### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 3578 4 DATE : 1/1 5 ADDRESS : 202 8 GRAN D AV REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 20l i 

### SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENT S 0 PR E AN D POSTVIDE O O F PORPERT Y (DVD ) H EXECUTIV E SUMMAR Y 0 EPA-PROVIDE D PROPERT YSKETC H S ^ SIGNE D ACCES S AGREEMEN T FOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT{S ) FOR ADJACEN T PROPERT Y 0 RESTORATIO N AGREEMEN T D SETTLEMEN T DOCUMENTS (I.E. , FOR DAMAG E O R T O REPLACE PLANTS , ETC. ) 0 CONFIRMATIO N DAT A T

^

PHOTOGRAPH S W AS-BUIL T SKETC H 0

^

SATISFACTOR Y RESTORATIO N SIGNE D B Y PROPERT Y OWNE R ^

PROPERT Y CLOSE-OU T CHECKLIS TSIGNE D B Y EP A D DESCRIPTIO N O F AREA S NO T MEETIN G RO D CLEANU P CRITERI A TT / UT I LIT Y CLEARANCE S C KPROPERT Y INFORMATIO N FRO M DOUGLA S COUNTS ASSESSOR'S OFFIC E D D D Bc^-sft ^ 3)lZ/l i JNAT l DAT E SIGNATUR E 

### 3021836 1 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 : 202 8 GRAN D A V A . EXECUTIV E SUMMAR 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 :

B l = 29 8 PP M @ 2" ; E A = 6 2 PP M @ SCRAP E (~1" ) ATTACHMENT S 1 ) Property sketc hprovide db y EPA 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 Checlclis t 6 ) As-Built sketc h­ i ) Shal l includ e final 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 din 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 For msigne db y property owne r iii ) Excavatio n digita l vide o i n MPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio n ofarea s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC .Fin d Record 

### Backfill : Remediatio n Quer y Lea d Remainin g Quer yPropert yDamag e Query 

### Sampl e Area : 3578 4 ­ 202 8 GRAN D A V Owner : Use rProvide d Owne rInformatio n Resident : D Owne rOccupie d Owne rName : AUCHJEREM Y J Owne rAddressl : Owne rAddressZ : J201 4 GRAN D AV E City : loMAH A Owne rPhon e (402)672-754 0 State : Zi p Code : N E |68110 - Alternat e Phone : Owne rName : 

### Owne r Address :
City : Owne rPhone : State : Zi p Code : Alternat e Phone : Residen t Name : Propert yAddress : }202 8 GRAN D A V Zi p Code : 68110 - Residen t Phon e

Contract : Assessment : Contractor : jPRUDENT2010_S Qualifyin g Grou p 40 0 Contrac t Optio n jOPTIO N 2 " Assessmen t Ma xXR F Valu e f 

### 475.1 7' TECHNOLOGIES , INC . "yn'^.-.. y s^' ^ 

# EP A Propert y Oos e Ou t Propeit y # : " ? ^ 7 S: ' ^ Propert y Address : '7 6 2 ^ ^ " ^ ^ ^ Date/Time : Owner' s Name : "S.t.T-cwv.- v 'T<^OCA/ \ Quad s Excavated : m Contracto r Group : Pruden t Technollogies , Inc. , Excavatio n Genera l Ye s N o 

### I .

I f necessary , wer e th e correc l quadrant(s ) excavatedandrestored ? 

# y 2 .

I f necessary , wer e th e correct area s o f drip zone e.xcavate dandrestored ? 

# y Gradin g Sodan dVegetatio nYe s N o 1 .

Doe s the gradin g aroundthe perimete r o

f th e hous e in excavate darea s generall y slop e awa y fro mth e house ? 

# y 2 .Has so dbee n lai di n all area s tha t wer e excavated ? 

# y 3 .

Doe s tli e sodappea r t o b e generall y health y andgrowing ? (Onl y evaluate i f inspecteda t a3 0 

# y da

y time period) 4 .Ar e sodde darea s generall y finn an devenl y graded ? 

# y 5 .Ar e die joint s between the sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da t a3 0 da y tim e period) 

# y 6 .Wa s the propert y grade dsuchtlia t wate r wil l not pool on the property ? 

# y 7 .

Wa s damag e t o Lindscapin g o r plan t material s avoided ? 

# y Gates , Fence s an dRetainin g WalS sYe s N o 1 .

Do gate s ope n an dclos e freely ? (I f apphcable ) 

# y 2 . Wer e al l gale s o r fence s taken dow n diuin g restoratio n activitie s reinstalled ? (I f apphcable ) 

# y 3 Wa s dainag e t o gate s or fence s avoided ? (I f applicable ) 

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

# y Foundation , Sidin g an dGutter s Ye s N o ] . Wa s damag e t o the sidin g o r trimavoided ? 

# y 2 . Wa s damag e t o th e foundation avoided ? 

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

# y 4 . Wa s damag e t o window s o r doo r screen s avoided ? 

# y 5 . Wa s damag e lo downspout s or downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Ye s N o Wa s damag e l o diivewa v surface s avoided ? 

# y Wa s damag e t o walkwa y surface s avoided ? 

# y ^

## Owner s comments :

Inspectio n notes : 

# y^ / . . 

# y

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e ^"^ ^ ^Date: A ^CIINOUXilES , INC . 

### A S - BUIL T DRAWIN G OL. S #3578 4 Dat e Excavated : 10/22/201 0 

### OMAH A LEA D SUPERFUN D SIT E IISEP ASigned-OfTDate : i. '

Omah a Lea d Sit e Sit e Sketc h Own s rName : DOMINIC KJ ZAPPI A /Wddress : 202 8 GRAN D A V

Phone : H W . Lea d Sampl e Sampl e Numbe r LA B Concentratio n Ccllecte d RY.ASCPXA-3578 4 F l .' 7 6 pp m 

## n RYBSCPXA-357e 4 F 2 3 5 / pp m 

### T3 r 

## n RYCSCPXA-3578 4 B l W7 T pp m 

## n RYD3CPXA-3578 4 B 2 . 9 2,' 7 pp m 

### D- ' 

### D • Re2Sef'XA'95-?-8 4 ©2 - — pp m 

### D D — pp m 

### D D RPZ0CPXAOG7C 4 P? - - pp m 

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B l = 29 8 PP M a :

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## Al± . Staff : r'^.^A ^ 

# ENTERE D HA Y

'>n«h 8 I «i d Sit e 4M3 0 E. \= 6 2 PP M .- dSCRAP E (-1" ) CONTRAC T # : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .TllNOLOUIES . INC . 

### A S - BUIL T DRAWIN G OL S #3578 4 Dat e Excavated : 10/22/201 0 

### OMAH A LEA D SUPERFUN D SIT E ISEP A Signed-Of f Date :

Owne rName : DOMiNic KJ ZAPPi AOmah a Lea d Sit e A.d(ircss : 202 8 GRAN D A V Sit e Sketc h Phone : H W : S ampl e Numbe r Lead Concentratio n Sampte Collecte d LA B RY/ASCPXA-35784 F 1 / 7 8 pp m 

## n RYBSCPXA-3578 4 F2 -3 5 / pp m D RYCSCPXA-3578 4 B l _M12_Pp m 

### \3 r D RYDSCPXA-3578 4 8 2 o * 2.-°? pp m 

### B- ' D •ez ­ ~ pp m 

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### D D RPZ0CPXAOG70 4 -PZ ­ ~ pp m 

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### 3578 4 Exterio rPain t Nort h Arro w n Goo d • Poo r 0^No t pain t Sample s Coliecte d Firm : FJ^ M \RS i Q J Pate : r,S - i g - Qj . Tim e I : ^ n p N ^ Sample s Analyze d XR F Unit : 902 . Book : tl 8

Dat e 

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### A£ ± Staff : f^.T W 

# ENTERE D HA Y2 i . m m

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A = 6 2 PP M @ SCRAP E(-1" )

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

### 0 

# «ERI V Propert yCompletio n Agreemen t Thi s agreemen t documents the completion of remova l activitie s performedo n the below listedproperty . Th e propert y owner' s signatur e indicate s tha t the propert y owne r i s satisfiedwit hthe restoratio n of the subject property , an dtha t no item s ar e i n question , now , o r a

t an y tim e i n the future , excluding an y remaining warrant y (3 0 day s total ) except thos e item s listedbelow , if any . Propert y ID : Propert y Address : • l ^ o L"i (^^^^ ^ J 0 ^ ^ ^t- y ^ -^^- C 

# T^c Owner : -f^^^-x y 0 ' A^oi , Phone : {HoZ ^ ^"7 ^ -" 7 J ^ ^ Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item :

• 

### Require d correction s t o complet e th e propert y 

## S.o M u^cS t C ^ - ^ r— 

# f A .s ^ ^ b 

### h/^ c K£y [ S r 

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

# Q y y ^ \ A / ^ iV-^-i u Owner' s Signatur e Dat ePruden t Technologies , Inc . (Prudent ) i s under contrac t wit hth e U . S . Environmental Protectio nAgenc y (EPA) t o cleanup lead
contaminate dsoU s at anumbe r ofpropertie s locate dinOmaha , Nebraska , includin g th e property locate dat 3 - 0 H RWfCKir^U K

A\ / Th e EPA request s you r permissio nt o allo w Pruden t t o perfor masoi l cleanu p a t thi s property t o tetnoi i lead-contamuiate dsoil . B y signin g thi s form , tti e property owne r grant s permissio nt o Pruden t t o perfor m activitie s relate dt o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio nofth 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 Pruden t Sout hOmah aOffic e fo r th e Omah a LeadSit e cleanup.a t (402 ) 733-1188 ; 733-1455 . General question s abou t th e Omah aLeadSit e cleanu p ca nb e directe dt o th e EPA Publi c Informatio nCenter s at (402 ) 731-304 5 (Sout hOmah aoffice) . Property Acces s Grante dBy : 

# yj i cy- c 

# A^c C (Pleas e Prin t Name ) Property Owne r Signature : (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r —pleas e print ) RESIDEN T NAME : Owne r Rente r RESIDEN TADDRESS : ^ k A 

# r)w.^>X ^

4y( / O --^ ^ I F RENTAL , PROPERT Y OWNE D B Y 

## n ^ OWNER' S MAILIN G ADDRESS ; Y ' Y ^<y^ r' ( \ ^^ . 'Z. ^ TX A OWNER' S TELEPHON E NUMBE R - HOME : J L 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 7 

### YE S NO 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 CHILDRENUNDE 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 : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t ar e pursuan t t o Sectio n10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t ofacces s t o th e property i s provide dfor i nSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry for "determinin g th e nee dfo r response , o r 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. "

8080 Ward Parkway , Suit e 405 5600 S . 10' " Stree t 4242 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 68107 Sa n Antonio , T X 7822 9 Phone : (816) 363-3703 Phone : (402)733-145 5 Phone : (210)822-958 8ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^ D 2 - ^ CUcoiod l A v>- ^ Date : I O | Z* ^ ) ( Q Phone : BVID :



# y ^ Propert y Ch ^ 808 0 War d Parkway , ^uit e 40 5 560 0 SI O S t MMHca l Drive , Suit e 425 0 Kansa s city , M O 6411 4 Omaha , Nebrask a 6810 7 San'AntonIo , TX 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 Fax : (210 ) 579-657 7

# 3578 4 Own e rName : DOMiNiC KJ ZAPPI AOmah a Lea d Sit e /Wddress : 202 8 GRAN D A V Sit e Sketc h Phone : "^ w : S ampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B RYASCPXA-3578 4 F l 

# I2_a . pp m 

## \3 r 

# D RYBSCPXA-3578 4 F2 

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# D RYCSCPXA-3578 4 B 1 pp m 

# D RYDSCPXA-3578 4 B 2 pp m 

# n RD200PXAO070 4 BZ ­ pp m 

# n n RQJ0GPXAO570 4 GZ ­ pp m 

# n D RPZ0GPXAf357( M PZ ­ pp m 

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# n Numbe ro f Sample s = ; 4 * "<*lVe \ 

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## HA Y

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Wa-^ i .QUrflif x «i . - i^v^ . Omah aLeadSit e 4613 0

# Lega l Description : 3 2 X 12 5 

# A ViHiii M 

### Printed : Oct 25 , 201 0 www.dcgis.org/dogi sTicke t Tex t an dMa p displa y fo r Ticket : #262547 ht^://w\yw.dhoaor^irthintemet/MessageTexl/MessagpTextAndMap.a. . 547 0 0 ^irth i Origina l Cal l Date : 10/25/1 0 Wor kto Begi n Date : 10/27/1 0 Time : 11:3 2 am Time : 12:0 0 pm Op : SIVA1896 7 State : NE Address : 202 8 County : DOUGLA S Street : GRAN D AV E Place : OMAH A Twp : 15 NRng : 13 E Sect-Qtr : 03-NW Twp : Rng : Sect-Qtr : Lega l Given : C Typ e of Work : SOI L LEA D REMEDIATIO NPROJEC T Locatio nof 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 of Excavation : 6 FT Corne r Lot: N Front : Y Rear : Involve s Tunnelin g or Horizonta l Borin g : N Explosives : N CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIE S DISTRIC T SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO F CIT YOFOMAHA
TRAFFICSEWE R RICH/TRAFFI C Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLI C POWE R DISTRIC T EL M LOCATIN G Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNN E 1C QWES T LOCA L NETWOR K EL M LOCATIN G Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

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### CONSTHUCTIO N me . SOLUTION S 

## SIT E SAFET Y HAZARD ANALYSI S Address : 2/ ? 2y i -^sgrua^JLJ&/.
- Excavatio n Date : Crew : BackfiU 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 Wail s Fence s Tree s Structure s Drivewa y Sprinkle r Syste m Othier Cre w Forema n Conditio n Hazard s Correctiv e Actio n c:/ ^ A=^. > 1..,^ . "-^ 3 - i 

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## Sit e Safet y Offic e Date :

B O Wtaf d Vaitaray . Suil B 4ff 5 SSOOSIOS t 424 2 Medica l Drive , Suit e 726 0 nsasa)y;Ma««11 4 OiKtta rNebnMta i 0810 7 So n Antonio , T X 7822 9 ftaiM : (402)733-110 8 Phcme : (2t0)822«58 8 C inS ) 363.J70 7 Flax : (402)733^108 3 Fax : (210 ) cr9-6«7 7