaining warrant y (3 0 day s total ) except thos e items listedbelow , i f any . Propert y ID : Propert y Address : Ql^iji p \ ^ HJ ^ Owner : Phone : Restoratio n Item s i n Question : Item : 

### Item : Item : Item : Item : Item : Require d correction s t o complet e th e property :

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



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Pruden t Technologies , Inc . (Prudsnl ) i s unde r contrac t withth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clea n u p lead
contaimnale dsoil s a t anumte ' ofpropertie s locate di n Omaha , Nebraska , includin g th e propert y locate da t P ^D( o A/ > 3^/.^ ^ • Tli e EP A reque.st s you r pennissio n t o allo w Pruden t t o performasoi l cleanu p a t thi s property t o remove lead-contaminate dsoil . B y signin g thi s form , th e property owne r grant s pennissio n t o Pruden t t o perfon n activitie s relate dt o th e cleanu p includin g soi l sampling , remova l oflead-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 planne dfor you r property , pleas e contac t Pruden t southoffic e _fo r th e Omah aLea d Sit e cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSH e cleanu p can b e directe dt o th e EP A Publi c Informalio n Center s a l (402 ) 731-304 5 (Sout hOmah aoffice ) o r (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Grante dBy : (Pleas e Prin t Name ) 

# jM l y~u^^ L -^jy^' o Property Owne r Signature : (_ ^ ' (Signature ) ' ^ ^ (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r — pleas e print ) RESIDEN T NAM E Rente r RESIDEN T AODRESS : 

# ^19 9 M < 71^
- O/nctJin , ^ e &Vi O I F RENTAL , PROPERT Y OWNE D BY : 

# y i

OWNER' S MAILIN G ADDRESS ; 

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/!?^Pt> e OWNER' S TELEPHON E NUMBE R - HOME : ( Vo a > SB^-SOl S WORK :

(^01 ) ^03 ' 9iS0' ^ AG E O F HOME? : 

# ^ 3 YEARS . HO W LON G HAVE 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 ? AYE S N O NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : B ' NUMBE R O F OCCIJPANT 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 Y I N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : 

# Ji
COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. ) (JAU P

### JAra e doGi / M \Aiie > . Ce^ K

S ^ €Ka\.iyKi^'tf ^ LeflA S s o /i.fvi^. p fn^t^p r CAis t inoL-P arrAi^^P/^eM'l r ij y alo£/ s AUTHORIT Y FO RENVIRONMENTA LRESPONS E ACTIONS : Th e activhie s t o b e implemente db y EP A unde r thi s agreemen t are pursuan t t o Sertio n 104 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f

acces s l o th e propert y i s provide dfor i n Sectio n 104(e ) o f CERCLA , 4 2 U . S . C 9605(e) , whic hprovide s entry for "detenninin g th e nee dfor response , or choosin g o r takin g an y respons e aaio n unde r thi s title , o r olherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkway , Suit e 40 5 560 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 , TX 7822 9 Phofie : (81SJ 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 Fax : (815)363-370 7 Fax : (402 1 733-128 3 Fax:(210)579-857 7ENVIRONMEiVTAL & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE. S 

# ^V(9 G, Propert y Statu s For m/ , Addres s 

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Alk / Cff^hiPr - e f Propert y Owne r Pniden t Employe e Signatur e Signature : S08 0 War d Parkway , Suit e 40 5 560 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 t^-
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# ^ mil l m i D 2837 6 Exterio rPain t Nort h Arro w Owne rName : JEFFER YHARRINGTO N Omah a Lea d Sit e • Goo d Address : 2408 N 2 1 S T Sit e Sketc h • Poo r t ^ ^ Phone : »' • 402-884-5073 W : 402-813-1184 [ 3 No t pain t Sampl e Numbe r RYASCPXA-2837 6 RYBSCPXA2837 6F l P ^ Lea d Concentratio n 30> O pp m 2L R pp m Sampl e Collecte d 

## I T LA B 

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## D D Sample s Analyze d 'RDZ0CPXA-2037 G RG2SCPXA-2037 6 RPZSCPXA-2B37 6 -BZ r S2 ­ P? " pp m pp m pp m 

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# n D D D XR F Unit : Date : _ Time : /OD I Book : \6L P -\-\-\-ckj . 

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V Numbe ro f Sample s • Staff . _4i^sJi» L Legend : F l = Fron t Left , F2 = Fron t Right , 8 1 = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , PZ = Pla y Al l quadrant s ar e a s viewe d fro m th e street , ^cin g propert y

Rev4 - 046141.012 3

## N 

# 240 6 N 2 1 ST:88 X 17 3 

# A Printed : De c 03.201 0 www.dcgis.org/dogi s

### (..uwsiKucriO N SOLUTIONS 

## SIT E SAFET Y HAZARD ANALYSI S

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## Backfil l Date : t^/a^Astia .

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808 0 Wafitf«aflany , Sut e 40 5 SSOOSIOS t 424 2 Medica l Drive , Suit e 725 0 Kanst t Giiy > BIO«411 4 Omatoa , Nebcasfc a C810 7 Sa n Anterrio , T X 7822 9 Phone : (816 ) 363'370 3 Pbone : (402)733-118 8 Phone : (210 ) 822-S58 8 F^s:(8t6)363''370 7 Fax : (402)733^88 3 Fax : (210 ) S79-657 7