## TRANSMITTA L o f OMAH A LEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAE)# : 7i^7^ q Date : ) I5 ~ Address : \^\ ^ Q,-l 1 ^ f Remediado n Contractor . ?f\)JfJJ^ ^ Xll U [it ^ Year : ^CTl o SOI L REMEDIATIO N PROPERT Y FIL E FOLDE RDOCUMENT S 1 2 Vide o o f property (DVD ) E Executiv e Summar y h EPA-provide dproperty sketc h E Signe dAcces s Agreemen t for subjec t propert y D Signe dAcces s Agreement(s ) fo r adjacen t propert y II IRestoratio n Agreemen t Q Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc. ) d

l Confiimatio n dat a 0

1 Photograph s l b As-buil t sketc h D Sadsfiwtor y restoratio n signe db y Propert y Owne r 

# 4 Propert y close-ou t chec k lis t signe db y EP A D Descriptio n o f area s no t meetin g RO D cleanu p criteri a E Utilit y clearance s 

## U

l Property informatio n fromDougla s County Assessor' s Offic e D D D 

## Signatur e Dat e 3021860 0 

# llU i Superfun dHn d Recor d Remediatio n Query I Lea d Remainin g Query I Propert y Damag e Query 

### Backfill :

Sampl e Area : 2029 9 - 131 7 S 2 7 S T Owner : Resident : Contract : n Owne rOccupie d Contractor : Residen t Name : 

# t Owne rName : [ANDERSO N CHARLAS/BERR Y |PRUDEN72009_ S [l^IMBAC H RONNAL D L Propert y Address : Contrac t Optio n Owne rAddressl : |131 7 S 2 7 s r JBAS E Zi p Code : Owne rAddress2 : [6810 5 Assessment : [381 8 S 3 4 s r Residen t Phon e aty : State : Zi p Code : Qualifyin g Grou p 

# 1 jOMAH A JN E {6810 7 J400/CHIL D Owne rPhone : Alternat e Phone : Assessmen t Ma x XR F Value * |(402 ) 734-306 1 |(402 ) 639-472 4 1 741.5 2 

# t

### PROPERT Y SUMMAR Y Date : /15/201 0 | Omah aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l | Mont h o f Q g C Propert y Address ; 131 7 S 2 7 S T A . EXECUTIV E SUMMAR 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 N SAMPLIN G DATA/RESULTS : B l = 24 6 PPM @ 6" ; B 2 = 25 8 PPM @ 6" ; D Z = 39 2 PP M @ 13" ; E A = 13 5 PP M @ SCRAPE (~1 ) ATTACHMENT S 1 ) Propert y sketc h providedb y EP A pursuan t t o contrac t specification s 2 ) SignedAcces s Agreemen t including acces s agreement s requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l vide o clip/photograph s 4 ) Post-Excavation digita l vide o clip/photograph s 5 ) Documentation - CompletedClose-ou t Checkhs t 6 ) As-Buil t sketch ­ i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contamination lef t behindarea s vi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s to b e includedi n th e individua l propert y file , i f available , or obtainedinclude : i ) Pre-excavation agreemen t detail s (if an y ar e mad e wit h the propert y owner ) ii ) Propert y Statu s For msignedby propert y owne r iii ) Excavation digita l vide o in MPEG , WM V (Window s Medi aVideo ) or SW F (Flash Player ) forma t and/or photograph s iv ) Signedfor mverifyin g satisfactor y restoratio n v ) Descriptio n o f area s no t meeting InterimRO D cleanu p criteria .TECHNOUOGIBS , INC . Propert y # : Z ( ^ Z*^ ^ Date/Time : Quad s Excavated : 02
- 8\6>2 ^ 

# EP A Propert y Clos e Ou t Propert y Address : \'^< 7 9-2 7 *>i" ' Owner' s Name : ^a>r^a\ A L ^'-^^QCVVS . Contracto r Group : Pruden t Technologies , Inc , Excavatio n Genera l Ye s N o I , I f necessary , wer e th e correc t quadrant(s ) excavatedandrestored ? / 2 . I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? 

## y Gradin g Sodan dVegetatio n Ye s N o 1 . Doe s the grading aroundtli e perimete r o

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

### y fro mthe house ? 2 . Ha s sodbeen laidi n all area s tha t wer e excavated ? y 3 . Doe s th e sodappea r to b e generall y health y andgrowing ? (Onl y evaluat e i

f inspecte dat a3 0 y da

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

f inspecte da t a3 0 da y y tim e period) 6 . Wa s tli e propert y grade dsuc h tha t wate r wil l not pool on the property ? / 7 . Wa s damag e t o landscaping o r plan t material s avoided ? 

## y Gates , Fence s an dRetainin g Wall s Ye 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 applicable ) 

## y 3 . Wa s damag e t o gate s o r fence s avoided ? (Ifapplicable ) 

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

### y Foundation , Sidin g an dGutter s Ye s N o 1 . Wa s damag e to th e siding o r tru n avoided ? 

## J 2 . Wa s damag e t o the foundation avoided ? 

## y 3 . Wa s damag e t o window s avoided ? 

## y 4 . Wa s damag e t o window s o r doo r screen s avoided ? / 5 . Was damag e to downspout s o r downspou t extension s avoided ? 

### y Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e t o drivewa y surface s avoided ? / 2 . Wa s damag e t o walkwa y surface s avoided ? 

## y

## 3i: > 

## ^ S ^ ^ 

# V

Owner s comments :

Inspectio n notes :

v ^ y ^ d/> ^

Remova l an drestoratio n activate s complet e includin g th e 30-da y so dwarranty : EP A Representativ e 9'- ^ ^ ^ ^Date : IIPII Q

## Propert y Completio n Agreemen t Thi s agreemen t documents th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e propert y owne r i s satisfie dwith th e restoratio n o f th e subjec t property , an dtliat n o item s ar c in question , now , o r a t an y tim e i n th e fiiture , excludin g any remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Property ID : ^ ^ ^'f ^ Propert y Address ^ J^/ 7 Owner : ^ 7 jZ" ? "^^ ^ Phone : yS^r ^^^ ^ / ^*^^ ' ^^O^ ^ Restoratio n Item s i n Question :

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



### u/\ a agre e restoratio n i s completed . I— I I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above )



## (T U 

# /Ji^/r-^ r Owner' s Signatur e Dat e

## TECHHOLOGmS,WC . lfTudt!«Lle<amoVogjea.\i)c . (Pnidco Q i s vjwiie t cerBtoAva%%«\J,S.fe«i(t«nmeinte\I^tecifita i Agenc y (EPA ) to clea n u

p lead
cortMfjo ^ 3!?i\ s ^ anumbefcttft^opertie s locatedin Omaha , Nebraska , includin g th e propert y locateda t / ^ / f

^ . ^ / ^ y • Th e EP A request s you r permission t o allo w Pruden t t o perfonn asoil cleanu p a

t thi s ]fcopert/to ranov e lead-cft&timinate dsoil . B y sigmn g thi s form, the propert y owne r grants permission to Pruden t t o perfor m activitie s relatedto the cleanu p includin g soil sampling , remova l o

f lead-contaminate dsoil , an drestoration o f th

e reference dproperty . t f you hav e an y question s abou t th e soil cleanu p plannedfo r you r property , pleas e contac t Prudent' s Admim.sirauv y Ck-r k

fo

r the OmahaLea dSit e cleanup . Is/I s Siv aS Jampana-a t (402) liiiiiSS . Geiiera l question s abou tthe Omah aLea dSit e cleanu p ca n b e directedt o th e EP A Publi c Infonnation Centa s a t (402) 73 1 -304 5 (Sout h Omah aoffice ) o

r (402) 991-958 3 (Nort h Omah aoffice) . Propert y Acces s GrantedBy : K ^ N L ^ S ^ f /^ l Q fhC ^ T T ^ pleas e Prin t Name) Propert y Owne r Signature : / ( P^ v >>^--w ^ - ~ (Signature) (Date ) PROPERTY INFORMATIO N (To becomplete dbymiden t and/o r propert y owne r - pleas e print ) Rente r Owne r RESIDEN T NAME : RESIDEN T ADDRES S 

# /

J / 7 3 d^ yyiyi r I F RENTAL , PROPERT Y OWNE D °^^ ^

y| ^ J _^ / f^ J / ^ /^ C / / OWNER' S MAILIN G ADDRESS-. ^ ^ ^ g , ^ ^ $ </^ ^

^ ^ / 6 7 OWNER' S TELEPHON E NUMBE R - HOME : < t / J T " J <^ ^

/wORK : AO E O F HOME? : / 1 ^ ^

YEARS . HO W LON O HAV E YO U LIVE D HERE ? f^^xZo^if i EARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDIN G SINC E 1978 ? J- ^ 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 N UNDE R 7 YEAR S OL D WH O PLA Y I N TH E YAR D FO R S HOUR S O R MOR E PE R WEEKCOMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. ) ^-^^^ ^
AUTHORIT Y FO RENVIRONMENTA L RESPONS E ACTIONS : Th e activitie s t o b e implemente db

y 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 o

f acces s t o th e propert y i s provide dfo r i

n Sectio n 104(e ) o

f CERCLA , 42 U.S . C 9605(e) , whio h provide s entr y fo r "determining th e nee dfo r response , o r choosin g o r taking an y respons e actio n unde r thi s title , o r otherwis e enforcin g the provision s ofth e title. "

8080 Wan l Parkway , Suit e 40 5 5600 S 10 * Stree t 424 2 Medica l Drive , Suit e 42S 0 Kansas Crty , M O 641 U Omaha , Nebrask a 68107 Sa n Antonio , T X 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 Fav'"•"• • —

### TECHNOLOGIES , INC . 

# Propert y Statu s For m Address : /3/ 7 :S ' ^ 1 ^T T Date : /Ac^'^ f Phone : BVID :

- 

### Ite mN O Plant s & Permanen t Landscapin g T o Remai n I n Plac e O n Map Descriptio n & Locatio n 

# h fil/^k ^/uc^ f 

# U p ^i^k i ftufii ^ I 

# W^ 4 ioMf/d e o f 6m0 i jt/oyji/tfiju(/ l Im e Adir i i dlep T Pre-Existin g Conditio n o f

Struct^re/j^^^^^^P^^ ^ pu f ^l/fi ^ /^iCH f Doe s you r Basemen t hav e ahistor y o f

leaking ? Ye s 

# X . N o Ite mN O Descriptio n & Locatio n O n Ma p

Propert y Owne r Pruden t Employee/ ] Signature:^ ^ f ' 

### Signature : f^ ^ //A__^-^'~ "

805 0 WardParkway , Suit e 40 6 250 5 N . 24" ' Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha . Nebrask a 6811 0 San 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 Pav . (210 ) 579-657 7^HNO l (KHF.S . INC , 

### AS - BUIL T DRAWIN G OI,f*:2029 9 Dat e Excavatc-d : 12/01/200 9 ISEPASigntdOtrOatc : 

### OMAHA LEAD SUPERFUN D SIT E

Name : ^nj ^

Jr-J-^H ^ W^ ^ Omah a Lea d Stt e Date : '7//i:/£' ^ Address : . nr-7. S y ^ ^ T Sit e Sketc h Time ; /e, ' f ^ Phone :

Omah aLea dSite 4613 0 CONTRAC T #:EP - R7-07-0 6 T0# 1 PRUDEN T TECHNOLOGIES , INC .

### Name: ^ai^l J /-'j-gi f k^ ^ Omah ^ Laa d SH e Date : 7//^/^ ^ NorthAno w - • 

### Address^^5^^3 r SH B Sketc h Time : /olZj " 

## Phone : C^E2^E2S ^ 

## /



# 6. 1 

# ^^- ^ ff . OmahaLea dSite 4613 0

### Page l of l



# r I3 n 5 ^^

http://douglasne.mapping-online.com/assessdoc/Photos/18/Tl22186900000001.jp g 11/20/2009

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### y Interstate s InUff-^UL- ^ Parcel s 

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### DnvenD vl\('/^CUIDH ' Disclaimer : Thi s ma p i s not guarantee d t o b e accurate , correct , cun'ent , o r complet e an d conclusion s draw n are th e responsibility of th e user .utilitie s

YOU R TICKE T NUMBE R I S 2410483 . Origina l Cal l Date : 11/19/0 9 wor k t o Begi n Date : 11/24/0 9 Time : Time : 7:3 7 p m 7:1 5 a m op : SIVA1896 7 State : N E Address : 131 7 County : DOUGLA S Street : S 27T H S T Place : OMAH A TWp : 15 N Twp : Rng : 13 E Rng : Sect-Qtr : 28-NE 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 : 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 : NFront : Y Rear : involve s Tunneling o r Horizonta l Borin g : NExplosives : N CXCAT V

LEVEL 3 MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F Servic e Are a Contac t Phon e Numbe r utilit yTyp e CXCAT V

co x COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL 3 LEVEL 3 COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4 MUD0 2 METROPOLITA NUTILITIE S DISTRIC T SANDY Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO F CITY O F OMAHA-TRAFFIC,SEWE R RICH/TRAFFI C Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 6 OMAH APUBLI C POWE R DISTRIC T N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI F QWES T LOCA L NETWOR K N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

Pag e 1ENVIRONMENTA L & CONSTRUCTIO N TECHNOLOGIES , INC . SOLUTION S 

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## Address : Z^/ ? S . yL ^ Crew : Date : // • ,'?o
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## Sit e Safet y Office r

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 725 0 Kansa s City , 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 7