## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL EFOLDE R SAE)# : ^-7/ 7 Date : <^jldt> ^ Address : t^7. C r^^c j A ^ ' Remediatio n Contractor : /VVAJX^/
- ^^J ^ 

## - T^r , Year : ^1.^0*= ) SOI LREMEDIATIO N PROPERT Y ¥IL EFOLDE RDOCUMENT S ^ Vide o o f property (DVD ) _^__ y Executiv e Summar y 0 EPA-provide dproperty sketc h I I Signe dAcces s Agreemen t fo r subjec t property D Signe dAcces s Agreement(s ) fo r adjacent property Z

l Restoratio nAgreemen t D Settlemen t document s (i.e. , for damag e art e replac e plants , etc. ) y Confinnatio ndat a 0 ^ Photograph s ._ y As-buil t sketc h l aSatisfactor y restoratio nsigne db y Property Owne r y Property close-ou t chec k lis t signe db y EP A D Descriptio no f area s no t meetin g RO D cleanu p criteri a [ 3 Utilit y clearance s 

## Q

^ Property informatio nfromDougla s County Assessor' s Offic e D D

^ D 

## Ignature / Sigjisiure/ " 'Dat e 3005424 7 

# nmHniii i Superfun dPROPERT Y SUMMAR Y Date : 9/15/200 9 | Omali aLea dSit e Remedia l Actio n Contrac t f

t EP-R7-07-0 6 TO# l | Mont hof : Augus t Propert y Address ; 142 5 CAD Y A V 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 : F l = 29 1 PP M @ S" ; B l = 6 5 PP M @ 13" ; D Z= 24 7 PP M @ 13 " ATTACHMENT S 1 ) Property sketc hprovide db y EP A pxirsuan 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 ) Docimientatio n - Complete dClose-ou t Checklis t 6 ) As-Buil t sketc h­ i ) Shal l includ e finalleadlevel 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 nimibe 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 ) Propert y Statu s Formsigne db y propert y 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 .Rn d Record Remediatio n QueryI Lea d Remainin g QueryI Propert yDamag e Quer y Backfill :

Sampl e Area : 2871 7 ­ 142 5 CAD Y A V Owner : Resident : Contract : n Owne rOrnipie d Residen t Name : Contractor : Owne rName : [TENAN T jPRUDENT2009_S |GOSSEr rMELVI AL Propert yAddress : Contrac t Opbo n Owne rAddressl : 1142 5 CAD YA V OPnO N 1 Zi p Code : Owne rAddress2 : |6811 0 Assessment : |561 8 N 5 0 S T Residen t Phon e City : State : Zi p Code : 

# I '. Qualifyin g Grou p jOMAH A JN E |6810 4 |400/CHIL D Owne rPhone : Altemat e Phone : Assessmen t Ma xXR F Value : j(402 ) 451-102 3 j(402 ) 301-421 0 

# r 787.9 7T1CHN0L0GIBS.INC 

# EP A Propert y Clos e Ou t Propert y # : 3^t I "^ Propert y Address : ItfJl ^ G ^ ^ Date/Time : ^-'2''C>' V Owner' s Name : JA.*Iv/vo c ^ossctt ' Quad s Excavated : &' , F'/Z>2
- Contracto r Grou p Pniden t Technologie s Excavatio n General Ye s N o 1 . If necessary , wer e th e correct quadrant(s ) excavatedan drestored ? / 2 . If necessary , wer e the correct area. s of dri p zone excavatedan drestored ? 

# y Gradin g Sodan dVegetatio n Ye s No 1 . Doe s th e grading aroundth e perimete r ofth e hous e i n excavatedarea s generall y slop e awa y / fromthe house ? 2 . Ha s sodbee n laidi n all area s tha t wer e excavated ? 

# y 3 . Doe s th e sodappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e if inspecteda t a3 0 

# y da

y tim e period) 4 . Ar e sodde darea s generall y firman devenl y graded ? ^ 5 . Ar e th e joint s betwee n th e sodstrip s generall y tight ? (Onl y evaluat e i

f inspecteda t a3 0 da y 

# y tim e period) 6 . Was th e propert y gradedsuc htha t wate r wil l not pool o n th e property ? 

# y 7 . Wa s damage t o landscaping or plan t material s avoided ? 

# y Gates , Fence s an dRetainin g Wall s Ye s No 1 . D o gate s ope n an dclos e freely ? (I f applicable) 

# y 2 . Wer e all gate s or fence s take n dow n during restoration activitie s reinstalled ? (If applicable ) 

# y 3 . Was damage to gate s o r fence s avoided ? (If applicable) 

# y 4 . Wa s damage t o retaining wall s avoided ? (If applicable) 

# y Foundation , Sidin g an dGutter s Ye s No 1 . Was damage t o th e siding or trimavoided ? 

# y 2 . Was damage t o the foundation avoided ? 

# y 3 .

Was damage t o window s avoided ? 

# y ' 4 . Was damage to window s o r doo r screen s avoided ? 

# y 5 . Was damage t o downspouts or downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Ye s No I . Was damage t o drivewa y surface s avoided ? 

# y 2 . Was damage to walkwa y surface s avoided ? 

# y

### Owner s comments :

Inspectio n notes :

Remova l andrestoratio n activate s complet e including th e 30-da y sodwarranty : EP A Representativ e £L.j ^ Date : S'/^//o 9

## Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e property owner i s satisfie dwithth 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 any remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Propert y ID : Propert y Address : j g g c ; ^g.A ^ ^^.^_ Owner : W\du A ^ ^ CUc^ , ^SnJ Phone : Restoratio n Item s i n Question :

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

li l 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 )

^-1^-C>c ^ Owner' s Signatur e Date IPruden t Technologies , Inc . (Prudent ) i s unde r contrac t wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clea nxt p lead
contaminate dsoil s a t anumbe r o f

propertie s locate di n Omaha , Nebraska , includin g th e propert y locate da t

. Th e EP A request s you r permissio n t o allo w Pruden t t o performasoi l cleaniq> at thi s propert y t o remov e lead-contaminate dsoil . B y signin g thi s form , ttie property owne r grant s permissia n t o Pruden t t o pexfor m activitie s relate dt o th e cleanu p includin g soi l saii^ling , remova l o f lead-contaminate dsoil , an drestoratio n ofth e reference dproperty . I f

yo u hav e an y questicm s abou t th e soi l cleanu p plarme dfor you r property , pleas e contac t Prudent' s Admimstrativ e Clerk for th e Omah aLea dSit e cleanup . Ms . Si\' aS . Jampana-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informatio n Center s at (402 ) 73 1 -304 5 (SouthOmah aoffice ) o r (402 ) 991-9583 (NorthOmah aoffice) . Property Acces s Grante dBy : 

## (T\^\o\C U (oo^SeX V (Pleas e Prin t Name) Propert y Owne r Signature : rV\j|\> ^ jC j J\r<yh^ ^ ilS' ^ ^ ^ ^ (Signature r (Date ) PROPERT YINFORMATIO N (T o b e complete d b yresiden t and/o rpropert yowne r—pfeat e print ) RESIDEN TNAME : Owne r Rente r RESIDEN TADDRESS :
I F RENTAL , PROPERT YOWNE D BY :
OWNER' S MAILIN G ADDRESS ; 

### & V r^rY^?>\^ . VS ^ ^?no ^ OWNER' S TELEPHON E NUMBER-HOME : I ) WORK : 

## V O AO E O F HOME? : 1 V ^ ' YEARS . HO W LON O HAV E YO U 4HVEB-HERE ? YEARS . 

## 'iic U HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D Wrf H SIDIN G SINC E 1978 7 TES " "N O 

# 1 NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : " 3 NUMBE R O F OCCUPANT 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 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 : (LE . 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 n 10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t ofacces s t o th e property 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 "determinin g th e nee dfor response , o r choosin g o r takin g an y respons e actio n unde r thi s title , o r otherwis e enforcin g th e provision s ofth e title. "

808 0 War d Parkway , Suit e 40 5 250 5 N . 24" ' Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 KansasCity , MO6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7C'ONSTRUt'TJO. N 

### TECHNOLOGIES , INC . SFRVlCE S 

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808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 KansasCity , M O 6411 4 Omaha . Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402 ) 504-100 5 Fax : (210 ) 579-657 7rciTso i o(iiF,s . T\ c 

### A S - BUIL T DRAWIN G ()I.Ss:2871 7 Dat e K\ia\attcl : (17/27/200 9 

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### YOURTICKE T NUMBE RI S 2319650 . Origina l Cal l Date : 7/16/0 9 Time : 2:4 5 pm Op : SIVA1896 7 Wor k t o Begi n Date : 7/20/0 9 Time : 3:1 5 p m State : N E County : DOUGLA S Place : OMAH A Address : 142 5 Street : CADY AVE Twp : 15 NRng : 13 E Sect-Qtr : 10-SE-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 PROPERTY 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 Being Don e For : EPA Dept h o f Excavation : 6 FT Corne r Lot : NFront : Y Rear : Y Involve s Tunneling o r Horizonta l Boring ; NExplosives : N CXCAT V

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## OS ENVIRONMENTXtfJSt - t • "S t " . v..,» . CONSTRUCTfqjN;.^^ . ., ; TECHNOLOGIES , INC . SOLUTION S 

# Sit e Safet yHazar d Analysi s Address : /^JL S C^ y ^^ ^ Crew : 

# Bf.7/3 0 Date : "7'r^-c ?


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## Site Safet y Officer

808 0 War d Parkway , Suit e 40 5 250 5 H. 24
- Street , Suit e 30 8 424 2 Medica l Drive . Suit e 725 0 KansasCity , MO 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (Stt ) 363-370 3 Phone : (402 ) 504-100 4 Phone ; (210 ) 822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210)579-657 7• tf-. :