# TRANSMPCT ^ <i|f>pAHA LEA D SITE SOIL llEMDtAM) N FIL E FOLDE R SAID# : 

# 10 6 ^ 3 Date : 

# ^/l/o j Address : Jf^n£ > ^ /5'S h Remediatioi i Contractor : r^y^'^^.J - /-etA - JLyiC ; Year : ^.firfi i SOI L REMEDIATIO N PROPERT Y FIL E FOLDE RDOCUMENT S 

# 4 Vide o o f propert y (DVD ) Executiv e Summar y EPA-provide dpropert y sketch Signe dAcces s Agreemen t fo r

subject propert y D 

## Signe dAcces s Agreement(s ) fo r

adja^«n t propert y Restoratio n Agreemen t Settlemen t document s (i.e. , fo r

damag e or t o replac e plants , etc. ) Confirmation dat a Photograph s As-built sketch Satisfector y restoratio n signe db y Propert y Owne r Propert y close-out check lis t signedby EP A Descriptio n o f area s no t meeting ROD cleanu p criteri a Utilit y clearance s [ / 

## Propert y infonnatio n fromDougla s Count y Assessor' s Of&c e D D D

Ooa n 

## ire ^ Signatur e 

# Hi ^ 3005423 5 

# in n Superfun d


## CH^ototii^s.iric .Rn d Recor d 

### Backfill :

Sampl e Area : 1064 3 - 450 6 S 1 5 S T Owner : n Owne rOccupie d Owne rName : VANDERPOO L SHONN A M Owne rAddressl : Owne rAddressZ : 450 6 S 1 5 S T City : State : Zi p Code : IOMAH A :N E 6810 7 Owne rPhon e Alternat e Phone : Remediatio n Quer y 1-ea d Remainin g Quer y

Resident : Residen t Name : JOHNSO N CIND Y L Propert yAddress : 450 6 S 1 5 S T 

### Zi

p Code : 6810 7 Residen t Phon e PropertyDamag e Quer y

Contract : Contractor : PRUDENf2609_ S Contrac t Optio n BAS E Assessment : Quaiifyin g Grou p 40 0 Assessmen t Ma xXR F Valu e 47 0

### TECHNOLOGIES . IN C Propert y # : lOi^ l Date/Time : Quad s Excavated : Pl ^ 0'2 - 

# EP A EP A Propert y Clos e Ou t Propert y Address : tt.So( > -5 / 5 S r Owner' s Name : Contracto r Grou p Pruden t Technologie s Excavatio n Genera l Ye s N o 1 .If necessary , wer e th e correct quadrant(s ) excavatedan drestored ? / 2 .If necessary , wer e th e correct area s ofdri p zone excavatedan drestored ? / Gradin g So dan dVegetatio nYe s N o 1 .

Doe s th e grading aroundth e perimete r ofth e hous e i n excavatedarea s generally slop e awa y fromth e house ? / 2 .Ha s sodbeen lai din all area s tha t wer e excavated ? / 3 .

Doe s th e sodappea r t o b e generally health y an dgrowing ? (Onl y evaluat e if inspecteda t a3 0 da

y tim e period) / 4 .

Ar e soddedarea s generall y firman devenl y graded ? / 5 .Ar e th e joint s betwee n the sodstrip s generall y tight ? (Onl y evaluat e if inspecteda t a3 0 da y tim e period) / 6 .Wa s th e propert y gradedsuch tha t wate r wil l not poo l on the property ? 

# y 7 .

Wa s damag e t o landscaping or plan t material s avoided ? 

# y Gates , Fence s an dRetainin g Wall sYe s N o I . D o gate s ope n an dclos e freely? (I f applicable ) / 2 .

Wer e all gate s or fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) 

# y 3 .

Was damag e t o gate s or fence s avoided ? (If applicable ) / 4 . Was damag e t o retaining wall s avoided ? (If applicable ) / Foundation , Sidin g an dGutter sYe s N o 1 .

Was damag e t o th e siding o r trimavoided ? / 2 .

Was damag e t o th e foundation avoided ? / 3 .

Was damag e t o window s avoided ? / 4 .

Was damag e t o window s o r door screen s avoided ? / 5 .Was damag e t o downspout s or downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete )Ye ^ N o 1 . Was damag e t o drivewa y surface s avoided ? ( / 2 . Was damag e t o walkwa y surface s avoided ? ( /

# 60 6 S 

# 1 5 St ­ 

# § Owner s comments :

Inspectio n notes :

Removal an drestoratio n activate s complete includin g th e 30-da y so dwarranty : EPA Representativ e ^9^ ^ j ^Date : ij/e/o f

### « 

## Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f remova l activitie s performedo n th e belo w liste dproperty . The propert y owner' s signatur e indicate s tha t th e propert y owne r i s satisfiedwit h th e restoratio n of th e subject property , andtha t no item s ar e in question , now , or a

t an y time i n th e future , excluding an y remainin g warrant y (3 0 day s total ) except thos e item s liste dbelow , if any . Propert y ID : Propert y Address : ^^ 6 

### C 

# 5 

# fSH ^ % ^ 

### Owner : ^cx W 

## c.\( - zr* ^ ».^^IJL>J ! ^ L^ ^ 

### Phone : Restoratio n Item s I n Question :

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

] ^ I agre e restoratio n i s completed , excep t a s note d above . L J I d o no t agre e restoratio n i s complete d 

# yK\%XJ e '^^..AJ^ ^ 

# l.ni-O' ) Owner' s Signatur e Dat e

### #

Pruden t Technologies , Inc . (Pmdent ) is unda - contrac t wit h th e U. S. Environmenta l Protection Agenc y (EPA ) to clea n

up lead oontaminate dsoil s at anumbe r ofpropertie s locate d in Omaha, Nebraska , includin g th e propert y locate d at

. Th e EP A requests you r pemiission to allow Pniden t to perfor masoil cleanu pat thi s propert y to remove lead-contaminate dsoil . By signin g thi s form, tfie propert y owne r grant s pemiission to Pniden t to perfor m activitie s relatedto th e cleanu p includin g soil sanq>ling , remova l of

leadHxmtaminate dsoi L andrestoration ofth e refotnoe dproperty . If

yo

u have an y question s abou t th e soil cleanu p planne dfo r you r property , pleas e contac t Prudent' s Administrative Cler k

fo

r the Omah aLea dSit e cleanup . Ms . Siv a S. Jampana-a t (402) 733-1188 . Genera l question s abou t the Omah aLea dSit e cleanu p ca n be directed to the EP A PubU c Infomiatio n Centers at (402) 73 1 -304 5 (SouthOmahaoffice ) or (402 ) 991-938 3 (Nort h Omah aoffice) . Propert y Acces s Grante dBy : (Pleas e Prin t Name ) . Propert y Owne r Signature : (Signature) (Date ) PROPERT Y INFORMATIO N 'T t I (T o be complete d by reddcn t aiul/o r properl y owne r — pleas e print ) RESIDEN T NAME : .S U-orJ/Qc ^ \)o.\juc=}tejr^O Q [ Rente r 

### er RESIDEN T 

# rr^?^ - .s i< ^ n...L.!^^./.^i^ i IF RENTAL , PROPERT Y OWNE D BY : OWNER' S MAILIN G ADDRESS : 

## Q<^C . 

# s 1 ^ ,<rh . OWNER' S TELEPHON E NUMBER-HOME : l^Oi ^

nf S I'Oc ^

lCS > WORK : J 1 •: AO E OF HOME? : 

# •.l!2J _ YEARS . HO W LON O HAV E YO U LIVE D HERE ? 

# i£ . YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WIT H SIDIN Q SINC E 1978 ? YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : L yNUMBE 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 Y

IN TH E YAR D FO R 8 HOURS OR MOR E PE R WEEK : COMMENT S

OR SPECIA L INSTRUCTIONS : (I.E . DOOS . ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA L RESPONSE ACTIONS : Th e activitie s to be implemente d by EP A unde r thi s agreemen t ar

e pursuan t to Sectia n 10 4 ofCERCLA ,42 U.S.C . 9604 . EPA' s righ t ofacces s to th e propert yis provide dfo r in Sectio n 104(e )of CERCLA, 42 U.S . C 9605(e) , whic h provide s entr y fo r "detennining die needfo r response ,or choosin g or

taking an y respons e actio n unde r thi s title , or

otherwis e enfcrcin g the provision s ofth e title. " 808 0 War d Parkway , Suit e 40 6 2605 N. 24* " Street , Suit e 30 8 4242 Medica l Drive , Suit e 426 0 KansasCity , MO6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)604-100 5 Fax : (210 ) 579.657 7

# 3 ENVIRONMENTA L & CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : Yf^ ^ ^ - ^ ^ ^ Date : ^-^-'-^ ^ Phone : f'^Z-a^^^ ^ BVID : ^(^^ ^ Ite mN O Plant s & . Permanen t Landscapin g T o Remai n I n Plac e O n Map Descriptio n & Locatio n Mou t qftEBt ^ (h^hi ^ 

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Propert y Owne r Pruden t Employe e J h 7?/V ^ Signatur e

808 0 War d Parlcway , Suit e 40 5 250 5 N . 24* ^ Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 KansasCity , M O 6411 4 Omaha , Nebraslc a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7JIES , INC . 

## A S - BUIL T DRAWIN G OLS#:1064 3 Dat e Excavated : 07/02/200 9 

## OMAHA LEA D SUPERFUND SIT E USEP A Signed-OfTDate : Name : \/iM\t - €lui . Omah a Lea d Sit e Date : Nonh Ano w Address : U</)L . i.'~l 5 

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# 0 Dougla s County-Omaha , N E

Parce l I D Owne r Nam e Propert y Addres s Cit y Zi p Owne r Addres s Owne r Addres s Owne r City Owne r Stat e Owne r 

### \zi p 054579000 0 VANDERPOO L SHONN A M 450 6 S 1 5 S T OMAH A 6810 7

450 6 S 1 5 S T OMAH A N E 6810 7 Sec-Twn Rn g Additio n Bloc k Lo t Legal 1 Lega l 2 Legal 3 Lega l 4 Treasure r Websit e Lin k Assesso r Websit e Lin k 03-14-1 3 BEGLE Y PAR K 8 2 50X12 6

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### http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Douglas%20Cou. . . 6/11/200 9

2• • 

### Pag e 1 of 2

• YOU RTICKE T NUMBE RI S 2298590 . Origina l Cal l Date : 6/19/0 9 Time : 9:3 6 a m Op : SIVA1896 7 Wor k t o Begi n Date : 6/23/0 9 Time : 10:1 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 450 6 Street : S 15T H S T Twp : 14 NRng : 13 E Sect-Qtr : 03-NE-S E 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 .: F7 ^ AL L CLEAR S T O (402)73 3 188 3 : UNSUR E COMMENT 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 o f Excavation : 6 F T Corne r Lot : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V DIGITE L LEVEL 3 MUD0 2 OMAHACO F OPPDGPR 6 PAETE C QLNNEI F

Servic e Are a Contac t Phon e Nunibe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , INC HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 DIGITE L LIGHTCOR E N A 

### Day : Alt : 866562434 9 800850904 8 Emer g 866562434 9 LEVEL S LEVEL S COMMUNICATIONS , LL C N A 

### Day : Alt : Emer g 877366834 4 877366834 4 MUD0 2 METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day : Alt : 402504782 3• • « Pag e 2 of 2 Emerg : 402504797 0 OMAHACO F CIT Y O FOMAHA TRAFFIC.SEWE R RO N Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 0PPDGPR 6 OMAH A PUBLI C POWE R DISTRIC T NA Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 PAETE C PAETE C COMMUNICATION S N O NEE D T O CALL OU T EMERGENC Y Day : 800289190 1 Alt : Emerg : 800289190 1 QLNNEI FQWES T LOCA L NETWOR K N A Day : Alt : 406728934 3 406207149 4 Emerg : 888728934 3# ENVIRONMENTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SOLUTION S 

# Sit e Safet yHazar d Analysi s Address : ^^C , ^.y < Ex . Crew : Bf . Date : C^'lSrO ^ 

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## Sit e Safet y Office r

808 0 War d Parkway , Suit e 40 5 250 5 N . 24 " Street , Suit e 30 8 424 2 Medica ! Drive , Soit e 725 C KansasCity . M O 641 U Omaha , Nebrask a 6811 0 San Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402 ) 504-100 4 Phone : (210 ) 822-958 8 Pa vi9.\f. \ •xfK^.-ya u Fax : (402 ) 504-100 5 Fax : (210)579-657 7