## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO NFIL EFOLDE R SAID# : ^7/| 4 Date : r Q I k ^ . Address : ^STf O T?lon/i o <^j Remediatio nContractor . fiUAf\li^Jr k \ WYear : (9^ 0 f Q SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S rf

Vide o o f propert y (DVD ) aExecudv e Stiinmai y ffl EPA-provide dpropeity sketc h 0 Signe dAcces s Agreement fo r

subject propert y D Signe dAcces s Agreenient(s ) fo r

adja^«n t propert y ^ 

## Restoratio nAgreement D Settlemen t document s (i.e. , fo r

damag e or t o replac e plants , etc. ) / ffl Confirmatio ndat a Pliotograpli s 

# d As-buil t sketc h 

# i Satisfector y restoratio nsigne db y Propert y Owne r Propert y close-oir t chec k lis t signe db y EP A 

# i D Descriptio no f area s no t meetin g RO D cleanu p criteri a Utilit y clearance s Propert y informatio nfromDougla s Count y Assessor' s OfBc e 

### D D D Signatur e " Dat eFin d Recor d Remediatio n Quer yI Lea d Remainin g Quer yI Propert yDamag e Quer y 

### Backfill :

Sampl e Area : 2711 4 - 351 0 BLOND O S T Owner : Resident : 

### Contract : D Owne rOccupie d Residen t Name : Contractor : Owne rName : |NUN N RENA PRUDENT200 9 S 

# I |NUN N REN A{ Propert yAddress : Contrac t Optio n Owne rAddressl : )351 0 BLONDO S T |OFnO N 2 

### Zi

p Code : Owne rAddressZ : 

### |6811 1 Assessment : |351 0 BLOND O ST Residen t Phon e City : State : Zi p Code : Qualifyin g Grou p 

# I |OMAH A :|N E , |6811 1 „ 

# po o 

# ' Owne rPhone : Alternat e Phone : Assessmen t Ma xXR F Value : |(402 ) 453-619 9 

# " 1 795.23 1

### PROPERT Y SUMMAR Y Date:^/15/201 0 | Omah aLea dSit e Remedia l Actio nContrac t #EP-R7-07-0 6 T0# 1 | Mont hof : ^' ^ Propert y Address : 351 0 BLOND O S T A EXECUTIV ESUMMAR Y A. l 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 GDATAVRESULTS : B l = 7 4 PP M @ 12" ; D Z= 8 8 PP M @ 12" ; E A = 11 6 PP M @ SCRAP E(~1" ) 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 ndigita l vide o clip/photograph s 4 ) Post-Excavatio ndigital 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 fma l 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 dinth e individual property file, i f available , o r obtaine dinclude : i ) Pre-excavatio nagreement detail s (i f an y ar e mad e withth e property owner ) ii ) Property Statu s For msigne db y property owne r iii ) Excavatio ndigita l vide o inMPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio no f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC .TECHNOLOGIES , INC . Propert y # : l~7lt'f Date/Timc : r : • V/- L41 . Quad s Excavated : g| , D2 - 

# EP A Propert y Clos e Ou t Propert y .Address : 3S» 0 (3r6»/vjL o 'ki ' Owner'sName : ^'y^c K jOtc\M ^ CoHJraclo r Croup : Pn,iden > Technologies , Inc. , F.xcavatio nGenera l Ye s N o 1 . 1 f iieccss;-m . wer e lh e correc t quadrani(s ) excavaie dan dresiored ? / 2 . I f necessar>' . wer e th e correc t area s of dri p zon e excavaie daji drestored ? / Gradin g So dan dVegetatio n Ye s N o 1 . Doe s th e gradin g aroun dth e perimete r of Ui e hous e i nexcavate darea s generall y slop e away 

### y fro

mlh e house ? 2 . Ha s so dbee nlai dmal l area s tha t wer e e.xcavaled ? / .1 . Doe s th e so dappear l o b e generall y healtli y ajidgrowing ? (Onl y evaluai e if inspecle da l a3 0 da

y tim e period ) 

## y 4 . Ar e sodde darea s generall y firmmidevenl y graded ? 

## y 5 . Are th e joini s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e ifinspecle dat a.30 day 

### y lim e period ) 6 . Wa s th e properl y grade dsuc htlia t wate r wil l no t poo l o nth e property ? / 7 . Wa s damag e t o landscapin g o r phm t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s No 1 . D o gale s ope nan dclos e freely ? (If applicable ) / 2 . Were al l gate s or fence s lake ndow ndurin g restoratio nactiviiie s reinstalled ? (I f applicabie ) 

## y .3 . Wa s daniiig e l o gale s o r fence s avoided ? (Ifapplicable ) 

## y 4 . Wa s damag e l o reiainin g wall s avoided ? (Ifapplicable ) 

## J Fouindation , Sidin g an dGutter s Ye s No 1 . Wa s damag e l o th e sidin g or tri mavoided ? 

# y 2 . Wa s daniag e l o lh e foundatio navoided ? 

## y 3 . Wa s damag e l o windows avoided ' / 4 . Wa s damag e l o window s o r doo r screen s avoided ? 

# 7 -•i

. Wa s daniag e to downspout s o r downspou t extension s avoided ? 

# 7 Sidewalk s .in dDriveway s (Concrete ) Ye s N o W:i > (i;iin.ii> c U > drivewav surface s avoided ? / 2 . Wa s damag e l o walkway suriace s avoided ? /

# 3^1 0 gloni o S ^ Owner s comineiiits :

Inspectio nnotes : 

# ^ ' ^ y

Remova l andrestoratio nactivate s complet e including th e 30-da y so dwarranty : i 

## EP A Representativ e Jdi>^4 j Date : //is/o'j i

# SHV K Propert yCompletio n Agreemen t Thi s agreement document s th e completio no f remova l activitie s performe do nth e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e property owne r i s satisfie dwit hth e restoratio nofth e subjec t property , an dtha t n o item s ar e inquestion , now , o r at an y tim e inth e fijture, excludin g any remainin g warranty (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Property ID : PropertyAddress : 3 5 • , o B \f . , ^ j ^ 

# Sl- ­ 0^"" = ck?NJ? < ^OJn^ ^ 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 :

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

# ^2?U^/ ^ >^DO ^

oWner' s Signatur e

## TECHNOLOGIES , INC . Pmden t Technologies , Inc . (Prudenl ) i s unde r contiac t withth e U . S . Environmenta l Protectio nAgenc y (EPA ) t o clea nu p lead contaminate dsoil s a t anumbe r ofpropertie s locate dinOinaha , Nebraska , includin g th e property locate da t

. Tb e EP A request s you r permissio nt o allo w Pruden t t o performasoi l cleanu p at thi s property t o remove lead<;ontaminate dsoU . B y signin g this form , tli e property owne r grant s permissio nt o Pruden t t o perform activitie s relate dt o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio nofth e reference dpropeity . [f

yo u hav e an y question s abou t th e soi l cleanu p planne dfor you r property , pleas e contac t Prudent' s Administraiiv c Cler k for th e Omah aLea dSit e cleanup . Ms . Siv u S . Jamaina-a t (402 ) 7.^.?-l 188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca nb e directe dt o th e EP A Pubhcjaftmyano nCenter s a t (402 ) 73 1 -304 5 (Sout hOmah aoffice ) o r (402 ) 99 1 -958 3 (NorthOmah aoffice) . 

## iVl^vi » M>//tJLr/ V ftoperty Acces s Grante dB y (Pleas e Prin t Name ) Property Owne r Signature : 

## ^ I "^ I 7^fi~ ^ 9 Signature ) (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r — pleaM£nat ) RESIDEN TNAME : ^ •€-y\jex . Rente r RESIDEN TADDRESS : .*

_i . iN-ijv-r<-g V 

# ^1 1 < J I F RENTAL , PROPERT YOWNE D BY : OWNER'S^^ILIN G ADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : ( T^ ^ ' ^ ^ ^ ^ ' 7 OvORK : AG E O F HOME? : I ^ Z xYEARS . HO W LON G HAV E YO U LIVE D HERE ? 0'2—YEARS . 

## <P^'d^ ' q HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WTT H SIDIN G SINC E 1978? _ YES " N O NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : ^—NUMBER O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBER 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. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS ; Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t ar e pursuan t t o Sectio n10 4 ofCERCLA , 4 2 U.S. C 9604 . EPA' s righ t o f

acces s t o th e property i s provide dfo r i nSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry fo r "detenninin g th e nee dfo r response , o r choosin g o r takin g an y respons e actio n under thi s title , o r otherwis e enforcin g th e provision s ofth e title. "

808 0 War d Parkway , Suit e 40 5 560 0 S 10* ^ Stree 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 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 7ENVIRONMENTA L & 

# >KUl)EN ' CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

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Propert y Owne r Pruden t Employe e Signature : ^ . AuLA*' ^ 308 0 War d Parkway , Suit e 40 5 560 0 S 10" " Stree t 424 2 Medica l Drive , Suit e 425 0 <ansasCity , M O 6411 4 Omaha , Nebrask a 6810 7 San Antonio . T X 7822 9 'hone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 -a%-. (815 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7

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## http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 9/3/2009Pag e 1 of 2

[ Creat e Anothe rTicke t ] [ Bac k t o Irt h Interne t ] Sen d Emai l

• YOU RTICKE T NUMBE RI S 2361718 . Origina l Cal l Date : 9/11/0 9 Time : 8:4 0 a m Op : SIVA1896 7 Wor k t o Begi n Date : 9/15/0 9 Time : 9:1 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 351 0 Street : BLOND O S T Twp : 15 NRng : 13 E Sect-Qtr : 08-SE,09-SW,16-NW,17-N E 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 : FA X AL L CLEAR S T O (402 ) 73 3 188 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 S MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Numbe r Utility Typ e CXCAT V CO X COMMUNICATIONS , INC HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL S COMMUNICATIONS , LL C N A Day : 877366834 4

Alt : Emerg : 877366834 4 MUDOl METROPOLITA NUTILITIE S DISTRIC T SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE RRO N Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0
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Alt : 406728934 3 406207149 4 Emerg : 888728934 3 QLNNEIC QWES T LOCA LNETWOR K

N A Day : 406728934 3

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### TECHNOLOGIES , INC . SOLUTION S 

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