TECHNOLOCIES. INC. 

PROPERTY SUMMARY SHEET 

Oinaha Lead Site Remedial Action Contract # EP-S7-10-05 

Said: 32258 PropertyAddress: 3614 N2 1 ST 

Executive Siummary: 

Issues Encountered: None 

Issues Resolved: None 

Unique Findings: 

Other Relevant Information: 

Confirmation Sampling data/results: F2=247 @ PPM @ 7"; EA=325 PPM @ Scrape; Fl =171 PPM 

(SScrape 2"; DZ=181 PPM@3". 

Attachments : 

Documents Included in the Property File: Yes No N/A 

Property sketch provided by EPA pursuant to contract specifications V 

onto adjacent properties 

Other Documents: 

Legend: Yes - Induded In the File; No - Not Included in the File; N/A - Does not Apply. 

Signed Access Agreement; including access agreements obtained (if required) for crossing V 

Pre-excavation agreement details (if any are made with the Property owner) V 

Pre-Excavation digital video clip V 

Sampling data sheet V 

Post-Excavation digital video clip V 

Documentation - Completed EPA close-out checklist V 

As-Built sketch V 

Omaha Lead Site Database sample information document. V 

Signed form verifying satisfactory restoration V 

30 day SOD warranty pictures V 

Utility clearances document V 

Property information from Douglas County Assessor's office. V 

Settlement documents (i.e. for any damages, replacement of plants, etc.) V 

Site safety hazard analysis document with pictures. V 

Prudent Representative: EPA Acceptance: 

..\' 

Date: Date: 

Prudent Technologies, Inc. | 2505 N. 24TH Street, Suite 308 jOmaha, NE 68110 USA j Tel. 402.504.1004 j 

Fax: 402.504.1005 

Environmental Engineering & Services j Remediation j Construction 
Name: 0Y6^e . oco^^ ^ 

Address: 3C ^ ^ *^ -xi ^ 

Phone: f^0>) ^/V-tf:72< r 

Omaha Lead Site 

Site Sketch 

Date: 

Time: iC'-/-i 

North Arrow 

Team zi/lc<^/^ig/fr6 YUS ^ BVID# 30.^5^ ^ XRF Code ^SO ^ 

Sample Number 

/?YAYirf>yA • 3P2s a 

Lead Concentration 

^Y' S ^ ^ ppm 

Mii^^^m 

^^ r i^ ^ ppm 

ppm 

ppm 

Confirmation Sample 

f Yes n 

f^Yes n 

P/ Yes n y res •—' 

/j2Yes n 

/}a:Yes n 

Yes n 

Yes • 

No 2 ^ 

No Q 

No E 

No 0 

No a 

No a 

No • 

• z^is -

Omaha Lead Site 46130 
PROPERTY ACCESS FORM 

Prudent Technologies, Inc. (Prudent) is under contract with the U. S. Environmental Protection Agency 

(EPA) to clean up lead-contaminated .soils at a number ofproperties located in Omaha. Nebraska, including the 

property located at '^C B t M Kf 2—\ S ^ . The EPA requests your permission lo allow Prudent to 

perfonn a soil cleanup at this property' to remove lead-contaminated soil. By signing this form, the property owner 

grants permission to Prudent to perform activities related to the cleanup including soil sampling, removal of leadcontaminated soil, and restoration ofthe referenced propert)'. 

If you have any questions about the soil cleanup planned for your propertj', please contact the Prudent 

Office for the Omaha Lead Site cleanup at (402) 733-1188. General questions about the Omaha Lead Site cleanup 

can be directed to the EPA Public Information Centers at (402) 731-3045 (South Omaha office) or (402) 991-9583 

(North Omaha office). 

Ifyour property has a gravel or dirt driveways or parking areas then the removal and replacement ofthe soil 

and/or gravel during the remediation process does not make your illegal gravel/dirt driveways or parking areas legal. 

Propertj' Access Granted By: 

Propertj' Owner Signature: 

(Please Prim Name) 

(Signature) 

4/y li 

(Dale) 

Propeny Accessed by: ,J^ ~ .0%^c-&J!!!^::X­ (Prudent Employee Name) 

PROPERTY INFORIVIATION (To be completed by resident and/or property owner ­ please print) 

RESIDENT NAME: Y)<ii l^V)\ C Wle.et<LjS . fowner\ Renter 

2. IF RENTAL, PROPERTY OWNED BY: 

3. OWNER'S MAILING ADDRESS; Sf\Ht-"' ( '' ^ SG^ M hO^ 2 J S H Q'^-^^oX^^. f^ & ^ ^ ' 

4. OWNER'S TELEPHONE NUMBER - HOME: {HbZ.) '"^( ^ ^^^Ift^ORK: _L J_ 

5. TENANT'S TELEPHONE NUMBER - HOME: X yfO^KTZL 

6. AGE OF HOME?: i ^.^^^ YEARS. HOW LONG HAVE YOU LIVED HERE? '^< > YEARS. 

7. HAS THE EXTERIOR BEEN PAINTED OR COVERED WITH SIDING SINCE 1978? -'^YES NO 

8. # OF OCCUPANTS UNDER AGE OF 7: / ) # OF OCCUPANTS AT OR OVER 7 YEARS OLD 

9. # OF CHILDREN UNDER AGE OF 7 WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

10. COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, NEIGHBORING PROPERTY 

ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this 

agreement are pursuant to Section 104 of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property is 

provided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entry for "determining the need for 

response, or choosing or taking any response action under this title, or otherwise enforcing the provisions of the 

title." 

Prudent Technologies Inc. 5600 S. lO"" St. Omaha, NE 68107, 

402.733.1188 (Office) 402.733.1883 (Fax) 
NRUDEN ENVIROMVlENTAL & ' CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: 3 fe I ^| \ ; -2. i ^ K Date: O*-/ / Z^l ) T-'^ • ( 

Phone: q^^^^ ^.^^ ^ _^^^ BVID: 3ZZ5 ? 

(> Z, 

NOTICE TO BE GIVEN TO: OWNER TENANT BOTH 

l O 'o 

HOW MUCH NOTICE IS NEEDED: 24 HOURS 48 HOURS 72 HOURS 

OTHER NOTICE NEEDED (PLEASE SPECIFY): 

PHONE # AND NAME TO WHOM NOTICE NEEDS TO BE GIVEN: 

WILL NEIGHBORING PROPERTY NEED TO BE USED FOR ACCESS? YES /N O ; ^ 

IF NEIGHBORING PROPERTY WILL NEED TO BE ACCESSED WHAT IS THE ADDRESS: 

WAS AN ACCESS FORM OBTAINED FROM THE NEIGHBOR? YES (NO 

WILL A FENCE NEED TO BE TAKEN DOWN TO OBTAIN ACCESS? YES •o 

IF ANSWERED YES TO NUMBER 12 PLEASE PROVIDE LOCATION OF FENCE: 

IS THERE PRE-EXISTING FACIAL DAMAGE TO THE PROPERTY AND IF SO PLEASE PROVIDED LOCATION AND DESCRIPTION 

OFSUCH: YES NO SPECIFY: 

IS THERE PRE-EXISTING CONCRETE DAMAGE TO THE PROPERTY AND IF SO PLEASE PROVIDED LOCATION AND 

DESCRIPTION OF SUCH: YES NO SPECIFY: 

\yCyU. ^-^ T) fi.^-^ ^-^ '^- ^ 

Prudent Employee ^/n J 

Signature: 

Prudent Technologies Inc. 5600 S. lO"" St. Omaha, NE 68107, 

402.733.1188 (Office) 402.733.1883 (Fax) 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC, SERVICES 

Property Inspection Form 

Address: 3 4* ^ Ki 7^\ <>\^- Date: LJ-30-l | 

Phone: ^03 . - II H - n U k i BVID: b 9­

Pre-Existing Damage: Please write in detail and included location 

and description of damage: 

Concrete Damage: 

.' rex cXc SL 

Facial Damage Including Siding: 

m ije..cO -|^32i=^, OU^JlXA. ' ^ d--^ v-v.C^ V^- ^ " ^ ''i' 

Does Basement have history of leaking or flooding? YES \NOy 

Does Homeowner want sod replaced in all areas?( YES/ NO IfNO please provide what 

areas are not to be sodded and what needs to be rcjilaced instead of sod (i.e. mulch, rock, 

leave bare) if mulch or rock please specify what type and color; 

ANY OTHER DAMAGE OR REQUESTS: 

Property Owner Prudent Employee 

Signatur ^^y~- Signature: 

DATE DATE: 
• • 

ENVmONM£NTAL& 

CONSTRUCTION 

TECHNOLOGIiES, INC. SERVfCES 

XMF CLEARANCE SMEET 


PROPERTYADDRESS: 3^7/^ /V ^1 ^"^ 


PROPERTY IB: 5'^'^ ^ ^z 


MAF HAS BEEN REVSEWEB AND NO MISSED AREAS EXIST, r-:? 

WAS CONTAMINATION LEFT BEHIND? IF YES WHERE AND MMENSIONSi 

:a A./. DATE DEPTH QUADRANT READING 

s Fl ^ 3 i 7 TA ^XRFTECHr^- ^^:. ^ <^ i. y< F2 2 4 7 

READINGS BO ,IENTEB IN Bl 

LOG BOOK? X^ NO .• B2 

GARDEN 

PLAYZONE • 

s EASEMENT / / .>'^S . V > ^ l^z \€l 

• 
'-. -X ,.iM.EiJWi 

TECHNOLOGIES, INC. 

Property #: '*^ '7.7-.'^'^ 

Property-Address: '5'5^-fH-/\J 2..\ y^-. 

Date/Time: Owner's Name: f-P^'Wi^ ' e M -^C'ViS 

Quads Excavated: p !, P2 - tO'2l Contractor Group: Prudent Technologies, Inc., 

E.xcavation General 

Yes No 

1. If necessary, were the correct quadra]it(s) excavaied and restored? J 

2. If necessary, were the correct areas ofdrip zone excavated aiid restored? y 

Grading Sod and Vegetation Yes No 

1. Does the gradmg ajound Uie perimeter of the house in excavated areas gener;illy slope away 

from tlie house? / 

2. Has sod been laid in all areas that were excavated? y 

3. Does tiie sod appear to be generally healtliy and growing? (Only evaluate if inspected at a 30 

day time period) y 

4. Are sodded areas generally firm and evenly graded? / 

5. Are tlie joints between vlie sod strips generally tight? (Only evaluate if inspected at a 30 day 

time period) y 

6. Was the property graded such Ihal water will not pool on the property? / 

7. Was daniage to landscaping or plant materiaJs avoided? / 

Gates, Fences and Retaining Walllls Yes No 

1. Do gates open and close freely? (Ifapplicable) y 

2. Were all gates or fences talven down during restoration activities reinstalled? (Ifapplicable) / 

3. Was damage to gales or fences avoided? (Ifapplicable) / 

4. Was damage to retaining walls avoided? (If applicable) / 

Foundation, Siding and Gutters Yes No 

I. Was dajnage to the siding or trim avoided? 

y 

2. Was damage to the foimdation avoided? 

/ 

3. Was daniage to windows avoided? 

/ 

4. Was damage to windows or door screens avoided? 

y 

5. Was damage to downspouts or downspoui e.-^tensions avoided? 

y 

Sidewalks annd Driveways (Concrete) Yes No 

1. Was daniage to dnveway surfaces avoided? / 

2. Was da.mage to walkway surfaces avoided? / 
Owmers c©mm«inits: 

Inspection Diioites; 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA Representati^ve Q*^ " ^ Dale- \lllln^_ 
AS - BUILT DRAWIN # 

Sample Araa: SiZSU - 3614 N 21 ST. 

Dste Excavated: 08/31/2011 OIVIAHA LEAD SUPERFUND SITE 

Samplad By: Isacc CONTRACT #: EP-S7-10-05 

Name: iJ.''.'-i:,.i • • <: c. o -> -: • • ^ Omaha Lead Site 

AadrebS". ^ t ' ^' '-- t, i ^-v 

Site SKetch 

PMone: t-^d-) 6 f -I - (.-ji s" 

:? /^c ^'/^'/gwzc• X-^5. -• BVID # 3 3. •> i>" ^ 

Sample Number 

Lead Concentration 

ppm 

ppm 

ppm 

ppm 5 /?m,yiry=^.^ - sp^t,-^^ 

ppm 

ppm 

ppm 

• T • ^ -4 

"Cc-^y .y^ 

^ - VJ.. •-f n-'?-^ 

£ 3 3 i / 7 i/.S' 

DZ A '^2 7 iTify 

.:Xi^.iF..y..rx 

y K 

- H ­

y 

;:5-7:Sii'^^. y -J^O'<9 f 

' ^ y 

^-•^I-Jt- i'-v^.-xr.; 

Fi I y ­

OriiDli;i l.cad SiUDate: Mo.-th Arrcw 

Time: / Z '•' •-•'^< 

XRF Code 

r '

' "

V'

/'•Ye s E 

/liYe s • No SD 

Yes • No CD 

Yes a No • 

,© 

•. : g : ' 

(?; 

— > 

5':^aYConfirmation Sample 

 Yes • No Q " 

 Yes a No ^

 Yes a No 13 

• No

PrudentTechnologies, Ir.c. | 250S N. 24TH Str-eet, Suite 308 |Omalia, ^E 331:0 USA | Toi. <02.504.1C04 | Fax: 402.504.ICC5 

Environmental ^ngir.esring &. Services \ P.er.iediatioa | Construction 

46130 
Pnoperfy M o Clean-iip M b I Sample t-dRS ^VOGfffBHC KCpiVr' 

Sample Area: 32258 - 3614 N 21 ST 

Sa.T.ple Date - Quadrant Paramete » XRF Re - XRF Res .•.jEn^ r ^ MskerPtace ' LeadRfiiMffiaJ',.^ ^ Sampled B .4 QA Confirmee - LabJ 

8ai.^11D 1 LEAD 181 mgAcg 3! g . . _ ISSAC N/A 

8 /31/2011 E l LEAD — + 325 m9''kg 1 ISSAC N/A - D B 

8.'31/2011F1 LEAD 1 171 mykg 2 H ISSAC H/A 

J _8/31./2011 F2 LEAD 1 247 rT»3/kg Ii H ISSAC N/A 

• • '•" 1 LEAD mgi'kg 0 N,.'A 

I RtcoiA M M f *A N: . F,;-r Search < r 
I t-mo Kear a i | napeaeition yuery | Leaa Kemammg yuery ; j woperty Ligr^ e yuern' 

[ftpperty M b Oean-up M b Sample Inf^P^i^omer Caite^ ni 

Sample Area: 32258 3614 N 21 ST 

Lab Resul - Lat> Result Unifc •. 1 , . •. •- ••,...:.-.. y ^-•• ,-•- .;,--.,^. .-~/-ii jfe_.-^m^v Rwnaik s .•• .- . ^j. . v , ,r^ w, ^ 

. Omgflt g j •. • . •"- - ; . " " . --.• . •'.-./" • .• ; ; .. . '". '•• .. ,••; . - ,'/• ' - / ; 

0 mg'kg _ _ ^ ^^^^_^__ _ 

0 rpg'Tcg J _ ^ __ _ 

0 rng/kg ] ^ ^ .___ ^ .._ ^ _ ^_^_^. 

_ 0 mg/kg _ j _^^__ ^ _^^_^_^ ^ 

|Reco«fcl9' < i • H •- ^fe fig filter .[SMfdJ 
<i>trr\ 

Property Coinpletion Agreement 

This agreement documents the completion of removal activities performed on the below listed property. 

The property owner's signature indicates that the property owner is satisfied with (he restoration ofthe 

subject property, and that no items are in question, now, or at any time in the future, excluding any 

remaining warranty (30 days total) except those items listed below, if any. 

Property ID: ^^^^'j p 

PropertyAddress: 3^/ V //-^^ - ^ 

Owner: OtUA/lTlF^tA 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Required corrections to complete the property: 

5TI agre I e restoration is completed. 

 I I do not agree restoration is completed at (noted deficiencies above) 

V'^/ZI 

Owner's Signature ' Date 

I
^/^^^^^^^^^^^^^^B^ ^^^^^^^^^^^H r. . 

Kii^V^ 

IRTH One Call Page I of 1 

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Create Another Ticket Go to Home Page Send Email 

• YOUR TICKET NUMBER IS 2840506. 

Original Call Date:

Work to Begin Date:

 9/06/11

 9/08/11

 Time:

 Time:

 2:21 pm 

 2:30 pm 

Op: ASHLEIGH18967 

State: NE 

Address: 3614 

County: DOUGLAS 

Street: N 21ST ST 

Place: OMTUiA 

Twp: 15N Rng: 13E

Twp: Rng:

Legal Given: C 

 Sect-Qtr: 03-SW,10-NW 

 Sect-Qtr: 

Type of Work: LEAD SOIL REMEDIATION PROJECT 

Location of Work: ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: EMAIL ALL CLEARS TO: AANIKPUTA@PRUDENTWEB.COM 

: UNSURE CORNERS 

Company 

Contact Name 

Alt. Contact 

PRUDENT TECHNOLOGIES 

ASHLEIGH ANIKPUTA 

NONE 

Phone: (402)733-1188 

Work Being Done For: EPA 

Depth of Excavation: 6 FT Corner Lot: N Front: Y Rear: 

Involves Tunneling or Horizontal Boring : N Explosives: N 

ALT872 CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 

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Create Another Ticket Go to Home Page Send Email 

• YOUR TICKET NUMBER IS 2836533. 

Original Call Date:

Work to Begin Date:

 8/31/11

 9/02/11

 Time: 11:40 am 

 Time: 12:00 pm 

Op: ASHLEIGH18967 

State: NE 

Address: 3614 

County: DOUGLAS 

Street: N 21ST ST 

Place: OMAHA 

Twp: 15N Rng: 13E

Twp: Rng:

Legal Given: C 

 Sect-Qtr: 03-SW,10-NW 

 Sect-Qtr: 

Type of Work: LEAD SOIL REMEDIATION PROJECT 

Location of Work: ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: EMAIL ALL CLEARS TO: AANIKPUTA@PRUDENTWEB.COM 

: UNSURE CORNERS 

Company 

Contact Name 

Alt. Contact 

PRUDENT TECHNOLOGIES 

ASHLEIGH ANIKPUTA 

NONE 

Phone: (402)733-1188 

Work Being Done For: EPA 

Depth of Excavation: 6 FT Corner Lot: N Front: Y

Involves Tunneling or Horizontal Boring : N Explosives: N 

ALT872 CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 

 Rear: Y 

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• YOUR TICKET NUMBER IS 2831312. 

Original Call Date:

Work to Begin Date:

 8/25/11

 8/29/11

 Time:

 Time:

 9:18 am 

 9:30 am 

Op: ASHLEIGH18967 

State: NE 

Address: 3614 

County: DOUGLAS 

Street: N 21ST ST 

Place: OMAHA 

Twp: 15N Rng: 13E

Twp: Rng:

Legal Given: C 

 Sect-Qtr: 03-SW,10-NW 

 Sect-Qtr: 

Type of Work: LEAD SOIL REMEDIATION 

Location of Work: ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: EMAIL ALL CLEARS TO: AANIKPUTA@PRUDENTWEB.COM 

: UNSURE CORNERS 

Company 

Contact Name 

Alt. Contact 

PRUDENT TECHNOLOGIES 

ASHLEIGH ANIKPUTA 

NONE 

Phone: (402)733-1188 

Work Being Done For: EPA 

Depth of Excavation: 6FT Corner Lot: N Front: Y Rear: 

Involves Tunneling or Horizontal Boring : N Explosives: N 

ALT872 CXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 

http://www.dhon.org/IRTHOneCaliyTicketyTicketCreation.aspx7ViewTicketI D=803582 8/25/2011 

N 361

4 N 21 St 

A Printed

: Mar 3 1.201 

^^•\\^^•.dcyi?: cfii'ilo^i': 
bite Job Hcza. 

AddressiUy_ika\^A : 14f^/ 

Analysis Compieted By L^^<^Vi roc^A Prudent Technologies Health and Safety Officer 

Location 

Item B1B2 Condition Hazards Corrective Action 

Overhead Power Lines Electrocution 

Gas Lines Underground Gas, water Call Digger Hotline Prior to perform locates prior to 

Water Lines Utilities leaks beginning work on property 

Sewer Line If utilities are not located contact Supervisor, Safety 

Septic Tank Personnel to notify them of issue 

Propane/Butane Go to another property to work as directed 

Foundation (DZ) •iS&cl 

Driveway 

Side walk M 

Trees 

Plants/Garden GZ 

Access to Property 

Busy Street (need to close 

off Lane) 

Hand Dig b-^ 

Pets /bees/wasps/ticks/red 

ants/spiders 

Poison Ivy/Poison Oak 

Miscellaneous (^OiGJX'^'* 

Time Print Name ofeach Signature of each Changes in conditions resulting in additional 

Date Revie\iewe^ d Reviewed crew member crew ra ember safety assessment ifapplicable 

H 3_o_ P A 3 £ '^rlc>£'L(Z^ 

J. c^ ^ y li 'X^/y "-f^x: 

Ail..^/ ­ / ^ ^ . .u 

^ Q!g fjur./ft'^ 

^ ^ -4 M.4^g^ 

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