### CONTRAC T# EP-R7-06-0 4 

### AS WAssociate s Inc . Omah a Lea d Siit e Remediation , Omaha , N E EP A 

### AS W Associate s In cCertificatio n fo rPropertyCloseou t BVI D 2122 8 PropertyAddres s 424 4 Maso n Stree t Fiel d Wor k Starte d 20-Oct-0 6 Fiel d Wor k Complete d 28-Oct-0 6 

### Summary : Th e excavatio n wa s performe d i n complianc e wit h th e wor k plan s an d specifications . Th e F 1 quadran t wa s excavate d t o a dept h o f6 inch . Th e F 2 quadran t wa s excavate d t o a dept h o f 6 inch . Th e B 2 quadran t wa s excavate d t o a dept h o f6 inch . Th e dri p zon e wa s excavate d t o a dept h o f 6 inch . Verificatio n sample s confirme d tha t th e cleanu p standard s wer e met . Verificatio n sample s wer e take n fro m botto m o f excavation . Th e sit e wa s backfille d wit h material s whic h meet s contract specifications . Th e backfil l wa s compacte d t o acceptabl e standards . So d placement s an d sit e restoration s wer e conducte d i n complianc e wit h wor k plan s an d specifications . Analytica l dat a provide d i s pos t excavatio n at th e botto m of th e excavatio n fo rconfirmatio n purposes . 4026172 7 

### Comments : SUPERFUN D RECORDS 

### None . Ja n Prawdzi k AS WProjec t Manage r Nam e Titl e 

### bal e Signatifre

### CONTRAC T# EP-R7-06-0 4 AS W Associate s Inc . Omah a Lea d Sit e Remediation , Omaha , N E EP A 

## Analytica l Resul t Summar y OL S ID : 2122 8 Property Address : 424 4 Maso nStreet XR FResult s La b 

### Sampl e I D Avg . 

### Result s (ppm ) (ppm ) 

### 21228-DE-F1-0 6 

### 90. 2 ±4 1 N A 

### 21228-DE-F2-0 6 

### 113. 6 ±4 2 N A 

### 21228-DE-B2-0 6 

### 129. 3 ±3 9 N A 

### 21228-DE-DZ-0 6 

### 90. 6 ±

### 42. 3 N A



### Ja n Prawdzi k AS WProject Manage r

Nam e Titl e 

## Dat e Signature

Sampl e Designatio n OLSID-DE-Location-d d OLSF D i s a particula rresidentia l propert yI D fio m whic h th e sampl e i s collected . D E = Durin g an d Post Excavatio n Locatio n o f th e sampl e a s follows ; F l = Fron t Yar d (1 s tQuadrant ) B l = Bac k Yard (1 ° Quadrant ) F 2 = Fron t Yar d (2 n d Quadrant ) B 2 = Fron t Yar d (2 n d Quadrant ) D Z = Dri p Zon e P Z = PlayZon e G A= Garde n E A= Easemen t d d describe s th e dept h fro m whic h th e sampl e* ra s collected . N A= No t Applicabl e

# <vEP A Remediation/Excavatio nContrac t (ASW ) EP A Propert y Clos e Ou t For m Property# : Propert yAddress : Date/Time : Owner' s Name : a € I Quad s Excavated : ff { F< ? ff) 2 -4 - Contracto rGrou p Excavatio n Genera l 1 .I f necessary , wer e th e correc t quadrant(s ) excavate d an d restored ? 2 .

I f necessary , wer e th e correc t areas of dri p zon e excavate d an d restored ? Gradin g So d an d Vegetatio n 1 . Doe s th e gradin g aroun d th e perimete ro f th e hous e i n excavate d area s generall yslop e awa y fro m th e house ? 2 .Ha s so d bee n lai d i n al l areas that wer e excavated ? 3 .

Does th e so d appea rt o b e generall yhealth yan d growing ? (Onl yevaluat e i f inspecte d a t a 3 0 da

ytim e period ) 4 .Are sodde d areas generall yfir m an d evenl ygraded ? 5 .Ar e th e joint s betwee n th e so d strip s generall ytight ? (Onl yevaluat e i f inspecte d a t a 3 0 da y lim e period ) 6 .Wa s th e propert ygrade d suc h tha t wate rwil l not poo l o n th e property ? 1 .Wa s damag e t o landscapin g o rplan t material s avoided ? Gates , Fence s an d Retainin g Wall s 1 .D o gate s ope n an d clos e freely ? (I f applicable ) 2 .

Wer e al l gate s o rfence 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 rfence s avoided ? (I f applicable ) 4 .

Wa s damag e t o retainin g wall s avoided ? (I f applicable ) Foundation , Sidin g an d Gutters 1 .Wa s damag e t o th e sidin g o rtri m avoided ? 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 rdoo rscreen s avoided ? 5 .Wa s damag e t o downspout s o rdownspou t extension s avoided ? Sidewalks an d Driveway s (Concrete ) 1 .Wa s damag e t o drivewa ysurface s avoided ? 2 .Wa s damag e t o walkwa ysurface s avoided ? Ye s N o S t* S Ye s N o ^ ^

*

^ t S ^ t

/ ^ Ye s N o ^ ^

> ^ • t

^ Ye s N o i ^ ts ' i / t^

s t

^ Ye s N o

( ^ I S

### Owner s comments :

Inspectio nnotes :

Remova l an drestoratio nactivate s complet e includin g th e 30-day so dwarranty : EPARepresentativ e {)„. „ J l Date : i f

# f Contract : No : E P - R 7 - 0 6 - 0 4 Propert yCloseou t Agreemen t @ 

### Omah a Lea d Superfun d Sit e OLSI D Propert y Addres s 

# 4 2 r/ WAtei f Propert y Owne r 

## K v 

# ^*Z \

_. , 

# if\ru . w I s th e Residen t th e Owne r [0£Ye s D N o Complianc e Statement : U.S . Environmenta l Protectio nAgenc y (EPA ) o r it s authorize drepresentatives , (o r it s contractors) , t o ente r an dconduc t environmental restoratio nservice s fo r th e Omah aLea dSite . You r cooperatio ni ngivin g EPA/AS Wpermissio nt o acces s you r propert y durin g th e removal/restoratio n phas e i s sincerel y appreciated . Thi s documen t certifie s tha t al l wor k performe da t thi s propert y wa s complete di naccordanc e wit hth e contac t specification s an dEP Arequirements . I f

yo u hav e question s o r nee dadditiona l informatio npleas e contac t th e EP APubli c Informatio nCenter s a t (402 ) 731-304 5 o r (402 ) 991-958 3 o r th e EP AOffic e o f Externa l Program s a t 1-800-223-0425 . Additiona l Comment s b y EP Aand/o r ASW :

CONTRACTO RCERTIFICATIO N Ja nPrawdzi k AS WProjec t Manage r Nam e Titl e Dat e Signatur e 

### Propert y Owne r Sectio n Thi s agreemen t document s th e completio no f remedial/restoratio neffort s a t th e propert y t o m y satisfactio n & 1 agre e tha t restoratio ni s complete da t m y propert y D I D o No t Agree : Comments :



## ,- x

## y 

# I//04/ 0 6 Propert y Owner' s Signatur e ' Dat e 

### i ^ i 

# lt/of/0 6 EP X Heptfsentativ e Signatur e 1 Dat e

### Pag e 1 o f Omah aLea dSit e xSf""^ v Omaha , N E i s ^ \A U.S . Environmenta l Protectio nAgenc y Regio nVI I ( i ^^ 7 f l Residentia l Yar dSoil s XSb^^ y Environmenta l Restoratio n Xj^n.o^ '



### ^

— Service s 

# I '' PROPERT YACCES S (t o b e complete db y Propert y Owner ) Par arecibi r est aform aespaiio l po r lavo r ilam ea l 1-800-223-042 5 i Granto r (th e propert y owner) , consent s t o an dauthorize s th e Unite dSate s Environmenta l Pr o tectio nAgenc y (USEPA ) o r

it s authorize drepresentative s (o r it s contractors} , th e Grantee , t o ente r an dperfor mcertai i i environmenta l respons e activitie s upo nth e followin g describe dpremises . Fo r furthe r informatio npleas e contac t EP /i a t 1-800-223-0425 .

. —— i 

# |V

j . / • , c~~- > — Propert y Acces s Grante dB y \\'Cf]C( P| -- } • ^ — , « ___----^ 7 

### (Pleas e Prin t Name ) 

# ^ti,j ) d) <

# ^rjtij~ ~ ii>c-o u (P'ropert y Owne r Signature ) (Date ) NOTE : Grantin g permissio nDOES NO T necessarily imply you r property wil l b e remediate dat thi s time . 

# 1 PROPERT YINFORMATIO N (t o b e complete db y residen t and/o r propert y owne r — Pleas e Print ) Residen t Name : [ H (cllQ F\' ["ATUK A ES I Owne r D Rente r * A/ I• 1 L/ 

### Residenc e Address : M^-H M IMA^ M -S \C )Wt^C \M<5 . (o^lO*5 ~ (CITY ) (STATE ) (ZIP ) Propert y owne dby : ^ | lo/V/\B- ( | f\'^L) ^ Owner s mailin g address : M^M M 1 l&Jv)/ 1



### - ^ 

# o / Owner' s telephon e numbe r— Home:_5^?U"5(A i 

### ' ] 1

### Work : Mcr-Q^' " M" ! Ag e o f Home ? <^Z > year s Ho w Ion ? hav e vo u live dhere?c>-- 3 year s Ha s th e exterio r bee npainte do r covere dwit hsidin g sinc e 197 8 I X YE S D N O 

### Ha s th e interio r bee npainte do r covere dsinc e 1978 ? t S YE S D N O 

### Tota l numbe r o f

occupants : O Lis t Ages : —> n<"C o <^-^~ ~ lS Lis t age s o f occupant s unde r 6 year s ol dwh o pla y i nth e yar dfo r 5 o r mor e hour s pe r week : 

# *i/ h Comments : AUTHORIT Y FO RENVIORNMENTA LRESPONS EACTION S Th e activitie s t o b e implemente db y EP Aunde r thi s agreemen t ar e pursuan t t o Sectio n10 4 o f CERCLA , 4 2 U.S.C . 960 4 EPA' s righ t o f

acces s t o th e propert y fo r i nSectio n104(e ) o f CERCLA , 4 2 U.S.C . 9604 (e) , whic hprovide s entr y for , "determinin g th e nee dfo r response , o r choosin g o r takin g an y respons e actio nunde r thi s title , o r otherwis e enforcin g th e provision s o f thi s title. " 

### Acces s Attempts : First : Second : Third :

# Lis t o f existin g Condition s Pg - of . 

### Propert y Address : 

# : 42-4 4 (V\AS0r J Owner : Date : [ O 4 ? ~ O ^QL S # Description : 

# ( o 

# S

O\vne r Signature : AS WAssociate s In c Prin t & Sig n ; 

### Prin t

# 2122 8 Exterio rPain t 

### Omah a Lead Site Owne rName : MICHAE L S TATU M Good 

### Site Sketc h Address : 424 4 MASO N S T P J Poo r Phone : H : 402-556-518 9 W : 402-426-412 1 No t paint Lea d Sampl e Sample s Collecte d Sampl e Numbe r Concentratio n Collecte d Firm : tf^t J O 5 RYASCPXA-2122 8 Date : RYBSCPXA-2122 8 Time : . ^ -If ) RYCSCPXA-2122 8 Sample s Analyze d RYDSCPXA-2122 8 RDZSCPXA-2122 8 RGZSCPXA-2122 8 RPZSCPXA-2122 8 Numbe ro f Sample s = ;



# ENTEBE D

Omah aLeadSit e 4613 0