### PROPERT Y SUMMAR Y Date : 09/18/200 7 | Omah aLea dSite Remedia l Actio nContrac t #EP-R7-07-0 6 | Mont hof : Septembe r Propert y Address : 250 2 Ame s A v A . EXECUTIV ESUMMAR Y A. I Issue s Encountered : Garde nAre ano t sodde d A. 2 Issue s Resolved : Re-See dwil l occu r i nOctober/Novembe r o nan y dea dspot s t o encourag e sprin g growt h A. 3 Uniqu e Findings : A. 4 Othe r Relevan t Information : CONFIRMATIO N SAMPLIN GDATA/RESULTS : 

### Y A- 16 7 @ 6 " GA - 5 4 @ 8 " Y C - 25 8 @ 14 " ATTACHMENT S 1 ) Propert y sketc hprovide db y EP Apursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfo r crossin g othe r propertie s 3 ) Pre-Excavatio ndigita l vide o clip/photograph s 4 ) Post-Excavatio ndigita 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 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 di nth e individua l propert y file , i f available , o r obtaine dinclude : i ) Pre-excavatio nagreemen t detail s (i f an y ar e mad e wit hth e propert y owner ) ii ) Excavatio ndigita l vide o i nMPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) forma t and/o r photograph s iii ) Signe dfor mverifyin g satisfactor y restoratio n iv ) Descriptio no f area s no t meetin g Interi mRO D cleanu p criteria . 4028507 3 

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### HNOLOCIES , INC .

## 60 2 t e Exterio rPain t Nort h Arro w 

### Owne rName : Omah a Lea d S n Goo d A 

### Address : 250 2 AME S A V Sit e 

### Sketc h / \ 

### Phone : H : Sampl e Numbe r RYASCPXA-60 2 RYBSCPXA-60 2 RYCSCPXA-60 2 RYDSCPXA-60 2 RDZSCPXA-60 2 RGZSCPXA-60 2 RPZSCPXA-60 2 D Poo r 1 

### w : |~ | No t pain t 

### Lea d Sampl e (. „ Sample s Collecte d Concentratio n Collecte d Firm : Sverdru p Y A430. 8 pp m 0 D Date : Y B 299. 2 po m p ] |~ | Time Y C 80 6 po m p | ^ 

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### . 10/22/199 9 p z 

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### P I P I Time : 03:4 6 NumDe rO To a m pie s —u I i Legend : Y A= Yar d (NE) , Y B = Yar d (SE) , Y C = Yar d (SW) , Y D = Yar d 

### (NW) , D Z = Dri p Zone , G Z = Garden , P Z = Play
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### owne rName :Omah a Lea d S D Goo d 

### A Address : 250 2 AME S AVSit e 

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J No t pain t Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d .. 0 Firm : Sample s Collecte d Sverdru p RYASCPXA-60 2 YA430. 8 pp m 0 D Date : RYBSCPXA-60 2 Y B 299. 2 po m |7 | f l Time . RYCSCPXA-60 2 RYDSCPXA-60 2 YC Y D 80 6 293. 2 pp m

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. — , Sample s Analyze d RDZSCPXA-60 2 D Z 385. 4 pp m 0 D XR F Unit : Book : RGZSCPXA-60 2 G Z 740. 8 pp m p | H Dat e 10/22/199 9 RPZSCPXA-60 2 P Z PP m l~ l F l Time : 03:4 6 Legend : Y A= Yar d (NE) , Y B = Yar d (SE) , Y C = Yar d (SW) , Y D = Yar d (NW) , D Z = Dri p Zone , G Z = Garden , P Z = Play

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## Agreem o Allo wAcces s T o Omah a Lea d PropertyT o Conduct Easemen t Sit e Remedia l Samplin g an d Cleanu p Actio n S h

Under Contrac t EP-R7-07-06 , th e U . S . Environmenta l Protectio n Agenc y (EPA) ha s Contracte dPrudent Technologies , Inc . (Prudent) , t o cleanu p lea dcontaminatio n o n variou s residentia l propertie s includin g you r property . Yo u can hel p wit hthi s activity b y givin g permissio n t o conduc t easemen t samplin g an d conduc t cleanu p o n you r property . I f yo u sig n thi s form , Prudent wil l return i n afe w week s an dperform th e work . W e will coordinate samplin g an dcleanup wit hyo u prio r to commencement . I f

yo u hav e an y question s abou t th e propose dwork , pleas e contac t Da n Garvey , EPA' s Projec t Office r fo r our Omah aLea dSit e Contrac t Mr . Garvey ca n b e reache da t (402) 731-0788 . Property Acces s Grante dBy : 

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### (Pl»a » Print Wim» ) Property Owner Signature : * 

### VI l€U>Ua/L a 7 - / / - 0 (Doit )


### PROPERT YINFORMATIO N (T o b e complete db y resident and/o r property owner - pleas e prat) RESIDENTNAME : \ ' 1 f V Jl^S ^ t \^)n.^\-C3j P 

### fawne rDenie r RESIDEN TADDRESS : ^ 2 f 5 f i 9 A Tf\< ? S\ P\^ - P (*^W \ "^iXvn i ^Xj- C V£ D \ \ \

— ... . — ^ I F RENTAL . PROPERT YOWNE D BY : *» ^ OW N ER-StSAILW G ADDRESS ; 0 2 - YWL A A \\
- OWNER' S TELEPHON E NUMBE R -HOUSE : ( >WORK : £1 7 3 ^ ° \ AG E O F HOHE? : 1 (H ^ YEARS . HO W LON G HAV E Y O LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERDE D WITH SIDIN G SINCE1378 ? '^YE S N O HA S TH E INTERIO R BEE N PAWTE D O R COVERE D SINC E 1978 ? YE S N O NUHBE R O F OCCUPANT S UNDE R C YEAR S OLD : NUMBE R O F OCCUPANT S 6 YEAR S OL D AN D OLDE R _ _ NUMBE R O F CHILDREN TUNDE R 6 YEAR S OL D WH O PLAYI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : \ k COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS . ENTR YGATES . ETC. ) j)<y< a J(A\* \ ^ G CJfL . 

### Clh O J 0. . v^il V Vsee^ L Ir o AUTHORIT Y FO RENVIQRNMENTALRESPONS EACTION S ^^<d>/^_^)LAu> C . U^ 2 J-X&-VJL & <-< ^

i^ \ TheacUvitiestobeirr4)lementsbyEPAimderthisagrecrnerlarepursuai^toSectimlC 4 , , 0" ? v 

### &r 9604 . EPA'sri§hto f acces s to th e pr^erty i s provide dfo r i nSedics n104(e ) o f CERCLE , 42U.S . C 9605(e) , whic h
- X4tu3,4^ provide s aitr y fo r "determinin g th e nee dfo r response , o r choosin g o r takin g an y respons e actic nunde r thi s title , o r ' otherwis e enf ortin g the provision s o f the title. "

# &EP A EP APropert y Clos e Ou t Propert y # : Propert y Address : Date/Time : Owner' s Name:-v ^ Quad s Excavated : Contracto r Grou p Pruden t Technologie s Excavatio nGenera l 1 .I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 2 .I f necessary , wer e th e correc t area s o f dri p zon e excavate dan drestored ? Gradin g So dan dVegetatio n 1 . Doe s th e gradin g aroun dth e perimete r o f

th e hous e i nexcavate darea s generall y slop e awa y fro mth e house ? 2 . Ha s so dbee nlai di nal l area s tha t wer e excavated ? 

### 3 . Doe s th e so dappear t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t a3 0 da y tim e period ) 

### 4 . Ar e sodde darea s generall y fir man devenl y graded ? 

### 5 . Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte da t a3 0 da y tim e period ) 

### 6 . Wa s th e property ' grade dsuc htha t wate r wil l no t poo l o nth e property ? 

### 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? Gates , Fence s an dRetainin g Wall s 1 .D o gate s ope nan dclos e freely ? (I f applicable ) 2 .

Wer e al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (I f applicable ) 3 .Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) 4 .Wa s damag e t o retainin g wall s avoided ? (I f applicable ) Foundation , Sidin g an dGutter s 1 .Wa s damag e t o th e sidin g o r tri mavoided ? 2 .Wa s damag e t o th e foundatio navoided ? 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 t o downspout s o r downspou t extension s avoided ? Sidewalk s an dDriveway s (Concrete ) 1 .Wa s damag e t o drivewa y surface s avoided ? 2 .Wa s damag e t o walkwa y surface s avoided ? Ye s N o 

### / / Ye s N o 

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### t / / / / / / Ye s N o 

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### Owner s comments :

Inspectio nnotes :

Remova l an drestoratio nactivate s complet e includin g th e 30-day so dwarranty : EP ARepresentativ e x£L^7. u

### Date :

## 60 2

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Exterio rPain t Nort h Arro w

Owne rName : Omah a Lea d J 

### Sit e D Goo d A 

### i Address : 250 2 AME S AV Sit e Sketc h Q Poo r|

Phone : H : W : [ ] No t paint Sampl e Numbe rLea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Collecte d Sverdru o RYASCPXA-60 2 CYA > 4M & \r f pp m p ) 

### D Date : RYBSCPXA-60 2 Y B 299. 2 DD m p ] Time : RYCSCPXA-60 2 RYDSCPXA-60 2 CYC" ) Y D M B 3 Q 293. 2 PP m oo m p | p ] 

# a Sample s Analyze d RDZSCPXA-60 2 D Z 385. 4 pp m p ) 

# a XR F Unit : Boo k RGZSCPXA-60 2 (<3? ) W* « 5^ . pp m p ) 

# a Date : 10/22/199 9 RPZSCPXA-60 2 P Z op m f l 

# a Time : 03:4 6 Numbe ro f Sample s = 6 

# 1 , Staff : Legend . YA= Yar d (NE) , Y B = Yar d (SE) , Y C = Yar d (SW) , Y D = Yar d (NW) , D Z = Dri p Zone , G Z = Garden , P Z = Pla y

# I S

# SEP A PropertyCompletio n Agreemen t Thi s agreemen t document s th e completio no f remova l activitie s performe do nth e belo w liste dproperty . Th e property owner' s signature indicate s that th e propert y owner i s satisfie dwit hth e restoratio no f th e subjec t property , an dtha t n o item s ar e i nquestion , now , o r a t an y tim e i nth e future , excludin g an y remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Propert y ID : [ ^ Q £ Propert y Address : Qr C ' Q 

# 5 A/n^j y l v* s Owner : /"V l • f 1 1 \"v O hy ) y - hf (2
- Phone : L/^ T / ^ ~ 7 S ^ tP
Restoratio n Kern s i n Question :

Hem : Hem : Hem : 

## Item : Item : Item : Required correction s to complete th e property : 

## OWrte. r VOOu^j AJL-i " He . ^ ° &&
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## Soc. P C *



### L_ l I agre e restoratio n i s completed , excep t a s note d above . LJ I d o not agre e restoratio n i s complete d



# * * / . ^ aJ ^ %-Jit-6 7 Owner' s Signatur e Dat e

### Prin t Previe w Pag e 1 o f 1 

## Dougla s County-Omaha , N E

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GRUENIGAD D 3 1 5 ,54X106 )

http://douglasne . mapping online . com/DouglasCoNe/static/accountinfojsp ? accountno=R 1 22257000 0 Disclaimer. Ma p an d parce l dat a are believe d t o b e accurate , bu t accuracyi s not Ma p Scal e guaranteed . Thi s i s no t a lega l documen t an d shoul d no t b e substitute d fo ra titl e search , 1 inc h = 3 2 fee t appraisal , survey , o rfo rzonin g verification . 

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### [PRUDENT200 7 BARTE E MELISS AL Propert yAddress : Group : Owne rAddressl : 250 2 AME S A V 

# r Zi p Code : Assessment : Owne rAddress2 : J6811 1 J250 2 AME S AV E Residen t Phon e Qualifyin g Grou p City : State : ZipCode : [80 0 

### OMAH A Assessmen t XR F Date : Owne rPhone : Alternat e Phone : I 

### Assessmen t Ma xXR F Value : I 878 ~