### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID* : 2221 1 DATE : 1/1 5 ADDRESS : 255 9 MARC YS T REMEDIATIO N CONTRACTOR : PRUDEN T TECHNOLOGIES . IN C YEAR : 20lj > 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S 0 PRE AN D POS T VIDE O O F PORPERT Y(DVD ) o f EXECUTIV E SUMMAR Y ^

EPA-PROVIDE D PROPERT YSKETC H S f SIGNE D ACCES S AGREEMEN TFOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FOR ADJACEN TPROPERT Y E l RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) m CONFIRMATIO N DAT A Q PHOTOGRAPH S Q AS-BUIL TSKETCH 0 SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R ^

PROPERT YCLOSE-OU TCHECKLIS T SIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A 0 UTILIT YCLEARANCE S H PROPERT YINFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E 

# n a D

SIGNATUR E DAT E 

### 3021759 3 

# iHMHI i Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 255 9 MARC Y S T 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 : ARE A NO T EXCAVATED : U C (4'X30' ) = 28 0 PPM @ SCRAP E CONFIRMATIO N SAMPLIN GDATA/RESULTS :

F 2 = 16 3 PP M @ 2" ; E A = 9 3 PP M @ SCRAP E(~1" ) ATTACHMENT S 1 ) Property sketc hprovide db y 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 digita l 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 fina l 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 any 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 o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOGIES . INC .Fin d Record 

### Backfill :

Sampl e Area : 2221 1 - 255 9 MARC YS T Owner : n Owne rOccupie d Owne rName : )K M DEVELOPMEN TLL C 

### # Owne rAddressl : |C/ 0 JASO N MARTI N Owne rAddress2 : |521 3 MAR YST City : State : Zi p Code : jOMAH A " " |N E |68112 - Owne rPhon e Alternat e Phone :

Contract : Contractor : |PRUDENT2010_S Contrac t Optio n JOPTIO N I Remediatio n QueryI Lea d Remainin g Queryj Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : 

# 1 Owne rAddress : 

# 1 City : 

# 1 State : 

# 1 Zi p Code : 

# 1 Owne rPhone : 

# 1 " Alternat e Phone : 

# 1

Assessment : Qualllyin g Grou p J40 0 Assessmen t Ma xXR F Valu e ) 522.4 4 Resident : Residen t Name : 

# I Propert yAddress : |255 9 MARC YST Zi p Code : |68105 - Residen t Phon e 

# I1 )fS\ s TECHNOLOCriES , INC . 

# EF A Propert y Clos e Oui t Propert y # : 222/ I Propert y Address : 1,'^'y l AUrdc ^ '^ K Date/Time : OwBcr'sName : />JJU >C)e3i a Quad s Excavated : ^"2 , Comtractoi r Group : Prudeni t TechmoSogies , Unc . Excavatio n Genera J Ye s I .I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 

# J 2 .If aecessarv . wer e th e correc t are^ s o f dri p zon e excavate dan drestored ? b / Gradin g So dan dVegetatio n Ye s ] . Doe s th e gradin g aroun dth e perimete r o f th e hous e i n excavate darea s generall y slop e awa y fro mth e house' ? / 2 .Ha s so dbee n lai di n al l area s tha t wer e excavated ? 

## y 3 .Doe s th e so dappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e if inspecte da t a3 0 da

y lim e period ) / 4 .Ar e sodde 4 area s generall y fir man devenl y graded ? i / 5 .Arc tli e joint s betwee n tli e so dstrip s generall y tight ? (Onl y evaluat e if inspecte dat a3 0 day tim e period ) 

## J 6 .Wa s th e property ' grade dsuc htlia t wate r wil l no t poo l o n tli e property ? / 7 .

Wa s diiinag e t o landscapin g or plan t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s i .

D o gate s ope n an dclos e freely ? (If applicable ) / 2 .Were al l ga(e s o r fence s take n dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) / 3 .

Wa s damag e t o gate s o r fence s avoided ? (If applicable ) / 4 .Wa s damag e t o retainin g wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye s Wa s damag e t o th e sidin g or tri mavoided ? / 2 .Wa s damag e t o th e foimdalio n avoided ? / 3 .

Wa s damag e t o window s avoided ? / 4 ,Wa s damag e t o window s o r doo r screen s avoided ? / 5 . Wa s damag e to downspout s o r downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s fe g I .Wa s damag e l o diivewa y surface s avoided ? 7 ^ 2 .Wa s damag e t o walkwa y surface s avoided ? N o

N o

N o

N o

N o

## 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 V ^ A ^ ^Date: vtlt^jt o;(-'HN()1(K;IF:S . INC . 

## A S - BUIL T DRAWIN G OL S #2221 1 Dat e Excavated : 09/30/201 0 ISEP A Signed-Of f Date : 

## OMAHA LEAD SUPERFUND SIT E 2221 1

Omah aLea dSit e 461K ) CONTRAC T# : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# &BV < Propert yCompletio n Agreemen t Thi s agreement document s th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e property owner' s signature indicate s that th e property owner i s satisfie dwit hth e restoratio n o f th e subjec t property , an dtha t n o item s are i n question , now , o r a

t an y tim e i n th e fliture , excludin g an y remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Property ID : Property Address : 515-5-< ^ M o \rc\ j S*- . C^ww».c-.Ue» . J 

## fO £^8-/05 - Owner : ^^ ^ ^.^^. ^ ^ Jc^ l 

## Mei^+-r ^ Phone : Hoa.-6 ? (-Ofe l 3 Restoratio n Item s i n Question :

Item : 

## Sa' A 2t«*tJt.'-otjS''*u» , ii* ^ (e« ^ Item : Item : Item : Kem : Kem : Require d correction s t o complet e th e property : 

## 3^ Are^e*l:c.t. wA> ^ I

" M I agre e restoratio n I s completed . L

j I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above ) 

# r^n i ( o Owner' s Signature Dat e

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## 'gft'fe/e i Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clean u p lead coptammate dsgj k a

t aimmb»p f prapertie s locate di n Omaha , Nebraska , includin g th e propert y locate da t f(yy - J t^T ) "" ^ ^ ^ ^^^i e EP A request s you r permissio n t o allo w Pruden tt o performasoi l cleanu p a t tlii s property t o remov e lead-contaminate dsoil . B y signin g thi s form , th e property owne r grant s permissio n t 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 n o f th e reference dproperty . I 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 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 aLea dSit e cleanu p can b e directe dt o th e EP A Publi c Informatio n Center s a t (402 ) 731-304 5 (SouthOmali aoflice)kor (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Grante dBy ; 

# cf^s^fT^ A (Pleas e Prin t Name ) property Owne r Signature : (Signature ) (Date ) PROPERT Y INFORMATIO N (T o b(*Bompletedb y residen t and/o r propert y owne r —pleas e print ) RESIDEN TNAME: ^ Owne r 

# S ^

U^^^nQA RESIDEN TADDRESS : 

## qo; ^ ^^.^~rP 2 ^(j ^ I F RENTAL , PROPERT YOWNE D BY : 

## O^^IUN G A^E^ ^ (/%5 e (jd t .SP)U^^" ^ 

## > ^ ^ ^

^^ ^ OWNER' S TELEPHON E NUMBE R - HOME : fidPtC^J^ J C\ ^ } ^ WORK : A^^yf^tlfi € AG E O F HOME?:(af)r)r?) ^ 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 ? 

# X 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 PLA Y I NTH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : 

# d COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. ) ,. —\ / »- )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s l o b e implemente db y EP A unde r thi s agreemen t ar e pursuan t t o Sectio n 104 o f CERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f

acces s t 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 actio n unde r thi s title , o r otherwis e enforcin g th e provision s o f th e title. " 808 0 War d Parkway , Suit e 40 5 S60 0 S 1 0 S t 424 2 Medica l Drive , Suit e 425 0 KansasCity.'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)822-968 8 Fax:(816)363-370 7 Fan ; (402)733-188 3 Fax : (210 ) 579-667 7ENVrRO<NMEM,/VL & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE. S 

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^ - ^ ^ Propert y Statu s For m_/ / Addres s 

# f<^ ^ % -S^^i k »- ' "ififf^ ^ Phone : 

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### Propert y O w Pruden t Employ e Signatur e 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 , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-968 8 Cv . fU M S7«JS«7 7

# 1 2221 1 Owne rName : PHYLLI S STOCKE R Address : 255 9 MARC YS T Phone : H : 402-593-929 8 Sampi e Numbe r RYASCPXA-2221 1 F l RYBSCPXA-2221 1 F2 RYCSCPXA-2221 1 B 1 RYDSCPXA-2221 1 B 2 RDZCCnXun i 2221 1 D Z RGZOCP)( A222 1 \ ­ -RPggCPXi ^ 3221 1 PZ..- . 

### Omah a Lea d Sit e Sit e Sketc h W

: 402-636-235 1 Lea d Concentratio n Sampi e Collecte d LA B pp m 

## D pp m 

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### Date : 

## '^hv/d'- ^ Time : 9 ' Y? Sampie s Anal\/ze d XR F Unit : \ Boo k :'=\ \ Date: 

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# 255 9 marc y 

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### Printed : Dec 08 . 201 0 «A\'u ' dcei s orc'doei siHtC . 

### CONSTRUCTIO N SOLUTION S 

## SIT ESAFfeT Y HAZAR D ANALYSI S Address : -2r££2—0L-iiy-Ji2l - Excavatio n Date : Crew : Backfil l Date :

Ite m Overhea dLine s Ga s Lin e Wate r Lin e Sewe r Lin e Septic/Leec h Fiel d Propane/Butan e Sidewal k Foundatio n Retainin g Wall s Fence s Tree s Structure s Driveway Sprinkle r Syste m Othe r Cre w Forema n Conditio n a>e ^ 

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## Sit e Safet y Offic e Date :

98 0 WaftfVarfaKay . Sut e 40 S flnaasG«yiHa«4114 SSOOSIOS t OHKlia , MahMtl M oatO T 424 2 Medica l Drive , Suit e 726 0 Sa n Antanlo , T X 7822 S Phom : (402)733-118 8 Phone : (2t0 ) 822f«58 8 v c fStt ) 363<47a7 Fa c (402)73»d8S 3 Fax : (210 ) 6T»-65 n