## lUANSMITTA Lo f OMAB A LEA B SIT E SOI LREMEDIATIO NFIL EFOLDE R SAI D # : t^l^^hDate : ^^|\io|n 9 Address : ^\ 0 S \ Q 91 - Remediatio n Contractor : P^JU.^ h^ock . Dy^r- ^ Year : Q-QO ^ SOI LREMEDIATIO N PROPERTY FIL EFOLDE RDOCUMENTS o

i Vide o o f

propert y (DVD ) I I Executiv e Summar y EPA-provide dpropert y slcetc h ESigne dAcces s Agreemen t fo r

subjec t propert y D Signe dAcces s Agreement(s) fo r

adjacen t propert y I I Restoratio nAgreemen t D Settlcimen t document s (i.e. , fo r

damag e o r

to replace plants , etc. ) 

# i Confirmatio ndat a Photographs S As-buil t sketc h 0 Satisfector y restoratio ns^pe db y Propert y Owne r ffl Propert y close-ou t chec k

lis t signe db y EP A D Descriptio no f

area s no t meetin g RO D cleamq ) criteri a Utilit y clearance s ^ 

## Propert y informatio n fromDougla s Count y Assessor' s Offic e D D D 

## isignatur e Dat e 3005417 6 

# • H i Superfun dFin d Record Remediatio n Quer yI Lea d Remainin g QueryI Propert yDamag e Query 

### Backfill :

Sampl e Area : 4729 6 - 561 0 S 1 9 S T Owner : Resident : Contract : D Owne rOccupie d 

### Contractor : Residen t Name : Owne rName : PRUDENT200 9 S 

# I |DELEO N JOS E C Propert yAddress : Contrac t Opbo n Owne rAddressl : 

### |5610S19S r JOPTEON T 

### Zi

p Code : Owne rAddressZ : 

### [6810 7 Assessment : 11775 2 MARG O ST Residen t Phon e City : State : Zi p Code : Qualifyin g Grou p 

# r~— |OMAH A |N E |6813 6 |400/CHIL D Owne rPhone : Alternat e Phone : Assessmen t Ma xXR F Value : 1(402)884-098 3 |(402 ) 517-643 8 

# 1 60 9

### Date : l4/15/200 9 | Oinah aLea dSit e Remedia l Actio nContrac t #EP-R7-07-0 6 TO# l | Mont hof : Octobe r Propert y Address : 561 0 S 1 9 S T A . EXECUTIV ESUMMAR 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 Information : NON E CONFIRMATIO NSAMPLIN GDATA/RESULTS : B 2 = 19 9 PP M @ 12" ; D Z= 39 5 PP M @ 12" ; E A = 13 6 PP M @ SCRAP E(~1 ) ATTACHMENT S 1 ) Property sketc hprovide db y EP A piu'suan 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 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 final lea dlevel s v ) Legen d ii ) Contaminatio nlef t behin darea s vi ) Contracto r identificatio n iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include dinth e individua l property file , i f available , o r obtaine dinclude : i ) Pre-excavatio nagreement detail s (i f an y ar e mad e withth e property owner ) ii ) Propert y Statu s Formsigne db y propert y owne r iii ) Excavatio ndigita l vide o i nMPEG , WM V (Window s Medi aVideo ) o r SWF(Flas hPlayer ) format 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 . 

# tw m TKfflWDOBIBSSJM C

### TECHNOLOGIES , INC . Property # : ^ 72i?t ' Date/Time : Quad s Excavated : gl , "p^ : 

# EP A Propert y Clos e Ou t Propert y Address : 5=$ ^ S/<?St : Owner' s Name : ^^^^rS ^ O e. - /^I C > x Contracto r Grou p Pniden t Technologie s Excavatio nGenera l Ye s N o 1 . I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? y 2 . If necessary , wer e th e correc t area s ofdri p zon e excavate dan drestored ? ty Gradin g So dan dVegetatio n Ye s N o 1 .Doe s th e gradin g aroun dth e perimete r o f th e house inexcavate darea s generall y slop e awa y • ' fromth e house? 2 .Ha s so dbee nlai dinal l area s that 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 dat a3 0 day tim e period ) y 4 .Are sodde darea s generall y fir man devenl y graded ? y 5 .

Are th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 day tim e period ) y " 6 .Wa s th e property grade dsuc hthat wate r wil l no t poo l o nth e property ? 

## y

• - - - . 7 .

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

## y 2 .Were al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (I f applicable ) 

## y 3 . Wa s damag e t o gate s o r 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 1 .Wa s damag e t o th e sidin g o r tri mavoided ? 

## y 2 .Wa s damag e t o th e foundatio navoided ? 

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

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

## y 5 .

Wa s damag e t o downspout s o r downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e t o driveway surface s avoided ? 

## y 2 . Wa s damag e t o walkway surface s avoided ? 

# J

## Owner s comments :

Inspectio nnotes :

^» s tk> r sooeeo .



# - H K ,ol^ '



## Remova l andrestoratio nactivate s complet e including th e 30-da y so dwarranty : EP A Representativ e Date : /o/2f/o j ^ 'asa . ^

I A

## Propert yCompletio n Agreemen t Thi s agreemen t dociunent s th e completio no f removal activitie s performe do nth e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e property owner i s satisfie dwithth e restoratio no f th e subjec t property , an dtha t n o item s ar e inquestion , 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 D) : Propert y Address: ^ ^ ( 0 ^ [ < ^ t ^ ^ ^ 

## Owner : Q^ ^ (Z^J> ^ L&)A ' Phone : Restoratio n Item s i n Question :

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

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

# TAO M )wner' s Signatur e IPruden t Technologies , Inc . (Piudent ) i s unde r contrac t withth e U . S . Environmenta l Protectio nAgenc y (EPA ) t o clea nu p lead contaminate dsoil s at anumbe r ofpropertie s locate di nOmaha , Nebraska , includin g th e property locate dat

. Th e EP A request s you r permissio nt o allo w IMident t o performasoi l cleanu p at thi s property t o remov e 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 relate dt o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio no f th e reference dproperty . I f

yo u hav e an y question s abou t th e soi l cleanu p planne dfo r you r property , pleas e contac t th e Pruden t Offic e for th e Omah aLea dSite cleanu p at (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca nb e directe dt o th e EP A Publi c Informatio n Center s at (402 ) 731-304 5 (SouthOmah aoffice ) o r (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Grante dBy : (Pleas e Prin t Name ) Property Owne r Signature : (Signature ) (Date ) PROPERT Y INFORMATIO N (X ab t complete db y residen t and/o r propert y owne r— pleas e print ) RESIDEN TNAME : 

### eJ».^>A-.>J O Owne r Rente r RESIDEN TADDRESS : 

## \^vt ^ 9>t - (^^•>^\ ^ \ ^

(^^0 ^ I F RENTAL . PROPERT YOWNE D BY: . 0-^g^> ^ OWNER' S MAILIN G ADDRESS ; f . . Aa , ^
OWNER' S TELEPHON E NUMBER-HOME : ( > WORK : AG E O F HOME? : tOf > YEARS . HO W LON G HAV E YO U bWC B HERE ? 

### ^ YEARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDIN G SINC E 1978 ? 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 1^ 1 BE 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. )

ALITHORm r FO RENVIRONMENTA LRESPONS EACTIONS i 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 960S(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. "

ttA n *Hr*f*'i . -« i n..Uf. \ctENVIRONMENTA L& CONSTRUCTIO N 

## TECHNOLOGIES , EVC . SERVICE S 

# Propert y Statu s For m Address : t ? Q . IC ? " ^ \ ^ ' ^ V— Date : Phone : BVID : ItemN O Plant s & Permanen t Landscapin g T o Remai nI n Plac e O nMap Descriptio n& Locatio n 

# ^ o Ji^Unlc i Vbi^ r «i3--enrv^^Dc»v~<'^-ci-fiCJS V '^^'"^^—^^xs t



## Pre-Existin g Conditio no f

Structure s Doe s you r Basemen t hav e ahistory o f

leaking ? Ye s ISoyy / Ite mN O Descriptio n& Locatio n O nMa p 

# u ^ c W-J-^- ^ '^^^t ^

Propert y Pruden t Employe e Signature ! Signature : )08 0 War d Parkviray , Suit e 40 5 560 0 S lO" ' Stree t 424 2 Medica l Drive , Suit e 425 0 <an5a s City , M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , T X 7822 9 'hone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 -ax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7niE.S . INC . 

## AS-BUIL T DRAWIN G Ot,S#:4729 6 Dat e Kxiavatrd : 09/16/200 9 rsKP A Si|>nc(l-Ot r Dote : 

## OMAHA LEAD SUPERJtJNl ) SfT E 4729 6 Exterio rPain t Oniah a Lea d Sit e • Goo d Sit e Sketc h Samplin g Addras* : S61 0 S1 9 S T n Not pain t Sampl e Numbe r Lea d Sampl e |. _ Sample s Collecte d Concentratio n Collecte d RYASCPXA-472e e F 1 2\\oo mS ^ n Dale : L,nL.in' A RVB3CP)(A-t72« l RYCSCPXA-4729 6 RYDSCPXA-472e 6 -F2 - B 1 B 2 3Sf i GXi ^ poit i pp m oo m

n S I Ca ^ n

\ Z D Time : iO - )• ? Sample s Analyze d RD2SCPXA-4729 e DZ ^2. 0 > Do m B ^

D XR F unit : QS*i( i Boole : JAA WQZ60P)tA-4729 6 nPZSCPX A47206 -PZ La b RYC8CPLA^729 6 Resul t 41 1 pp m pp m pp m Numbe ro f Sample s = D D D D Date : T-O l Time : _j^t l Staff : _t\SW '0 &

, . . - Fron t Right , B l = Bac k Left , B 2 = Back Rig m DZ -^

Dri p Zone . G Z = Garden , P Z = Pla y Al l qua^wit s u n u wwa d fro m th e elrea t ten^jropTly

CONTRA a # : E P - R7^7-0 6 T0# 1 PRUDENTTECHNOLOGIES , INC .Omah a Lea d Sit e Sit e Sketc h Samplin g Address : 561 0 S 19 ST Sampl e Numtie r RYASCPXA-4729 6 RYD3CPXA-4729 0 RYCSCPXA-4729 6 RYDSCPXA-4729 6 RDZSCPXA-4729 6 ROii60P)(A-47£B 6 RPiZOOr'XA4720 6 Lea d Sampl e Uk B Concentratio n Collecte d F1 pp m D pp m D Bl pp m ET 82 pp m D 

## 4729 6 Exterio rPain t Nort hArro w • Goo d Ea^oo r [ 3 No t pain t Sample s Collecte d Firm :PE Tr.r . Q& T \ Date : L*hL,inf i Time : 10-1 ? Sample s Analyze d

_ La b RYCSCPLA-4729 6 

# n Staff : Resul t 41 1 pp m Numbe r of Sample s 

# LC Li ns w • Fron t Right , 81 = Bac k Left , B2 = Bac k Righ t DZ • Dri p Zone , GZ = Gatden , PZ = Pla y Al l quadrant s ar e as vienw d fro m the strsat , < rty vt/AU . ALL'C ^ '•••»T4';*r>" » k 

## JUN f 8 POOi

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# '(^m &1 

## 35 6 

# mr tTiEcK

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# r ;ZI I DZ pp m D XR F Unit : 

### GSH O Boole : ?Af t -SZ - pp m 

### D D Date : _ OB -P2 - pp m D Time : 

## Ad V\/AU< . 

## S. :1*= 1 3^ . 0««cd . 31.DecJ) 7

## 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 Cit y Owne r Stat e Owne r Zi p Sec-Twn Rn g 181467000 0 DELEO N JOSE C 5610S1 9 S T OMAH A 6810 7 ^^^^ ^

^ARG O S T OMAH A N E 6813 6 10-14-1 3 Additio n Bloc k Lo t Lega l 1 Lega l 2 Lega l 3 Lega l 4 Acre s Treasure r Websit e Un k Assesso r Websit e Lin k MORRISON S AD D T O S O OMAH A A 3 N1/ 2 25X13 3

0.0 8 http://webapps.dotcomm.org:8080/TreasTax/faces/pages/taxinfo.jsp ? parc=181467000 0 http://douglasne.mapping online.com/DouglasCoNe/static/accountinfo.jsp ? accountno=R181467000 0 

## http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 8/18/2009

### Pag e 1 of 2

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### [ Creat e Anothe rTicke t ] [ Bac k t o Irti i Interne t ] Sen d Emai l



### • YOU RTICKE T NUMBE RI S 2359829 . Origina l Cal l Date : 9/09/0 9 Time : 11:0 1 a m Op : SIVA1896 7 Wor k t o Begi n Date : 9/11/0 9 Time : 11:3 0 a m State : N E County : DOUGLA S Place : OMAH A Address : 561 0 Street : S 19T H S T Twp : 14 NRng : 13 E Sect-Qtr : 10-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 : FAX AL L CLEAR S TO : (402)733-188 3 : FA X AL L CLEAR S T O (402 ) 73 3 188 3 : UNSUR E CORNER S Compan y: PRUDEN T TECHNOLOGIE S Contac t Name : SIVAJAMPAM 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 : Y Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N ALT87 2 ATTNEBR l CXCAT V LEVEL 3 MUD0 2 OMAHACO F 0PPDGPR 6 PAETE C QLNNEI F



### Servic e Are a Contac t Phon e Numbe r Utilit y Typ e ALT87 2 WINDSTREA M COMMUNICATIO N N A Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 ATTNEBR l ATT/ T Day : 8002413624 9 Alt : Emerg : 8002413624 9 CXCAT V CO X COMMUNICATIONS , IN C HEID I 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL 3 LEVEL S COMMUNICATIONS , LL C N A 

### Day : Alt : 877366834 4

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