### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 2005 5 DATE : 12/15/201 0

ADDRESS : 31 7 WOOLWORT H A V REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201 0 

### SOI L REMEDIATIO N PROPERT

YFIL E FOLDE R DOCUMENT S d PR E AN D POSTVIDE O O F PORPERT Y(DVD ) D i EXECUTIV E SUMMAR Y d EPA-PROVIDE D PROPERT YSKETC H U\ SIGNE D ACCES S AGREEMEN TFO R SUBJECTPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FO R ADJACEN TPROPERT Y m RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENT S (I.E. , FO R DAMAG E O R T O REPLAC E PLANTS , ETC. ) I D CONFIRMATIO N DAT A D l PHOTOGRAPH S m AS-BUIL TSKETC H h SATISFACTORYRESTORATIO N SIGNE D B YPROPERT

YOWNE R h PROPERT

YCLOSE-OU TCHEC KLISTSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A h UTILITYCLEARANCE S

• PROPERT

YINFORMATIO N FRO M DOUGLA S COUNTYASSESSOR' S OFFIC E 

## n n <h'^<y

\ SIGNATUR E DAT E 3026109 2 Superfun dFin d Record Remediaao n Quer y Lea d Remainin g Quer y; Propert yDamag e Quer y 

### Backfill : Sampl e Area : 2005 5 - 31 7 WOOLWORT H A V Owner :

• Owne rOccupie d Owne rName : ROBERTSO N JAME S J Owne rAddressl : 

# 1 ~ "^ ' 

# ' Owne rAddress2 : 151 3 S 4 S

T City : State : Zi p Code : lOMAH AJN E 68108 - Owne rPhon e Alternate Phone : 1(402 ) 593-052 5

Contract : Contractor : PRUDENT2010_ S Contrac t Optio n OPTIO N 1 Jse rProvide d Owne rInformatio n Owne rName : Owne rAddress : 

# 1 City : State : Zi p Code :



# 1 Owne rPhone : Alternate Phone :

Assessment : Qualifyin g Grou p 40 0 Assessmen t Ma

xXR F Valu e | 504.3 6 Resident : Residen t Name : 

# 1 Propert yAddress : 31 7 WOOLWORT H A

V Zi p Code : 168108 - Residen t Phon e

### PROPERT Y SUMMAR Y

Date : 12/15/201 0 Oinah aLea dSit e Remedia l Actio nContrac t #EP-R7-07-0 6 TO# l Mont hof : Decembe r Propert y Address ; 31 7 WOOLWORT H AV A . EXECUTIV ESUMMAR Y A, l Issue s Encountered : NON E A. 2 Issue s Resolved : NON E A J Uniqu e Findings : NON E A. 4 Othe r

Relevan t

Infonnation : U C = 69PPM@6 " CONFIRMATIO NSAMPLIN GDATA/RESULTS : B l = 22 0 PP M @ 6" ; E A= 13 4 PP M @ 2 " ATTACHMENT S 1 ) Property sketc hprovide db y EPApursuan t t o contrac t

specification s 2 ) Signe dAcces s Agreemen t inciudin 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 ndigital vide o clip/photograph s 5 ) Documentatio n- Complete dClose-ou t Checklis t 6 ) As-Built

sketch
i ) Shal l includ e fina

l leadlevel s v ) Legen d ii ) Contaminatio nlef

t behin darea s vi ) Contracto r identificatio n iii ) Property addres s vii ) Date iv ) BVI D numbe r 7 ) Othe r item s t o b e include di

nth e individual property file , i f available , o r

obtaine dinclude : i ) Pre-excavatio nagreemen t detail s (i f

any ar e mad e wit

hth e property owner ) ii ) Property Statu s For

msigne dby property owne r iii ) Excavatio ndigital vide o i nMPEG , 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 no f

area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES . INC .TECHNOLCHSIES , INC .



## 'ZC'^^' ^ Property # : Date/Time : Quad s Excavated : ^ \ 

# EP APropert y Clos e Ou t Propert y Address : 1 ( 7 O) ^ W^ K >W ^ Owner' s Name : " 5 cu^e<T 6< r ix*rV>< ; /

> Contracto r

Group : Pruden t

Technologies , Inc. , Excavatio n Genera l Ye s N o I f necessary , wer

e Ui e correcl quadrant(s ) excavatedan drestored ? / 2 . I f necessary , wer

e th e correc l area s o

f drip zon e e.xcavate

dandrestored ? / Gradin g So dan dVegetatio n 1 . Doe s th e gradin g aroun dth e perimete r of th e hous e i n excavate darea s generall y slop e awa y fromlh e Iiouse ? 2 Ha s so dbee nlai din al l area s that wer e excavated ? -T . Doe s th e so dappea r

t o b e generaJl y health y an dgrowing ? (Onl y evaluat e i f inspecte dal a3 0 day lim e period ) 4 Are sodde darea s generall y finnan devenl y graded ? 5 . Ar c th e joint s belwee nUi e so dstrip s gener.^l y tight ? (Onl y evaluat e if inspecte da

t a3 0 da y lim e period ) 6 . Wa s th e property grade dsuc htliat wate r wil l no t poo l o n di e property ? 7 . Wa s damag e to landscapin g o r plan t material s avoided ? Ye s 

# y / 

# y y y 

# y y N o

Gates , Fence s an dRetainin g Wali s 1 . D o gale s ope nan dclos e freely ? (Ifapplicable ) 2 . Were al l gale s o r

fence s taicendow ndurin g restoratio nactiviiie s reuistalled ? (I f applicable ) 3 . Wa s damag e t o gate s o r fence s avoided ? (I f

applicabie ) 4 . Wa s daniag e t o reiainin g wall s avoided ? (I f applicable ) Xe s / / 

# y No '

Foundation , Sidin g an dGutter s Ye s N o 1 . Wa s damag e t o th e sidin g o r tri mavoided ? 2 . Wa s damag e l o th e foundaiio navoided ? 3 . Wa s damag e l o window s avoided ? 4 . Wa s damag e l o window s o r doo r screen s avoided ? 5 . Wa s dainag e l o downspout s o r downspou t

extension s avoided ? 

# y y y y 

# A Sidewalk s an dDriveway s (Concrete ) 1 Wa s damag e l o diivewa y surface s avoided ? 2 . Wa s damag e l o walkwa y surface s avoided' ' Ye s ^ ^ No

## Owner s comments :

Inspectio nmotes :

Remova l an drestoratio nactivate s complete includin g the 30-da y so dwarranty : EP A Representativ e ^" ^ " ^ Date : v\\v^lu ^;CHNOLOGIES . INC .

OL S # 2005.' ! Dat e Excavaied : 09/28/201 0 rSEP ASigncd-Of

T Date : 

## A S - BUBL T DRAWIN G OMAHA LEAD SUPERFUIV D SIT E 2005 5 Owne rName : JAME S ROBERTSON Address : 31 7 WOOLWORT H A V Phone : H : 402-S93-OS2

5 W : Omah a Lea d Sit e

Sit e Sketc h Exterio rPaint • Goo d • Poo r g-' ^ paint Nort

h Arro w
< . Sampl e Numbe r RYASCPXA-2005 5 RYBSCPXA-2005 5 RYCSCPXA-2005 5 RYDSCPXA-2005 5 nDZGCPXA-200S G ROZ3CPXA"g005 S RP23CPXA-2005 5 F l

F2 B 1 B2 -BZ - -es- ' -P ? Lea d Concentratio n 3 8 2 

## J3i u 50 H g i g pp m

pp m pp m pp m pp m pp m pp m Sampl e Collecte d 

## u y D D D LA B D D D D D D D Numbe rof Sample s = ; L ^ • Firm :

Date : Time : Sampl i

e s Collecte d l o nL' D -o r / l-Jy > A ^ XR F Uni t Date : Time : Staff : Sample s Analyze d I03 1 Book

: /3 3 n-S'oS - 

# ' ± Legend : F 1 = Fron t Left , F 2 = Fron t Righ t B 1 = Bac k Left , B2 = Bac k

Righ t DZ = 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 

## :OC T 0 7 m
llC(10'.\15' ) = 69PPMfg!6 ' , ICVX.IO *

B l =22 0 PP.M®6 " 5 a 1 4

• - \ • - Q (•i_

_____:

_

V / 

# i i ; © 30 2 

# I I'ii ^ 

# \ j r f .4i.. . T t vx, ^ 

# ^ Y » P

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# m - ^ Uioolubtf H : K ^ E A= 13 4 PP.M ® 2 - CONTRAC

T# : EP-S7-10-0 5 PRUDENTTECHNOLOGIES , INC .

# p RIDE

N P^o^isrVi

f Completio nkgm<Bm®

m Tlli S S.gfec'li'Cii t

CiO"JUiiicl';.t S tii t

'J.-.',\iipic:t'i-C)i : 0" ; TclJiC/i'a i aCtiv'iiir i pci'iOiiiic dOi i yif ; bciC'i V ilS""ic; dpi'LipciT y Th e prope-iT}. ' ovvnev' s iignatiii e indicate s tha t th e prope.rt y cw'ne v l i ia?ii:fie' j vviti- i xiie ('estoia.tio no t

th e subjec l propenv . a;-i

dtba t si o neTV

i rir e i n q"j-5Sl;ion, riovv. , o r a' i &riy ' tim e i n th e fafire , cxcjudiii g an y reiiiainin g ivaiTaat;,- ' (3 0 day s tota? ) e.iccept thos e item s liste dbeiow , i f any . Frop<ir>:- ^ iB
- 

# L.SLoo£C l .p,o... . -uic/-nc/^ n lestoffBiitiioi" ! lii'^iiirii

s mQnsestScrii : ftercs :

ietr r SteiiT';
- SteiiTii ; ReqiiJSFedci-rreeftcoi^ s t o comiiolete^ ih s P'f'opsir^iy :
• I I

LlS^i ?.gi'e * rss'foratio n i s completed , excep t a s note dabov s i ! I -1 0 no t

agre e restoratio n i s ccrnpiele d

OW85£r' S ijJg.Criii u JifliiePruden l Technologies , Inc . (Prudenl ) i s unde r contrac l withth e U . S . EnvironmentaJ reelectio nAgenc y (EPA ) l o cleanu p lead
cotjiaminate dsoil s at anumbe r ofpropertie s locate dinOmaha , Nebraska , includin g th e property locate da l t>^ \\AJ)prO\<J^Oir-TY \Th e EP A request s you r permi.ssio nl o allo w Prudent l o performasoi l cleanu p a l this property l o remove lead-contaminate dsoil . B y signin g thi s form , th e property owne r grant s permissio nt o Pruden t t o perform activitie s relaie dt o th e cleanu p includin g soi l sampling , remova l o f lead-contanninate dsoil, " an drestoratio nofth e reference dproperty . Ifyo u hav e an y question s abou l th e soi l cleanu p planne dfor you r property , pleas e conlac l Pruden l southoffic e .for th e Omah aLea d Sit e cleanup-a l (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p canb e directe dl o th e EP A Publi c Informatio n Cenier s a t (402 ) 731-304 5 (SouthOmah aofiRce ) o r (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Granied.Bf r 

# fsu^- ^ Jl l Name ) PropertyOwne r

Signature : 

## ( ^ (si

5

RESIDEN TNAME : gnature ) PROPERT Y INFORMATIO N o b e complete db y residen t and/o r propert y owne r

— pleas e print ) Owne r (Date ) 

## \ l \CQ^^ \

f o (

- Rente r RESIDEN TADDRESS : 

# 0(\.v^>JLg . \S Piz ^ Io ^ I F RENTAL , PROPERT YOWNE D BY t
OWNER' S MAILIN G ADDRES S Itrt/Nt Ki l IVtAlLINt j AUUKti>i> ; ( . OWNER' S TELEPHON E NUMBE R - HOME : _i _ WORK :
AG E O F HOME? : 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 ? 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 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 : (I.E . DOGS , ENTR YGATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS i Th e activitie s t o b e implemente db y EP A unde r th; s agrcemc m are pursuan t

t o Sectio n10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ l o f acces s t o th e propert y i s provide dfor mSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) . whic hprovide s eiiti-y fo r "detenninin g th e nee dfo r response , or

choosin g or

takin g an y respons e actio n under tlii s title , o r

otherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkway . Suit e 40 5 Kansa s City,'M O 6411 4 Phone : (816 ) 363-370 3 Fax:(816)363-370 7 S60 0 S - 0 S t Omaha . Nebrask a 6810 7 Phone : (402 ) 733-118 8 Fax : (402 ) 733-188 3 424 2 Medica l Drive , Suit e 425 0 San Antonio . T

X 7322 9 Phone : (210)822-958 8 Fax : (210 ) 579-657 7

# •RUDEN : TECHNOLOGIES , INC . ENV[RO;VMEi\T.A L & CONSTRLCTIO N SERVICE. S 

# Propert y Statu s For m Address : 3^- ^ KiootcOOYH . A.-^-^ ^ ^^*^
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### Pruden t Employe e
308 0 War d Parkway , Suit e 40 5 KansasCity , M O 6411 4 Phone : (816 ) 363-370 3 ^oie * o o "JTA

T 560 0 S 1 0 S l Omaha , Nebrask a 6810 7 Phone : (402 ) 733-118 8 424 2 Medica l Drive , Suit e 425 0 Sa n Antonio , T

X 7822 9 Phone : (210)822-958 8 C..V - /9Hn > C70j:s7 71 Owne rName : JAME S ROBERTSO N

Address : 31 7 WOOLWORTH A V i Phone : »

• 402-593-052 5 W

: 

### Omah a Lea d Sit e

Sit e Sketc h 

# illlll l iniiii i Exterio rPaint • Goo d • Poo r Q'^fio t paint 

## 2005 5

Nort h Arro w
Sampl e Numbe r RYASCPXA-2005 5 F 1 RYBSCPXA-2005 5 F2 RYCSCPXA-2005 5 B 1 RYDSCPXA-2005 5 8 2 RDZOCPXA-2005 5 B2 - RQZ3CPXA-200G 5 S? - RPZ3CPXA-2005 0 P ? Lea d Concentratio n 

# 36 2 

# m ^ s o ^ ^ I g pp m

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(^(l . Date : l O C:L 5 O T Time : /

/ • ' J. D Ar ^ XR F Unit : Date : _ Time : Staff : Sample s Analyze d 

## t03 l Book

: 13 3 ll'^'OS
- ^ Legend : F 1 = Fron t Left , F2 = Fron t Right , B 1 = Bac k Lef t B 2 = Bac k

Righ t D Z = Dri p Zone . G Z = Garden , PZ = Pla y Al l quadrant s ar e a s viewe d firom th e street , facin g propert y 

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### Pag e 1 of 2

Creat e Anothe rTicke t Bac k t o Irt h Interne t Sen d Emai l 

### YOU RTICKE T NUMBE RI S 2594313 . Origina l Cal l Date : 9/16/1 0 Time : 3:0 6 p m Wor k t o Begi n Date : 9/20/1 0 Time : 3:3 0 p m State : N E Address : 31 7 County : DOUGLA S Street : WOOLWORT H AV E Op : SIVA1896 7 Place : OMAH A Twp : 15 NRng : 13 E Sect-Qtr : 26-NW 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)733-188 3 : UNSUR E CORNER S Compan y: Contac t Name : PRUDEN T TECHNOLOGIE S

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 : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V LEVEL 3 MUD0 2 OMAHACO F 0PPDGPR 6 QLNNEI F QWESTN E Servic e Are a CXCAT V

LEVEL S

MUD0 2 CO X COMMUNICATIONS , IN C

LEVEL S COMMUNICATIONS , LLC Contac t HEID I

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METROPOLITA NUTILITIE S DISTRIC T SAND Y Phon e Numbe r 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 Day : 877366834 4 Alt : 

### Emerg : 877366834 4 Day : 402504782 3 Alt : 

### Emerg : 402504797 0 Utility Typ e

OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE RRICH/TRAFFI C 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3 

### http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 9/16/201 0

### Pag e 2 of 2 Alt : 406207149 4 0PPDGPR 6 OMAH

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http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS.. . 9/16/201 0TEeHNOUMieS , INC . 

### CONSTRUCTIO N SOLUTION S 

## SIT ESAFi:T Y HAZAR D ANALYSI S Address : .^i^-^iJiMlil_i±' . Crew : Excavatio n Date : -JU-^I^ — 

## Backfi U Date : ^M.\J ^

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 Drivewa y Sprinkle r

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## Correctiv e Actio n

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## Cre w Forema n Sit e Safet y Offic e Date :

108 0 WanH?aritHay , Sut e 40 5 Cansas City ; Ha6411 4 •hone : (8f6 ) 363^370 3 ^a c(816 ) 363^370 7 :»00S10S t Phone : (402)733-118 8 Fax : fUO ) 733^188 3 424 2 Medica l Drive , Stdt e 725 0 Sa n Antonio , T

X 7822 9 Phone : (2T0 ) 822:^58 8 Fax ; (210 ) 579-657 7