SAID# : 3139 0 

### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R DATE : 1/1 5 ADDRESS : 322 1 PINKNE YS T REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201 ^



# i SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S d PR E AN D POS TVIDE O O F PORPERT Y(DVD ) d EXECUTIV E SUMMAR Y E f EPA-PROVIDE D PROPERT YSKETC H d SIGNE D ACCES S AGREEMEN TFOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FOR ADJACEN TPROPERT Y W RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R T O REPLAC E PLANTS , ETC. ) d CONFIRMATIO N DAT A PHOTOGRAPH S / AS-BUIL TSKETCH SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R PROPERT YCLOSE-OUTCHECKLIS TSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A m UTILIT YCLEARANCE S d PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E 

## D D D

SIGNATUR E DAT E 

### 3021843 4 

# Hillilli i Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Oniah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address ; 322 1 PINKNE Y 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 = 22 4 PP M @ 6" ; N O EASEMEN T ATTACHMENT S 1 ) Property sketc hprovide db y EP A 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 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 ) 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 nagreemen t detail s (i f an y ar e mad e withth e property owner ) ii ) Property Statu s Formsigne db y property owne r iii ) Excavatio n digita l vide o in MPEG , 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 .Fin d Recon j Remediatio n Quer y Lea d Remainin g Quer yI Propert yDamag e Quer y 

### Backfill :

Sampl e Area : 3139 0 ­ 322 1 PINKNE YS T Owner : Use rProvide d Owne rInformatio n Resident : n Owne rOccupie d Owne rName : [VINSO N WILLIA M Owne rAddressl : 

# 1 Owne rAddressZ : j 1405 5 PIN E ST City : lOMAH A Owne rPhon e 1(402 ) 758-187 9 State : Zi p Code : JN E |68144 - Alternat e Phone : 1(402 ) 714-020 0 Owne rName : 

# 1 Owne rAddress : 

# 1 City : 

# 1 Owne rPhone : 

# 1 " State : Zi p Code : 

# 1 1 Alternat e Phone : 

# 1 Residen t Name : Propert yAddress : |322 1 PINKNE YST Zi p Code : |68111 - Residen t Phon e

Contract : Assessment : Contractor : |PRUDENT2010_S Qualifyin g Grou p p'o o Contrac t Optio n |OPnO N 2 Assessmen t Ma xXR F Valu e | 496.7 4TECHNOLOCnSS . iiSic . 

# EP A Propert y Clos e Ou t Property# : 3>(3^< ^ Propert y Address:'5^'^ ^ P«^-J^r<o ^ 5"t . Date/Time : Owner'sName : t^'l^?*-" ^ l/iVso- ^ Quad s Excavated : B 2 - Contracto r Group : Pruden t Technologies , Inc. . Excavatio n Genera l Ye s I I f necessary , wer e th e correc t quadjnaiit(s ) excavate dan drestored ? / 2 . If necessary , wer e th e correc t area s o f dri p zon e excavate dan drestored ? 

# y Gradin g So dan dVegetatio n Ye s 1 .Doe s th e gradin g aroun dth e perimete r of th e house i n excavate darea s generall y slop e away / fromth e house' ' 2 Ha s so dbee n lai din al l area s tha t wer e excavated ? 

# y r^

. Doe s di e so dappear t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t a3 0 day lim e period ) 

# y 4 . Are sodde darea s generall y fim i an devenl y graded ? / 5 . Ar e th e joint s betwee n th e so dstrip s generall y light ? (Onl y evaluat e if inspecte dat a3 0 da y 

# y tun e penod ) 6 . Wa s th e property grade dsuc htliat wate r wil l no t poo l o ndi e property ? 

# y 7 . Wa s diiniag e t o landscapin g o r plan t material s avoided ? 

# y Gates , Fence s an dRetainin g WaU s Ye s 1 . D o gate s ope n an dclos e freely ? (I f apphcable ) 

# y 2 . Were al l gate s o r fence s take n dow n durin g restoratio nactivitie s reinstalled ? (I f applicable ) y / 3 Wa s dainag 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 1 Wa s damag e t o th e sidin g o r tri mavoided ? 

# y 2 . Wa s damag e l o th e foundalio n avoided ? 

## y Wa s damag e l o window s avoided ? 

# y 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 ) Ve s Wa s daiiiae c l o diivewa v surface s avoided ? 2 . Wa s damag e t o walkwa y surface s avoided'. ' No

No

N o

No

No

## Owner s comments :

Inspectio n notes :

/ .



## Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarranty ; EP A Representativ e j9ct o j^e* ^ Date : ijiiji iRJHNOl.OGIES , INC , 

### A S - BUIL T DRAWIN G OL S #3139 0 Dat e Excavated : 10/27/201 0 

### MAH A LEA D SUPERFUN D S I liSEP. 4 Signed-OI T Date : 

# L

3139 0 Exterio r Pain t Mort hArro w Omah a Lea d Sit e Owne r Name : WiLUAM VINSO N • Goo d Sit e Sketc h Address : 322 1 PINKNCYST__ _

Numbe r o

f Sample s '•-{ • Poo r Phone : » J!02-T58-16T 9 W g-lflo t pain l \ Sampl e Numbe r RYASCPXA-3139 0 RYBSCPXA-3139 0 F l F 2 Lea d Cor«:entrat(o n /y(t pp m ^/ O pp m Sampi e Collecte d 

### E K LA B 

### D D Sample s Collecte d 

### F^rm . .££.-AT4( A Date : Q H - l^ " Cv-^ ' Time : S-O T SAX RYCSCPXA-3139 0 RYDSCPXA-3139 0 8 1 B 2 

### ^J L ^? 7 pp m pp m 

### D D Sample s Analyze d RD2GCPXA-3139 0 O Z pp m 

### D D XRFUnit : /£ > i 7 Book : 1^2 . RG^-SGPJWr*^3&©—-«3
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### D D Date : J Q .-JI-OS
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### D D Tim e /'/ ^ Staff : 4 ^

­ legend : F 1 = Fron t Left . F 2 = Fron t Right , 8 1 - Bac k Left , B 2 = Bac k Righ t D Z • - Dri p Zone , G Z = Garden , P Z = Pla y Af

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; Pj-ft)VCA)£ y ;5 r N O EASEMEN T CONTRAC T# : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

### Thi s agreeinent document s th e completiono f remova l activitie s perfonne do n th e belo w hste dproperty Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth e restoratio nofth e subjec t property , an dtha t n o item s ar e in question , now , o r at an y tim e i n th e future , excludin g any remaining warranty (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Property ID : 

## •^^IS^c ? Property Address : ^ ^ ^ I P; > ^y - r ^ 

# ^"°"
- [A)?lPj7rvv ^\yYx.icA , I Phone : Restoratio n litem s i n Qyestiom :

V ] 1 agre e restoratio n i s completed , excep t a s note d above .

I I d o no t agre e restoratio n I s complete d


# I Z - Z l
- 

# 2,^1 ^ VxA / 'wner' s Signatur e I

# V yr»V i Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Environmental Protectio n Agenc y (EPA ) t o clea nup lead
contwiinate dsojl s at anumberp f propertie s locate di nOmaha , Nebraska , includin g th e property locate da t "^JTAP>''A-tg-VV£J- j J ^ Th e EP A request s you r pennissio n t o allo w Pruden t t o perfor masoi l cleanu p a t this profflt } t o remove lead-conniminate dsoil . B y signin g this form , th e property owne r grant s permissio n t o Pruden t t o perfor m activitie s relate dt o th e cleanu p includin g soi l sampling , removal o f lead-contaminate dsoil , an drestoratio n ofth 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,,at (402 ) 733-1188 ; 733-14SS . General question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informatio n Center s at (402 ) 731-304 5 (Sout hOmah aoffice) . Property Acces s Grante dI y" ^ (Pleas e Prin t Name ) 

# / o Propert yOwne rSimatuieK^ ^ lyUAjOuyiLMy ^ V JAy^STlAy ^

^ / / y(Signature ) / (Dale ) PROPERT YINFORMATIO N (T o b e complete d b yresiden t and/o rpropert yowne r—DleasCprhrtK. . RESIDEN TNAME : y V x(L^U^J ^ \tt\ r^ Owne r1 J Rente r RESIDEN TADDR I 

### ^%^ \ 

### gg^f r\\t ^ J^SJLi . I F RENTAL , PROPERT YOWNE D BY : 

### yO r\XJ < rtr\A.y ^ OWNER' S MAILIN G ADDRESS;; , > 

# S t QvoJ U K3 £ ^^)V c y OWNER' S TELEPHON E NUMBER - HOME : J _ 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 CHILDRENUNDE R 7 YEAR S OL D WH O PLA Y I NTH E YAR D FO R S 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 EPA unde r this agreemen t ar e pursuan t t o Sectio n 10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t ofacces s t o th e property i s provide dfo r i

n Sectio n 104(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 ofth e title. "

808 0 War d Parkway , Suit e 40 5 560 0 S . 10' " Stree t 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-145 5 Phone : (210)822-958 8ENVIRONMENTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : S* ^ l i \ ^ ' , Phon e

(_Pfopert y Owne r Signature : IfJ^f/uA* ^ [J . Xi^^kn A J 808 0 War d Parkway , Suit e 40 5 560 0 S 1 0 S t 424 2 Medica l drive , Suit e 425 0 Kansa s City , M O 6411 4 Phone : (816 ) 363-370 3 Omaha , Nebrask a 6810 7 Phone : (402)733-118 8 

### < L Sa n Antonio , TX 7822 9 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7

## H 

# lega l dimensions : 5 0 X 12 8 

# A Printed : De c 02 . 201 0 www.dcgi s org/dogi s 

## -^^U l f^nluie M Q
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### Pag e 1 o f 1

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

# r

• YOURTICKE T NUMBERI S 2624845 . Origina l Cal l Date : 10/25/1 0 Wor k t o Begi n Date : 10/27/1 0 Time : Time : 8:0 9 a m 8:4 5 a m Op : SIVA1896 7 State : N E Address : 322 1 County : DOUGLA S Street : PINKNE Y S T Place : OMAH A Twp : 15 NRng : 13 E Sect-Qtr : 09-N W Twp : Rng : Sect-Qtr : Lega l Given: , C Typ e o f Work : SOI L LEA D REMEDIATIONPROJEC 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: 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 : NFront : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V

MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Nunibe r Utility Typ e CXCAT V COX COMMUNICATIONS , INC HEIDI 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIE S DISTRICT SANDY 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACOFCIT Y OFOMAHA-TRAFFIC,SEWE R RICH/TRAFFIC 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 OPPDGPR5 OMAH A PUBLIC POWE RDISTRICT EL M LOCATING Day : 406728934 3 Alt : 406207149 4 

### Emerg : 888728934 3 QLNN EI C QWES T LOCA LNETWOR K 

### EL M LOCATIN G Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 

### http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT. . . 10/25/201 0TEmiNOUM|k , 

### mc . CONSTRUCnO N SOLUTION S 

## SIT ESAFET Y HAZAR D ANALYSI S j=^-*~ i 

## Address : 

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# lL=-=i.ji i 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 Sidewalk Foundatio n Retainin g Wall s Fence s Tree s Structure s Driveway Sprinkle r Syste m Othe r Cre w Forema n Conditio n Hazard s Correctiv e Actio n c:^/ ^ ^^ ' 

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## Sit e Safet y Offic e Date :

M Wan t Vaitanqr . Suit e 4(ff i SSOOSIOS t 424 2 Mwiica l Drive , Suit e 728 0 nsMCi|y;MO«411 4 Omata ^ NaliiaAl a 0810 7 Sa n AiKeoio , T X 7822 9 one : (Sn ) SCS-ST W Phoiw : fMO ) 733-118 0 Phone : (2t0 ) 822-858 8 (:{»» ) 363.370 7 ftDC (402)733^188 3 Fax : (210 ) 6T9-687 7