TRANSMITTA L of OMAH A LEA D SIT E 

SOIL REMEDIATIO N FIL E FOLDE R 

SAID#: iaZ^2,9> Date: U Jjh/o'f 

Address: ^<^I9. ^ '2D ^ 

Remediatioii Contractor: P-?^^nlo^J-. ^^c k .TnOCj Year: _QLO<^I — 

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SOIL REMEDUTION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of uroTJertv (DVD> 

Executive Summary 

EPA-provided property slcetch 

Signed Access Agreement for subject property 

Signed Access Agreemeat(s) for adjacent property 

Restoration Agreement 

Settlement documents (i.e., for dami^e or to replace plants, etc.) 

Confinnation data 

Photographs 

As-built sketch 

Satisfectory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Description ofareas not meeting ROD cleanup criteria 

Utility clearances 

Property information fiom Douglas County Assessor's Office 

TSSoT 

30054159 ini 

Superfund 
Rnd Record 

Backfill: 

Sample Area: 12433 - 3918 S 27 ST 

Owner: 

n Owner Occupied 

Owner Name: 

|BAIZ PEDRO 

Owner Addressl: 

Owner Address2: 

|3918 S 27 ST 

City: State: ZipCode: 

|OMAHA |NE |68107 

Owner Phone: Alternate Phone: 

1 

Remediation Query I Lead Remaining Query I

Resident: 

Resident Name: 

|BAIZ PEDRO 

Property Address: 

|3918 S 27 ST 

Zip Code: 

J68107 

Resident Phone 

r~— 

 Propeity Damage Query 

Contract: 

Contractor: 

|PRUDENT2009_S 

Contract Option 

[oFriONl 

Assessment: 

Qualifying Group 

pOO/CHILD 

Assessment Max XRF Value: 

679.05 
Date: l|/lS/2009 | Omaha Lead Site Remedial Action Contract # EP-R7-07-06 TO#l | Month of: October 

Property Address: 3918 S 27 ST 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE 

A.2 Issues Resolved: NONE 

A J Unique Findings: NONE 

A.4 Other Relevant Information: NONE 

CONFIRMATION SAMPLING DATA/RESULTS: 

Bl = 58 PPM @ 6"; DZ = 74 PPM @ 13"; F2 = 65 PPM @ 6"; PZ = 30 PPM @ 6"; EA = 139 PPM @ 

SCRAPE (~1) 

ATTACHMENTS 

1) Property sketch provided by EPA pursuant to contract specifica,tions 

2) Signed Access Agreement including access agreements required for crossing other properties 

3) Pre-Excavation digital video clip/photographs 

4) Post-Excavation digital video clip/photographs 

5) Documentation - Completed Close-out Checklist 

6) As-Built sketch ­

i) Shall include final lead levels v) Legend 

ii) Contamination left behind areas vi) Contractor identification 

iii) Property address vii) Date 

iv) BVID number 

7) Other items to be included in the individual property file, if available, or obtained include: 

i) Pre-excavation agreement details (if any are made with the property owner) 

ii) Properly Status Form signed by property owner 

iii) Excavation digital video in MPEG, WMV (Windows Media Video) or SWF (Flash Player) format and/or 

photographs 

iv) Signed form verifying satisfactory restoration 

v) Description of areas not meeting Interim ROD cleanup criteria. 
4

TECHNOLOGIES. INC. 

Property #: I 2^3 3 

Date/Time: 

Quad s Excavated: |J)yP2;D2.^ F ^ 

Excavation General 

xaE?Sg 

EPA Property Close Out 

Property Address: Z*hS S 2.7 S r 

Owner's Name: (Acr^c^Jj^i, v^<t< 2_ 

Contractor Group Prudent Technologies 

1. If necessary, were the correct quadrant(s) excavated and restored? 

2. If necessary, were the correct areas of drip zone excavated and restored? 

Grading Sod and Vegetation 

1. Does the grading around the perimeter ofthe house in excavated areas generally slope away 

from the house? 

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

3. Does the sod appear to be generally healthy and growdng? (Only evaluate if inspected at a 30 

day time period) 

4. Are sodded areas generally firm and evenly graded? 

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

time period) 

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

7. Was damage to landscaping or plant materials avoided? 

Gates, Fences and Retaining Walls 

1. Do gates open and close freely? (If applicable) 

2. Were all gates or fences taken down during restoration activities reinstalled? (If applicable) 

3. Was damage to gates or fences avoided? (If applicable) 

 Was damage to retaining walls avoided? (If applicable) 

Foundation, Siding and Gutters 

1. Was damage to the siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

4. Was damage to windows or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? 

Sidewalks and Driveways (Concrete) 

1. Was damage to driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

Yes No 

y 

y 

Yes No 

y 

y 

y 

y 

y 

y 

y 

Yes No 

y 

y 

y 

y 

Yes No 

y 

y 

y 

y 

y 

Yes No 

y 

y 
Owners comments: 

Inspection notes: 

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

EPA Representative S^,n.j ^ Date: /o///^c ^jj^fa^** "^V" ^ 
Property Completion 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 the restoration of the 

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: 

Property Address: . ^ ci 1 ^ S 2jlHv U_ Owner: ^Y'^A^< ^ ^'iO-'* ^ 

Phone: ^ 

Restoration Kerns in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Q/ 1 agree restoration is completed. 

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

^I^^A-^gJ ^ 

Owner's Signature Date 
mm 

TECHNOLOGIES, INC. 

Prudent Technologies, Inc. (Prudent) is under contract with the U. S. Enviranmental Protection Agency (EPA) to clean up leadcontaq)U)^Bfl soils at a num^ ofproDcrties located in Omaha, Neliraska, including the property located at 

Oy/o ' ..S f Ql ^ S Y ^. The EPA requests your permission to allow Pnident to perform a soil cleanup at this 

property to remove lead-contaminated soil. By signing this form,tiieproperty owner grants peimission to Prudent to perform 

activities related to the cleanup including soil sampling, removal of lead-contaminated soil, and restoration of the referenced property. 

Ifyou have any questions about the soil cleaniq) planned for your property, please contact Pnident's Adminislrative Clerk for the 

Omaha Lead Site cleanup. Ms. Siva S. Jampana-at (402) 733-1188. Qeneral questions about the Oinaha Lead Site cleanvq) can be 

directed to the EPA Public Infomiation Centers at (40^ 731-3045 (South Omaha office) or (402) 991-9583 (North Oinaha office). 

Property Access Granted By: JMerg?<jf^^ Pa s <^ 

(Pleas (Please ftint Nvne) ' e Print NM 

Property Owner Signature: iM-f.rrcigS RQ,^^ 7-1/'Of 

(Date) (Signature)^ 

PROPERTY INFORMATION 

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

RESIDENT NAME: Renter 

RESIDENT ADDRESS: 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS;

'$aM€ 

OWNER'S TELEPHONE NUMBER •-HOME HOME:

: l''^' r^^-^^ l 7JV - (^7^';i WORK: 

( ) 

AOE OF HOME?: YEARS. HOW LONO HAVE YOU LIVED HERE? I O YEARS. 

HAS THE EXTERIOR BEEN PAINTED OR COVERED WITH SIDING SINCE 1978? _YES NO 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: I NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement are pursuant to Section 104 ofCERCLA, 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 ofthe title." 

8080 Ward Parloway, Suite 405 5600 S 10*" Street 4242 Medical Drive, Suite 4250 

KansasCity, MO64114 Omaha, Nebraska 68107 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)733-1188 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)733-1883 Fax: (210) 579-6577 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: 3?/ ^ 5- 5 7 5^ - Date: 7'//'^ ^ 

Phone: '/O ? - 1 ^ ^ " (el^ ^' ^ 

BVID: f^ y ^ ^ 

Item NO Plants & Permanent Landscaping To Remain In Place 

On Map Description & Location 

^ln|2^- ^ :ee.v<sTV^ ^rcp-d ^ ^' ^ CU'KJ (LMTv..^ 

6«JJl HML 

{j^ccjL^^ te cut O ^<a-w>Ci.yvMv\oJ'^-<2l <3L^«-JC_£> - as. Pre-Existing Condition of Structures 

Does your Basement have a history of leaking? Yes No y 

Item NO Description & Location 

On Map f.^X' ccad^^ lA uUctlk i.jhc?ys^ C-ec.^i) 

j ^ ^ <S JO C^oiL^a>€-cfi^ <0V0 (^ui<L ^ ^ ^ 

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Property Owner Prudent Employe^ 

Signature: Signature: 

' ml/.^^'^'''^^— \ W^ce/AC"^ 6Ii i "2^ 

8080 Ward Parkway, Suite 405 5600 S 10*^ Street 4242 Medical Drive, Suite 4250 

KansasCity, MO64114 Omaha, Nebraska 68107 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)733-1188 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)733-1883 Fax: (210) 579-«S77 
___,_^ji||nrTTi II Illil I INC. AS - BUILT DRAWING 

ii-<.Kr.:i7ai 

OMAHA LEAD SUPERFUND SITE 

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Omaha Lead Sita .Exterior Paint NonhAnm Owner Hm»: AdStX^dSL^-BBiZL . Site Sketch • Good Address: 33i & t ? ig7// ) ^ D Poor PItone: H:7jV-g^^^W : Q^o t paint 

Sample Number Lead Sample 

Samples Collected LAB Concentration Collected Firm: ^ E ^^ T 4 /A.^ViO 

RYASCPXA-/<f.yj5 Fl ZT2 . Dom D Date: lOl-fe«:b 5 

RYBSCPXA- /e^3 3 F2 n Time: IV'- O Ci A ^ 

^7' ? Dom RYCSCPXA- /SH3 3 B1 n Samples Analyzed RYDSCPXA- /S¥3 3 B2 IT n 

2 2 ^ f ppm 

RDZSCPXA-/^yjra DZ 0" D XRF Unit: lO^ l Book: / JK 

ROZSCP)(A. 6 2 n n 

Date: /O-Z.S-oS ' 

,ppm RPZSCPXA- /t*f3 S PZ g»f 7 ppm B- n 

Time: P/y] 

Staff; L A Number of Samples = i ( ^ J — J 

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= 5«: 

ENTERED Ii •fiAtWie' OCT:2'8'2{ilJ5" Otrvft 

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Omaha Lead Site 

46130 • V . •'-'. ^ :>' J ^: i- s;;';i.\:':':(-:") 

CONTRACT #: EP - R7-07-06 T0#1 PRUDENTTECHNOLOGIES, INC. 
Owner Hami,: AfSTC^eS-Baiz. ^ °"?!'^i f ^** ^'*® 

Address: J^/ A c2 jfr/» ^ c2 ^ SiteSketc h 

Phone: ^T^H-Ge^e" ^ 

Sample Lead Sample Nuinber LAB Concentration Collected 

RYASCPXA- Fl ppm D 

RYBSCPXA­ /e¥33 F2 (^7^ ppm B- D 

RYCSCPXA- B1 ^OB ppm D /a^33 RYDSCPXA- B2 2 2 / ppm a" D /2¥33 RDZSCPXA- DZ 3\(a ppm 0" D

RGZGCPXA- -62 ppm D 

RPZSCPXA- /t'^33 PZ Cc>\ l ppm 

n D BNumber of Samples = ( p j j — 

fan-3 5 

-Exterior Paint North Arrow 

• Good 

• Poor 

ig'l'tot paint 

Samples Collected 

Firm: ^ E ^^ T 4 ^^ W 

Date: IO - l.feCb 5 

Time: IV' O Ci Ar ^ 

Samprfes Analyzed 

XRF Unit: /<??? Book: / ? ^ 

Date: / g - Z,B'0 ^ 

Time: ^.ll ^ 

Staff: L A 

Oniaha I.ead Site 46130 
If 

MAY 2005 - DOUGLAS COUNTY ASSESSO 
:iJV-M „.i ..^r^-v,;-:.^ '^-^i-MPrint Preview Page 1 of2 

Parcel ID 0403410000 Addition

Owner BAIZ Block Name PEDRO 

Property 3918 S27 Lot Address ST 

City OMAHA Legal 1 

Zip 168107 Legal 2 

Owner Legal 3 Address 

Owner 3918 S 27 . . . Address g J : Legal 4 

Owner OMAHA Acres City 

TrGQS urGr Owner NE 1/1/ h, t State l ^

 SOUTH OMAHA CITYLOTS 

26 

-EXW20FTFORH/W0.17 

 http://webapps.dotcomm.org:8080/TreasTax/faces/pages/taxinfo.jsp? 

j parc=0403410000 

Owner 

Zip 68107 

Assessor

Website

Unk 

 http://douglasne.mapping­

 online.com/DouglasCoNe/static/accountinfo.jsp? 

accountno=R0403410000 

Sec-TwnRng 

2 
Page 1 of2 

"> 

Create Another Ticket ] [ Back to Irth Internet ) Send Email 

YOUR TICKET NUMBER IS 2360626. 

Original Call Date: 9/10/09 Time: 8:12 am Op: SIVA18967 


Work to Begin Date: 9/14/09 Time: 8:45 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 3918 Street: S 27TH ST 


Twp: 15N Rng: 13E Sect-Qtr: 33-SE 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: SOIL LEAD REMEDIATION PROJECT 


Location of Work: LOCATE ENTIRE PROPERTY 


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


: FAX ALL CLEARS TO (402) 733 1883 


: UNSURE CORNERS 


Company : PRUDENT TECHNOLOGIES 


Contact Name: SIVA JAMPAMA Phone: (402)733-1188 


Work Being Done For: EPA 


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


Involves Tunneling or Horizontal Boring : N Explosives: N 


ATTNEBRl CXCATV LEVEL3 MUD02 OMAHACOF 0PPDGPR6 QLNNEIF 


Service Area Contact Phone Nuniber Utility Type 

Day: 80024136249 


ATTNEBRl ATT/T Alt: 

Emerg: 80024136249 


Day: 4029340469 


CXCATV COX COMMUNICATIONS, INC HEIDI Alt: 4029340469 

Emerg: 4029329757 


Day: 8773668344 


LEVEL3 LEVELS COMMUNICATIONS, LLC NA Alt: 

Emerg: 8773668344 


Day: 4025047823 

MUD02 METROPOLITAN UTILITIES DISTRICT SANDY Alt: 

Emerg: 4025047970 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/10/2009 
Page 2 of2 

OMAHACOF CITY OF OMAHA-TRAFFIC,SEWER RON

Day: 4024447197 

 Alt: 4024445161 

Emerg: 4024445160 

0PPDGPR6 OMAHA PUBLIC POWER DISTRICT NA

Day:

 Alt:

 4067289343 

 4062071494 

Emerg: 8887289343 

QLNNEIF QWEST LOCAL NETWORK NA

Day: 4067289343 

 Alt: 4062071494 

Emerg: 8887289343 

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS... 9/10/2009 
DS> 

ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SOLUTIONS 

Site Safety Hazard Analysis 

Address: ?7^ r S > J ^ Y 

Crew: 

Date: P'/f ^?^ 

Item 

Overhead Lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Structures 

Driveway 

Sprinkler System 

Crew Foreman 

Condition IHazards 

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S080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 IVIedical Drive, Suite 7250 

KansasCity, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
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