## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL E FOLDE R SAID# : ^^1) ^ Date : \ \|^(:.|o ^ Addiess : 1>15 ) I LoxM^o i A ^ Remediatio n Contractor : fiyu^g.J 7^p^ ^ - Tvl C y Year : ..^^L . SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S e

f Vide o o f property (DVD ) Q Executiv e Summary EEPA-provide dproperty sketc h Q Signe dAcces s Agreemen t for subjec t propert y D Signe dAcces s Agreement(s ) fo r adjacen t propert y o

i Restorado nAgreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) U Confirmatio ndat a EPhotograph s i l As-buil t sketc h H

! Satisfectory restoratio nsigne db y Property Owne r l i Property close-ou t chec k lis t signe db y EP A D Descriptio no f areas no t meetin g RO D cleanu p criteri a O Utilit y clearance s 

## EProperty informatio nfromDougla s County Assessor' s Offic e D Q D (^t ^

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## Signatur e Dat e 3005416 7 

# ni l Superfun dRn d Recor d Remediatio n Quei yI Lea d Remainin g Quer yj Propert yDamag e Query 

### Backfill :

Sampl e Area : 3811 8 - 372 1 LAURE L A V Owner : Resident : D Owne rOccupie d Residen t Name : Owne rName : [ANDERSO N JUDm i D JBLACKSTON E GAR Y Propeit yAddress : Owne rAddressl : [372 1 LAURE L A V 

# I Zi p Code : [6811 1 Owne rAddressZ : |372 1 LAURE L AV E Residen t Phon e 

### City : State : Zi p Code : 

# I [OMAH A [ N E |6811 1 Aitemat e Phone : Owne rPhone : 

# I Contract : Contractor : [PRUDEm7009_ S Contrac t Optio n OPTIO N 2 Assessment : Qualifyin g Grou p [40 0 Assessmen t l^a xXR F Value : 

# r 448. 9

### Date ; l4/15/200 9 | Omah aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l | Monthof : Octobe r Propert y Address : 372 1 LAURELA V A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : NON E A. 2 Issue s Resolved : NON E A J Uniqu e Findings : NON E A. 4 Othe r Relevan t Information : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : B l = 24 7 PP M @ 8" ; B 2 = 13 4 PP M @ 8" ; D Z = 8 5 PP M @ 12'' ; N O EASEMENT ATTACHMENT S 1 ) Propert y sketc hprovidedb y EP A pursuan t t o contract specification s 2 ) SignedAcces s Agreemen t including acces s agreement s requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l vide o clip/photograph s 4 ) Post-Excavation digita l vide o clip/photograph s 5 ) Documentation - CompletedClose-ou t Checklis t 6 ) As-Built sketch i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contamination lef t behindarea s vi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e includedi n th e individua l propert y file, i f available , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (i f an y ar e mad e wit hth e propert y owner ) ii ) Propert y Statu s For msignedb y propert y owne r iii ) Excavation digita l vide o i n MPEG , WM V (Window s Medi aVideo ) or SW F(Flas hPlayer ) forma t and/or photograph s iv ) Signedfor mverifying satisfactor y restoratio n v ) Description of area s not meeting InterimRO D cleanu p criteria .

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### TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Property # : S^^/'S r Propert y Address : S'T^ ) ^^" ^ Date/Time : Owner' s Name : /4 - n ^ | K \\^ay< ^ Quad s Excavated : 6 ' r *^ / ^ Contracto r Grou p Pruden t Technologie s Excavatio n Genera l Ye s 1 . I f necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? / 2 , I f necessary , wer e th e correc t area s o f dri p zon e excavate dan drestored ? / Gradin g So dan dVegetatio n Ye s 1 , Doe s th e gradin g aroun dth e perimete r o f th e house i n excavate darea s generall y slop e awa y / fromth e house ? 2 . Ha s so dbee n lai di n al 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 ) 4 . Are sodde darea s generall y firman devenl y graded ? / 5 .

Are th e joint s betwee n th e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 day / tim e period ) 6 . Wa s th e property grade dsuc htha t wate r wil l no t poo l o n th e property ? / 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? / Gates , Fence s an dRetainin g Wall s Ye s 1 . D o gate s ope n an dclos e freely? (I f applicable ) / 2 . Wer e al l gate s o r fence s take n dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) / 3 . Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) / 4 . Wa s damag e t o retainin g wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye s 1 . Wa s damag e t o th e sidin g o r tri mavoided ? / 2 . Wa s damag e t o th e foundatio n avoided ? / 3 . Wa s damag e t o window s avoided ? / 4 . Wa s damag e t o window s o r doo r screen s avoided ? / 5 . Wa s damag e t o downspout s o r downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s 1 , Wa s damag e t o drivewa y surface s avoided ? / 2 . Wa s damag e t o walkway surface s avoided ? ^ N o

N o

N o

N o

N o

## Owner s comments :

Inspectio n notes :

Remova l andrestoratio n activate s complet e includin g th e 30-da y so dwarranty : EP A Representativ e ^^>SL ^ 

## Date : lofiofo^

## Propert yCompietio n Agreemen t Thi s agreemen t document s th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth e restoratio n o f th e subjec t property , an dtha t n o item s ar e i n question , now , o r a t an y tim e i n th 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 ID : Propert y Address : 

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A^ ^ Owner : AAY ^ eldU> ^

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^ Phone : Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item : Require d correction s t o complet e th e property :

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

/Owner' s Signatur e Dat e I

### TECHNOLOGIES , INC . Pruden t Teohnologip , Inc . (Prudent ) i s unde r contrac t wit hthe U . S . Environmenta l Protection Agenc y (EPA ) to clea n u p leadcjmtammate d«oil s a t anymbe^ f propertie s locate di n Omaha, Nebraska , includin g the propert y locate da

t 37^ 1 l^f\jiff^ A rf^^K- ' • ^ * ^ ^ request s you r permissio n to allo w Pruden t t o perfor masoil cleanu p a t thi s propert y t o remove lead-contaminatedsoil . B y signing thi s form, the propert y owne r grant s permission t o Pruden t t o perfor m activitie s relatedto (h e cleaniq > includin g soil sampling , reniova l o

f lead-containinate dsoil , cm drestoration o f the reference dproperty . I f you have an y question s abou t the soil cleanu p platme dfo r you r property , pleas e contac t Prudent' s Adminislraliv e Cler k

fo

r th e Oinah aLea dSit e cleanup . Ms . Siv aS . Jampana-a t (402) 733-1188 . Genera l question s abou t th

e Omah aLea dSit e cleanu p ca n b e directedt o the EP A IPubU c hiformatio n Centers a t (402) 731-3045 (Sout hOmah aoffice ) o

r (402) 991-958 3 (Nort hOmah aofiice) . Propert y Acces s Grante dBy : Xi . (^>yOtU^ < fA*^-CaWicc HjtKfltf^J^r^f, " 1 (Pleas e Prin t Name) Propert y Owne r Signature : X > • (V^>.f.rr o M ^ ^JrJij^ - (^JLcuUCcil>vt^ » c I I « I A c , (Signature) ^ ^ (Date ) <ill»l® T PROPERT Y INFORMATIO N (To b e complete db y residen t and/o r property owner — pkas e print ) RESIDEN T NAME : MffC; , (XiLJN^tU^ i U*^ - ^ U « <hfsit'\(d/,^'(^ ^ Rente r RESIDEN T ADDRES S 1 : / / / )
I F RENTAL , PROPERT Y OWNE D BY : OWNER' S MAILIN G ADDRESS ; 

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### O 

# 3 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 I 

# y . a NUMBE^ F OCCUPANT S UNDE R 7 YEAR S OLD : e» C NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y I 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 Y GATES , ETC. ) 

## Of2 ^ - 

## ^Sj ^ AUTHORIT Y FO RENVIRONMENTA LRESPONSE ACTIONS i Th e activitie s t o b e implemente dby EP A unde r thi s agreemen t ar

e pursuan t to Sectio n 10 4 o f CERCLA , 4 2 U.S.C . %04 . EPA' s righ t o

f acces s t o the propert y i s provide dfo r i

n Sectio n 104(e ) o

f CERCLA, 42 U.S . C 9605(e) , whic hprovide s entr y fo r "determining th e needfo r response , o r choosing o r taking an y respons e actio n unde r thi s title , o r otherwis e enforcin g the provision s o f th

e title. " 808 0 War d Parkway , Suit e 40 S 560 0 3 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)733-118 8 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7

# IRUDE ] PECHNOLOGIES , INC . 

# Pronert y Statu s For m Address : 37^ / LaOht l Hu€ ^ Date : <f^/^^0 9 Phon e Plant s & Permanen t Landscapin g Item# O

n Ma p Description an dLocatio n


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Propert y Owne r Pruden t Employee Signature : • » OjuoafcJtc o H S WJVJULJ * 

## Signature : ^A//J^^te^yvO- ­ 808 0 War d Parkway , Suit e 40 5 250 5 N . 24* " street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask 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 7

### • • miKs . i\c . 

## A S - BUIL T DRAWIN G OMAHA LEA D SUPERFUN D SIT E

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## http://vvww.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 9/3/2009Pag e 1 of 2

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### . YOURTICKE T NUMBE RI S 2372127 . Origina l Cal l Date : 9/24/0 9 Time : 3:5 0 p m Op : SIVA1896 7 Wor k t o Begi n Date : 9/28/0 9 Time : 4:1 5 p m State : N E County : DOUGLA S Place : OMAH A Address : 372 1 Street : LAURE L AV E Twp : 16 NRng : 13 E Sect-Qtr : 32-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 : 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 : 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 : Y Involve s Tunnelin g o r Horizonta l Borin g ; NExplosives : N ALT87 2 CXCAT V METR O MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Number Utilit y Typ e ALT87 2 WINDSTREA M COMMUNICATIO N 

### N A Day : 406728934 3 Ah : 406207149 4 Emerg : 888728934 3 CXCAT V CO X COMMUNICATIONS , IN C 

### HEID I Day : 402934046 9 Ah : 402934046 9 Emerg : 402932975 7 METR O METR O COMM . COLLEG E CHRIS Day : 402457230 7 Ah : 402672703 3 Emerg : 402457231 3 MUDO l METROPOLITA N UTILITIES DISTRICT SAND Y Day : 402504782 3

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### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T N A 

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### TECHNOLOGIES , INC . SOLUTION S 

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