0 

### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAIDft : 2904 4 DATE : 12/15/201 0 ADDRESS : 150 7 1/ 2 OHI O S T REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201 0 

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

PR E AN D POS TVIDE O O F PORPERT Y(DVD ) G 1 EXECUTIVE SUMMARY • f EPA-PROVIDE D PROPERT YSKETCH m SIGNE D ACCES S AGREEMEN TFO R SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S) FO R ADJACEN TPROPERT Y [ ^

RESTORATIO N AGREEMEN T D SETTLEMENTDOCUMENTS (I.E. , FO R DAMAG E O R TO REPLACE PLANTS , ETC. ) ( 3 CONFIRMATIO N DAT A a PHOTOGRAPH S m AS-BUIL TSKETC H SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R d PROPERT YCLOSE-OUTCHEC KLIS TSIGNE D B YEP A n DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A UTILIT YCLEARANCE S d PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E 

### D D D

SIGNATUR E DATE 3026082 2 Superfun dFin d Record Remediatio n Quer y Lea d Remainin g Quer yI Propert yDamag e Quer y 

### Backfill :

Sampi e Area : 2904 4 -150 7 1/ 2 OHI O S T Owner : n Owne rOccupie d Owne rName : ITHOMPSOND L Owne rAddressl : 

# I Owne rAddressZ : 11682 WHITMOR E S T City : State : Zi p Code : JOMAHA NE " 16811 2 Owne rPhon e Alternat e Phone : )(402 ) 455-724 2

Contract : Contractor : |PRUDENT2010 . 

### . S Contrac t Optio n [OPTIO N 2 Use rProvide d Owne rInformatio n Owne rName : 

### ! Owne rAddress : 

# 1 City : 

# 1 State : 

# 1 Zi p Code : 

# i Owne rPhone : 

# 1 ' Alternat e Phone ; 

# 1

Assessment : Qualifyin g Grou p |40 0 Assessmen t Ma xXR F Valu e | 494.2 2 Resident : Residen t Name : 

# I Propert yAddress : J150 7 1/2OHIOS T Zi p Code : J68110 - Residen t Phon e

### PROPERT Y SUMMAR Y Date : 12/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Decembe r Propert y Address ; 150 7 V z Offl O 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 Infonnation : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : F 2 = 38 0 PP M @ 2" ; B 2 = 39 5 PP M @ 2" ; N O EASEMEN T 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 digital 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 leadlevel 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 individual 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 .TECHNDLOGDES , INC . 

# EP A Propert y CBos e Ou t Property# : 2-^b ^ Propert y Address : j^O T '9-0'K'^t > Date/Time : Owner' s Name : DL'^^'"^Q^OI ^ 

### Quad s Excavated : ^2 . 92 ^ Contracto r Group : Pruden t Tedhmologies , Inc. , Excavatio n Genera l Ye s N o 1 . [ f necessarv . wer e th e correct qiiadrant(s ) excavatedan drestored ? / 2 , I f necessary , wer e th e conec t area s o f drip zone excavaledan drestored ? 

## y Gradin g Sodan dVegetatio n Ye s N o 1 . Doe s th e grading aroun dth e perimete r o

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

# y fro

m(h e house ? 2 . Has sodbee n laidi n all area s tlia t wer e e.xcavated ? / 3 . Doe s th e sodappea r to b e generally health y andgrowing ? (Onl y evaluate i f inspecte dat a3 0 

# y da

y time period) 4 . Ar e soddedarea s generally fimi an devenl y graded ? 

# y 5 . Ar e the joint s betwee n tli e so dstrip s generall y light ? (Onl y evaluat e i

f inspecte da t a3 0 da y / tim e period) 6 . Wa s the propert y grade dsuc htlia t wate r wil l not pool o n tlie property ? / 7 . Wa s dajiiage t o landscapin g o r plan t material s avoided ? 

# y Gates , Fence s an dRetainin g Wall sYe s N o 1 . Do gate s ope n an dclos e freely ? (I f appUcable ) 

# y 2 , Wer e all gate s o r fence s take n down during restoratio n activitie s reinstalled ? (I f applicable ) ^ 3 . Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) 

# y 4 . Was damag e t o retainin g wall s avoided ? (I f applicable ) / ^ Foundation , Sidin g an dGutter s Ye s N o 1 . Wa s daniag e t o tli e siding o r trimavoided ? 

## y 2 . Was damag e t o the foundation avoided ? 

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

# y 4 . Wa s daniag e to window s o r doo r screen s avoided ? 

# y 5 . Was daniag e t o downspout s o r downspou t extension s avoided ? 

# y Sidewallks an dDriveway s (Concrele ) Ye s N o t .Wa s damage l o drivewa y surface s avoided ? 

## y / 2 . Was damag e to walkwa y surface s avoided ?

### Owneir s con n i n ents :

iBspectio Emotes :

Remova l an drestoratio n activate s complet e includin g th e 30-da y so dwarranty : EP A Representativ e Qc,„^^t ^ Date : i,ji?f, , lot ­

# i m CHNOLOGIES . INC . 

## AS - BUIL T DRAWIN G OL S #2904 4 Dat e Excavated : 10/29/201 0 USEP A Signed-Of T Date : 

## OMAHA LEAD SUPERFUND SIT E 2904 4 Extffri wPain t NorthAoo w Omah a Lea d Sit a Owne r Name ; P LTHOMPSO N Q Goo d Sit s Sketc h Address : 15071/ 2 OHI O S T n Poo r Phona : t t 402-455-724 2 MW : 

# 1 Qnolpatn t Lea d Sample s CoBecte d Sampl e I4ui n be r LA B \JV 1 ConoenlrdtiL M i Collecte d Firm : .ASkLVA^V^LE — RYASCPXAr2904 4 F l .pp m 

### I T D Oate : ft«i- a.*. . Ai i RYBSCPXA-2904 4 F 2 .pp m 

### 0 - D Time : t:nc j 

# .tns - RYCSCPXA-2904 4 B l 

## AJU . pp m 

### [ T D Sample s Analyze d RYDSCPX/ik-2904 4 B 2 W'* ^ .Pff i 

### Q ^ D nDgOOPWAgOO H Q g "" po m 

### D D XR F Uni t lOc n Bool e i(c2_ fiozoopxAgtwKc a _i: ^ pp m 

### D D Date : _ajL21li2 i nPilDOPXrt £004 4 M pp m 

# n D Time-j^n a Staf t /i^i.. ^ Numbe r o

f Sample s = | Jf. . Legend : F l = Fron t Left , F2 = Fron t Righ t 8 1 = Bac k L ^ B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , PZ = Pla y Al l quadrant s a n as viowii d ftom di e sdcel . faon g prapoty

CONTRAC T# : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# %!EP A Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio nof removal activitie s performe d on th e belo w liste dproperty . Th e property owner' s signatur e indicate s that th e property owne r is satisfie dwithth e restoratio n ofth e subjec t property , an dtha t no item s ar e in question , now , or at any tim e in th e future , excludin g any remaining warranty (3 0 day s total ) excep t thos e item s liste dbelow , if any . Propert y ID : Property Address ; VSo ^ 1/. ^ C UJ o ^j^ - Owner : 

### t ^ c mr^ o T U c\t. ^ pRfA>^ ^ Phone : Restoratio n Item s in Question :

Item : Item : Item : Item : Item : Item : Require dcorrection s to complet e th e property :

^ 

### agre e restoratio n is completed .

L J I do no t agre e restoratio n is complete d at (note d deficiencie s above ) 

# Danni l \ y 

# ^yy ^ -J ^ Owner' s s Signatur

Signature vner' e >

### FCHVfilC>t;iF.\!V : Pruden t Technologies , Inc . (Prudenl )is unde r contrac t wit hth e U. S. Environmenta l Protectio n Agenc y (EPA ) to clean up Icad contgminate dsoil s at anumbe r ofpropertie s locate d in Omaha , Nebraska , includin g th e property locate d at I^^ T 1% . C3V\( o ^^T " Th e EPA request s you r permissio nto allo w Pruden t to perfor masoi l cle-anu p at

thi s propert yto remov e lead-contaminate dsoil . By signin g this form , th e property owne r grant s permissio n to Pruden l lo perfor m activitie s relate d to th e cleanu p includin g soi l sampling , remova l of lead-contaminate dsoil , an drestoratio n of'.h 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 Prudent . .';:i - •. vi-: i ;• l)i: w fo r th e Omah a LeadSit e cleanup , at (402 ) 733-1188 ; 733-1455 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b; directe d lo th e EP A Publi c Informatio n Center s at (402 ) 73 1 -304 5 (SouthOmah aoffice) . Propert y Acces s Grante dBy . 

# ^^T^/^ A (Pleas e ffriul Name , 

# ^V> - 

# f ^ o V] Property Owne r Signature : _ (Signature ^^ V ^ (Date ) ; 0 PROPERT Y INFORMATIO N (T o be complete d by residen t and/o r propert y owne r - pleas e print ) RESIDEN TNAME : Owne r Rente r RESIDENJLABDRESS : 

# \S o" / Vo ok : A^ (S^vwJ ^ N> e fi^tt IF RENTAL , PROI^^T YOWNE D BY 

# v^^* ^ t V ^ p ?? (?/l ^ OWNER' S MAILIN G ADDRESS ;



# tr,^2 . (A_v^f-(-.v^-- ^ .st - o 

# .L^,__i^l S e- ^ OWNER' S TELEPHON E NUMBE R - HOME : _L WORK : 

### 1. MoL ) ^<<:-T2-M7 _ AG E OF HOME? : YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WIT H SIDIN G SINC E 1978 ? YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YIN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS , Th e activitie stobe implemente d by EP A .inder thi s agreemen i are pursuan tto Sectio n 10 4 ofCERCLA , 42 U.S.C . 9504 . EPA' s righ t of

acces sto th e property is provide dlb ' in Sectio n 104(e) of CERCLA , 42 U.S . C 9605(e) , whic hprovide s entry for "determinin g th e nee dfor response , or choosin gor takin g an y re.spon.<; e actio n unde r thi s title , or otherwis e enforcin g th e provision s ofth e title. "

808 0 War e Parkv;ay , S. " "Wciiic-.a ' :'-;vi. . Suit o ^2h : Kansa s City , WI O ^i'.'^' ­ ohone : (?16 ) 353-C""f "ENVIRONMENTA L& 

# IRUDEN ' CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : I 5 O ~7 j/^^OV U o ^i - Date : »o|2Lr3|(T > Phone : BVID : 

# \r^ni ^ cy ^ •€.C L



## Propert y Owne r Pruden t Employe e Signature : S08 0 War d Partcway , Suit e 40 5 

# /7/^ n Signature : 560 0 S lost 424 2 Medica l DTive , Suit e 425 0 Kansa s City , M O 6411 4 OMl^iJi ^ Nebrask a 6810 7 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone K(402 ) 733-118 8 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : ^02)733-188 3 Fax:(210)579-657 7

# 29044 Exterio rPain t Nort h Arro w Omah a Lea d Sit e Owne rName : D L THOMPSO N 

### • Goo d Sit e Sketc h Address : 150 7 1/ 2 OHI O S T • Poo r Phone : H : 402-455-724 2 W : 

# 1 Q^No t pain t Lea d Sampl e Sample s Collecte d Sampl e Numbe r LA B Concentratio n Collecte d Firm : As w\ R5.\N F RYASCPXA-2904 4 F 1 Z5 g pp m 

# I T D s.^-^ ^ Date : r,'^ - RYBSCPXA-2904 4 F2 pp m 

## D Time : \;.HSfhf t RYCSCPXA-2904 4 B 1 pp m 

## D Sample s Analyze d RYDSCPXA-2904 4 B2 pp m 

## D RDJOOPXJ ^ 2001 1 D J pp m 

## D D XR F Uni t /oo l Book : llo ^ 

### nogocpxj"iaoQi i pp m 

## D D Dat e 

### ^'2'^-Pi n pp m 

## ' D D Tim e UQO Staff ; Numbe ro f Sample s • 

# /ki j Legend : F 1 = Fron t Left , F2 = Fron t Right , B l = Bac k Left , B2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewe d fro m th e street , facin g propert y

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### • YOU RTICKE T NUMBE RI S 2624626 . Origina l Cal l Date : 10/23/1 0 Time : 11:4 0 am Op : SIVA1896 7 Wor k t o Begi n Date : 10/27/1 0 Time : 7:1 5 am State : N E County : DOUGLA S Place : OMAH A Address : 150 7 Street : OHI O S T 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 PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)7-33-188 3 : UNSUR E CORNERS.. . 150 7 1/ 2 OHI O S T 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 Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V MCINE B MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Nunibe r Utility Typ e CXCAT V CO X COMMUNICATIONS , INC HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MCINE B MC I N O CAL LPER MEM O 

### Day : 800289342 7 Alt : Emerg : 800289342 7 MUDOl METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 

### http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT. . . 10/23/201 0

### Pag e 2 of 2

0PPDGPR5 OMAH A PUBLI C POWE RDISTRIC T EL M LOCATIN G 

### Day :

Alt : 

### 406728934 3 406207149 4 

### Emerg : 888728934 3 QLNNEIC QWES T LOCA LNETWOR K

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### Day : 406728934 3

Alt : 406207149 4 

### Emerg : 888728934 3

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### SOLUTION S 

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## 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 Hazard s Correctiv e Actio n c^ ^ (1^-.^^— > A.t f ifc ^ . . » 1 = 1 r mrr—fft, ^ 1 

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