## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL E FOLDE R 

# SAn)# : ^^[^^'i Date: l^-flfif^ q Address : KviL^ ^ >4y^ ^ a/W Remediatio n Contractor : YSX/^JID A

### ^ •. U Tyi C Year : ^j^n< ^ SOI LREMEDIATIO N PROPERTYFILEFOLDERDOCUMENT S ! ^ Vide o o f propert y (DVD ) s f

Executiv e Summar y EPA-provide dpropert y sketch Signe dAcces s Agreemen t fo r

subject propert y D Signe dAcces s Agreement(s ) fo r

adjacen t propert y E Restoratio n i^reemen t I S Setdement document s (i.e. , fo r

damag e or t o replac e plants , etc. ) mConfirmatio n dat a Photograph s As-built sketc h Satisfector y restoratio n signe db y Propert y Owner 

# d Propert y close-out check lis t signe db y EP A D Descriptio n o f area s no t meeting ROD cleamq ? criteri a / Utilil y dearance s 

### Propert y informatio n fromDougla s Count y Assessor' s Of&c e D D D 

### Signatur e bat e 3005412 6 

# • Uii i Superfun dRn d Recor d Remediatio n QueryI Lea d Remainin g QueryI Propert yDamag e Query Backfill :

Sampl e Area : 3866 8 - 304 7 STON E A V Owner : Resident : Contract : D Owne rOcniple d Residen t Name : Contractor : Owne rName : [RESIDEN T |PRUDENT2009_ S JRAYE R WILLIA M J Propert yAddress : Contrac t Optio n Owne rAddressl : |304 7 STON E A V OPTIO N 2 Zi p Code : Owne rAddressZ : |6811 1 Assessment : |13406POLKS T Residen t Phon e City : State : ZipCode : Qualifyin g Grou p 

# I |OMAH A |N E |6813 2 

## po o Owne rPhone : Aitemat e Phone : Assessmen t Ma xXR F Value : 

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### Date : 12/15/200 9 Omah aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Montl i of : November Propert y Address : 304 7 STON E A V 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 2 = 16 3 PP M @ 4" ; D Z = 9 3 PP M @ 12" ; E A = 11 9 PP M @ SCRAP E (~1 ) ATTACHMENT S 1 ) Propert y sketchprovidedby EP A pursuan t t o contrac t 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 ) Shall includ e fina l lea dlevel s v ) Legen d ii ) Contamination lef t behm darea 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 mdividua l propert y file, if 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 msignedby propert y owne r iii ) Excavation digita l vide o mMPEG , 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 o f area s not meeting InterimROD cleanu p criteria .TECHNOLOGIES , INC . Property* : gft*^?: ^ ^gj^ g Date/Time : Quad s Excavated : Bi- ^ D'2 . 

# EP A Propert y Clos e Ou t Propert y Address . Owner' s Name : U) \l'Ui3LAv\ ^ ^tA^ n Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l Ye s N o 1 . I f necessary , wer e th e correct quadrant(s ) excavatedandrestored ? 

## y 2 . I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? 

# y Gradin g So dan dVegetatio n Ve s N o 1 .

Doe s the grading aroundthe perimete r o

f th e hous e i n excavatedarea s generall y slop e awa y fro mth e house ? 

# y 2 .

Ha s sodbee n lai di n all area s tha t wer e excavated ? / 3 .

Doe s the sodappea r t

o b e generall y health y an dgrowing ? (Onl y evaluat e i

f inspecteda t a3 0 da

y tim e period) 

# y 4 .

Ar e sodde darea s generall y firman devenl y graded ? 

# y 5 .Ar e the joint s betwee n the so dstrip s generall y tight ? (Onl y evaluat e i

f insperte da t a3 0 da y 

# y tim e period ) 6 . Wa s tlie propert y gradedsuc htha t wate r wil l no t pool o n the property ? 

# y 7 . Wa s damage t o landscaping 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 n andclos e freely ? (I f applicable) 

### ^ y 2 .

Wer e al l gate s o r fence s taken dow n during restoration activitie s reinstalled ? (I f applicable ) 

# y Wa s damage t o gate s o r fence s avoided ? (I f applicable) 

# 7 4 . Wa s damage t o retaining wall s avoided ? (I f applicable) / Foundation , Sidin g an dGutter s Ye s N o 1 .

Wa s damage t o the siding o r trimavoided ? 

### y 2 .

Wa s damage t o the foundatio n avoided ? c y 3 .

Wa s damage t o window s avoided ? 

# y 4 .

Wa s damage t o window s o r doo r screen s avoided ? 

# y 5 .Wa s damage t o downspouts o r downspou t extension s avoided ? 

# y Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damage t o drivewa y surface s avoided ? 

# y 2 , Wa s damage t o walkwa y surface s avoided ? 

# y

### Owner s comments :

Inspectio n notes :

Remova l an drestoratio n activate s complet e including th e 30-da y sodwarranty : EP A Representativ e />L , ^ ^ Date : //^Q/^* ?

# ^BV < Propert yCompletio n Agreemen t Thi s agreement docunient s th e completio n o f remova l activitie s performe do n th e belo w liste dproperty . Th e property ovraer' s signatur e indicate s tha t th e propert y ovmer i s satisfie dwithth e restoratio n ofth 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 .

Restoratio n Item s i n Question :

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

L J I agre e restoratio n i s completed , excep t a s note d above . L J I d o no t agre e restoratio n i s complete d



# y y 

# y^/^Ar Owner' s Signature ^ • ' ' DatePniden t Technologies , Inc . (Pnident ) i s unde r contrac t with th e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clea n u p lead contaminate dsoil s a t anumbe r ofpropertie s locate di n Omaha , Nebraska , includin g th e propert y locate da t

. Th e EP A request s you r permissio n t o allo w inden t t o performasoi l cleanu p a t thi s propert y t o remov e lead-contaminate dsoil . B y signin g thi s form , th e propert y owne r grant s permissio n t 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 n ofth 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 Pniden t Offic e for th e Omah aLea dSit e cleanu p a t (402 ) 733-1188 . Genera l question s abou t th e Omah aLea dSit e cleanu p can b e directe dt o th e EP A Publi c Informatio n Center s a t (402 ) 731-304 5 (South Omah aoffice ) o r (402 ) 991-958 3 (North Omah aoffice) . Property Acces s Grante dBy : •A.KVV ­ (Pleas e Propert y Owne r Signature : Pate ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r —pleas e print ) RESIDEN T NAME : 

### ^\^

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### ^ ^

/>J^- Owne rRente r £SIDEN T ADDRESS : 3 ^ ^ "" l SVT^'^-C - A«->-« -
I F RENTAL , PROPERT Y OWNE D BY : OWNER' S MAIUN G ADDRESS ; 

# JO ^

G^\1> 9 OVVNER'S T^EPHON E NUMBE R - HOME : J L WORK : AG E O F HOME? : 

# . O YEARS . HO W LON G HAV E YO U UVE D HERE ? 

## t t^ l EARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDIN G SINC E 1978 ? _ AffiS— - N O 

## o-vi'cU ^ NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : t~ ) 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. )

AUTHORIT Y FO RENVIRONMENTA L RESPONS E ACTIONS : 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 n 10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA'srightofacces s t o th e propert y i s provide dfo r i n Sectio n 104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic h provide s entry fo r "determinin g th e nee dfor 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. "

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### ECHNOLOGIES , INC . — 

# r Propert y Statu s For m Address : ^^e^- , ^ Vorxe . -^^ ^ °^^^ = " 7 / *? ) 5^ ^ ^ Phone : BVID : 3 o t » - 11 \ y 

# T Plant s & Permanen t Landscapin g Item# O

n Ma p Description an dLocation 

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Propert y Owne r Pruden t Emplg , Signature : lJ<y^^'^~yC:^'^'^-'i^y_,, ^ Signature : 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 KansasCity , 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

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### • YOU RTICKE T NUMBE RI S 2361704 . Origina l Cal l Date : Wor k t o Begi n Date : 9/11/0 9 9/15/0 9 Time : Time : 8:3 7 a m 9:1 5 a m Op : SIVA1896 7 State : N E Address : 304 7 County : Street : DOUGLA S STON E AV E Place : OMAH A Twp : 16 NRng : 13 E Sect-Qtr : 33-NE-NW-SE-S W 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 CXCAT V MAGELLANMETR O MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Nunibe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C 

### HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MAGELLA N MAGELLA N MIDSTREA M PARTNER S L P DEBORA H 

### Day : 918574709 8 Alt : 

### Emerg : 918574709 8 METR O METR O COMM . COLLEG E CHRI S 

### Day : 402457230 7 Alt : 402672703 3 Emerg : 402457231 3 MUDO l METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day: 402504782 3 Alt : Emerg : 402504797 0 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/1 1 /200 9

### Pag e 2 of 2

OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE R RON 

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

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### TECHNOLOGIES , INC . 

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S08 0 War d Parkv/ay . Suit s 40 5 250 5 W . 2 4 Street . Suit e SO S hoiicfl ! Uriv.: . i>;ii- e : ^;.. , KansasCit yM O 6^11 4 0(nfli',=t . vebrasK a 6811 0 S.i n aiiroiiio . T X 7S2? S Phone : (316 ) 36:;- ; •'0 ' P;^•.i^!•; : (402 ) J04-100 4 P?:;.:ie : 1^10 : ?22-^5S ? Fax ; (816 ^ 363:;"C: y F\-.x ­ .:J02 ! r,04-i00 5