### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 

### 3303 9 DATE : 1/1 5 ADDRESS : 381 9 N 1 8 S T REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 20H| l 

### SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENT S [ ^ ^ PRE AN D POS T VIDE O O F PORPERT Y (DVD ) EXECUTIV E SUMMAR Y 3023754 0 

# mi m d EPA-PROVIDE D PROPERT Y SKETC H Superfun d m SIGNE D ACCES S AGREEMEN T FOR SUBJEC T PROPERT Y D SIGNE D ACCES S AGREEMENT{S ) FOR ADJACEN T PROPERT Y

• RESTORATIO N AGREEMEN T D SETTLEMEN T DOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) a CONFIRMATIO N DAT A U PHOTOGRAPH S d AS-BUIL T SKETC H 1 3 SATISFACTOR Y RESTORATIO N SIGNE D B Y PROPERT Y OWNE R m PROPERT Y CLOSE-OU T CHECKLIS T SIGNE D B Y EP A ffl DESCRIPTIO N O F AREA S NOT MEETIN G RO D CLEANU P CRITERI A a UTILIT Y CLEARANCE S m PROPERT Y INFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E D D D 

# ^I K •ilaMft SIGNATUR E DAT E

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLeadSit e Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address ; 381 9 N1 8 S T A . EXECUTIV E SUMMAR 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 N SAMPLIN GDATA/RESULTS : B l = 34 6 PP M ( @ 4" ; N O EASEMENT ATTACHMENT S 1 ) Propert y sketc hprovidedb y EP A pursuan t t o contract speciflcation 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 video 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 behin darea s vi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s to be includedi n th e individua l propert y file, i f available , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (ifan 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(FlashPlayer ) forma t and/or photograph s iv ) Signe dfor mverifying satisfactor y restoration v ) Description of area s not meeting hiterimRO D cleanu p criteria .

ECHNOLOGIES . INC ,Fin d Record Remediatio n QueryI Lea d Remainin g Quer yI Propert yDamag e Quer y 

### Backfill :

Sampi e Area : 3303 9 ­ 381 9 N 1 8 S T Owner : Use rProvide d Owne rInformatio n Resident : n Owne rOccupie d 

### Owne rName : Owne rName : Resident Name : ISCOTTAN N 

# 1 I MARTI N IREN E Owne rAddressl : Owne rAddress : Propert yAddress : 

# 1 )381 9 N 1 8 S T Owne rAddress2 : Zi p Code : )382 1 N 1 8 S T |68110 - City : State : ZipCode : City : State: ' ZipCode : Residen t Phon e JOMAH A |N E |68110 ­ 

# 1 1 1 I Owne rPhon e Alternat e Phone : Owne rPhone : Alternat e Phone : 

# 1 1 1
Contract : Assessment : Contractor : jPRUDENT2010_ S Qualifyin g Grou p |40 0 Contrac t Opti i 3

n |BAS E Assessment Ma xXR F Valu e j 506.2 7TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t ?ro[itrty#.-^303 ^ Propert y Address : ^ B r 1 ^ A > \9
­ '? K Date/Time : Owner' s Name : /4n( v "^O ^ Quad s Excavated : ^ \ Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera ) Ye s N o I . I f necessarv . wer e ih e correct quadrant(s ) excavatedandrestored ? / 2 . I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? / Gradin g So dan dVegetatio n Ye s N o 1 .

Doe s th e grading aroundthe perimete r o

f th e hous e in excavatedarea s generall y slop e awa y / fro mthe house ? 2 .Has sodbee n laidi n all area s tha t wer e excavated ? / 3 .

Doe s Ih e so dappea r to b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecteda t a3 0 da

y lim e period) / 4 .

Ar e soddedarea s generally finn an devenl y graded ? / 5 .Ar e tli e joint s between the sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da t a3 0 da y / tim e penod ) 6 .

Wa s the propert y grade dsuc htlia t wate r will no l pool on lli e property ? / 7 .Was dainag e to landscapin g o r plan t material s avoided ? / Gates , Fence s an dRetainingWaii s Ye s N o 1 .

D o gate s ope n andclos e freely ? (I f applicable ) / 

### 2 .

Wer e al l gale s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f apphcable ) / 

### 3 .

Wa s damag e lo gate s or fence s avoided ? (I f applicable ) 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 the siding o r trimavoided ? 

# y 2 , Wa s damag e t o th e foimdation avoided ? 

# y 3 .

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

Wa s damag e t o window s or 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 ) Yes , N o Wa s damag e t o diivewa y surface s avoided ? 

# y 2 .

Wa s damag e t o walkwa y surface s avoided ?

### Owner s comments :

Inspectio n notes :

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### Remova l an drestoratio n activate s complet e includin g th e 30-da y so dwarranty : EP A Representativ e Qo y -^o ^ ^Date : njislio• X'ilNOl.OOlKS . INC . 

### A S - BUIL T DRAWIN G ()l. S #33(13 9 Dat e Kxcavated : 11/22/201 0 

### OMAH A LEA D SUPERFUN D SIT E ISEP A Signed-O n Dale : 

## 3303 S Exlerio rPain t North Arro w Omah a Lea d Sit e • Good Sit e Sketc h • Poo r Samplin g Address : 3SI" 1 N IS* ^ S + [g'No t pain t Sampl e Numbe r Lea d Sampl e Sample s Collecte d LA B Concentratio n Collecte d Fir m 

### AS W RYASCPXA-3303« l F 1 pp m 

### D Dal e <b/2g>/<:> 3 • TiYDGOrXra i 3303 ^ P S pp m 

### D D Tim e RYCSCPXA-3303* } B 1 pp m [ ^ 

### D Sample s Analyze d RYDSCPXl ^ 3303'- } B a pp m 

### D D RDZSCPXAaaOii S D Z pp m 

### D XR F Unit : 5S0 4 Book : . 

# n RGZSCPXA3303 q SZ . pp m 

### D Dale : <£./Z7/o3 , 

### D • RPZOCrX A93t53' ^ PZ ' pp m 

### D Time : 

### D p m Staff : 

### B^V Numbe ro f Sample s = Legend : F l = 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 = Play Al l quadrant s are a s viewe d fro m th e street , facin g propert y

CONTRAC T # : EP-S7-10-0 5 PRUDEN T TECHNOLOGIES , INC .

# SERI V Propert yCompletio n Agreemen t Thi s agreemen t document s th e completion of remova l activitie s performe do n th e below listedproperty . Th e propert y ovmer' s signatur e indicate s tha t th e propert y owne r i s satisfiedwit hth e restoratio n of the subject property , an dtha t no 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 remaining warrant y (3 0 day s total ) except thos e item s liste dbelow , ifany . Propert y ID : '^1 > Q 3 ^ Propert y Address : "" ^ < ^ j ( ^ ^ i ^ fi ^ S t ( ^ Owner ; -^Nf ^ ^Q , Restoratio n Item s I n Question :

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

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

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### Owner' s Signatur e Dat ePmden t Tectaologies , Inc . (Prudent ) is unde r contrac t withth e U. S. Environmenta l Protectio n Agenc y (EPA ) to clea n up lead
contaminate dsoil s at anumbe r of

prooertie s locate d in Omaha , Nebraska , includin g th e propert y locate dat y ^ ^ ' \ ^ fs j I oH > S f Tli e EP A request s you r permissio n to allo w Pruden t to performasoi l cleanu p at

thi s property to remov e lead-contaminate dsoil . By signin g thi s form , th e propert y owne r grant s permissio n to Pruden t to perfor m activitie s relate d to th e cleanu p includin g soi l sampling , remova lof lead-contaminale dsoil , an drestoratio n ofth e reference dproperty . If

yo 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 l sout hoffic e for th e Omah aLea d Site cleanup-a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n be directe d to th e EP A Publi c Informatio n Center s al (402 ) 731-304 5 (SouthOmali aoffice ) or (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 (T o be complete d by residen t and/o r propert y owne r —pleas e print ) RESIDEN T NAME : Cj(n\ \ ^ ^ -^Q X / ~ /•^wne r y Rente r RESIOEN T ADDRESS :
IF RENTAL , PROPERT Y OWNE D BY : 

## A.r\r\ S> Ci^ M OWNER' S MAILIN G ADORE S 

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OWNER' S TELEPHONENUMBE R - HOME : J L WORK :



# i%2 i 4S 3 -Ibli W AG E OF HOME? : H O ^ YEARS . HO W LON G HAV E YO U LIVE D HERE ? \< \ V ^ YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WIT H SIDIN G SINC E 1978 ? /^ YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : I Q NUMBE 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 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. ) [ SPECIA L INSTRU C

ALITHORIT y FO RENVIRONMENTA LRESPONS E ACTIONS . Th e activitie s to be implemente d by EP A unde r thi s agreemen t are pursuantt o Seaio n 10 4 ofCERCLA , 42 U S.C . 9604 . EPA' s rightof acces s to th e propert y is provide dfor mSectio n 104(e ) of CERCLA , 42 U.S . C 9605(e) , whic hprovide s enti y fo r "detenninin g th e nee dfor response , ov choosin gor takin g any respons e actio n underthi s title , or otherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkway , Suit e 40 5 560 0 S 10 St 424 2 Medica l Drive , Suit e 42S 0 Kansa s City,'M O 6411 4 Omaha . Metirask a 6210 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone ; •;402 l 733-118 8 Phone : (210)822-958 8 Fax : <816 ) 363-370 7 Fai- ­ (402 ) 733-188 3 Fax : (210)579-667 7ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address:3^2 l t ^ li^ ^ Si
- ^^t^'-1 1 - t ( ^ - A Q Phone : J^ £^-^-/^J ^

Propert y Owne r Signature : (CQA/L

## fee B08 0 War d Partcway , Suit e 40 5 KansasCity , M O 6411 4 Phone : (816 ) 363-370 3 Fax : (816 ) 363-370 7 560 0 S 1 0 S t Omaha , Nebrask a6810 7 Phone : (402)733-118 8

Fax : (402)733-188 3 ^ y 424 2 Medldti l Drive , Suit e 425 0 Sa n Antonio , T X 7822 9 Phone : (210)822-958 8 Fax : (210 ) 579-657 7

# 3303 q Bcterio rPain t N0i6iArrDB ( Omah a Laa d Sit o Q Goo d Sit e Sketc h • Poo r Samplin g Address : 3A\< i K l la ^

S f Q'No t pain t Sampt e Numlpe r Lea d Conoentra t o n Sampl e Collecte d Rm i Sampie s C (MeO M RYASCPXA ­ l<! 7 pp m 

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# n c n Tims : H;t>Sa m 5Q ^ pp m pp m 

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# c n XR F Unit : 55Qfc > Book : RCZSCPX A 3C100 T OZ pp m 

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# c n Date: ^ ^ •RPzoopx A siteg s ^ ^ pp m 

## D 

# c n Time : |2D 1 Numbe rGFSam]:Ae5= : 2 . Staff : £L ^ Legend : F 1 = Fron t Left , F 2 = Fron t Right , B l = Bac k Left , B 2 = Bacd cRi| ^ D Z = Drt p Zone , G Z = qam«t , P Z = Pla y Al

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# A Printed : No v 16,201 0 www.dcgis.org/dogi s

### Pag e 1 of 1

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

### YOURTICKE T NUMBE R IS 2642958 . Origina l Cal l Date : 11/16/1 0 Time : 12:2 9 pm Op : SIVA1896 7 Wor k to Begi n Date : 11/18/1 0 Time : 1:0 0 pm State : NE County : DOUGLA S Place : OMAH A Address : 381 9 Street : N18T H ST Tv*p : 15 NRng : 13 E Sect-Qtr : 03-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e of Work : soi l lea d remediatio n projec t Locatio n of Work : LOCAT E ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 Compan y: PRUDENT TECHNOLOGIE S Contac t Name : SIV AJAMPAM A Phone : (402)733-118 8 Wor k Bein g Don e For : EP A Dept h of Excavation : 6F T Corne r Lot : Y Front : Y Rear : Y Involve s Tunnelin g or Horizonta l Borin g : N Explosives : N CXCAT V

MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contact Phon e Nunibe r Utilit y Typ e 

### Day : 402934046 9 CXCAT V COX COMMUNICATIONS , INC 

### lElD l Alt : 402934046 9 Emerg : 402932975 7 Day : 402504782 3 MUDO l METROPOLITA N UTILITIE S DISTRIC T ) Y SAND Alt : 

### Emerg : 402504797 0 Day : 402444719 7 OMAHACOFCITY OFOMAHA-TRAFFICSEWERRICH/TRAFFIC Alt : 402444516 1 

### Emerg : 402444516 0 Day : 406728934 3 OPPDGPR5 OMAH A PUBLIC POWE RDISTRIC T EL M LOCATINGAlt : 406207149 4 

### Emerg : 888728934 3 Day : 406728934 3 QLNNEI C QWES T LOCA LNETWOR K 

### EL M LOCATIN GAlt : 406207149 4 Emerg : 888728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULT. . . 11/16/201 0Jt.i'^ivlJ.'^lLll.KJLINi V AM D 

### CONSTRUCTIO N 

## mc . SOLUTION S 

## SIT E SAFET Y HAZAR D ANALYSI S Address : •^&}c, ^ . j ^ 

## Excavatioi i Date : Crew : Backfil l 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 Sidewal k Foundatio n Retainin g Wall s Fence s Tree s Stracture s Driveway Sprinkle r Syste m Othe r Cre w Forema n Conditio n Hazard s Correctiv e Actio n OJ ^ 3jf^' ^ 

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