### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 2909 4 DATE : 12/15/201 0 ADDRESS : 141 9 Ohi o St REMEDIATIO N CONTRACTOR : PRUDEN TTECHNOLOGIES . IN C YEAR : 201 0 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S

• PR E AN D POS TVIDE O O F PORPERT Y(DVD ) [ ^

EXECUTIV E SUMMAR Y

• EPA-PROVIDE D PROPERT YSKETCH c f SIGNE D ACCES S AGREEMEN TFO R SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S) FO R ADJACEN TPROPERT Y d RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E OR T O REPLACE PLANTS , ETC. ) ^

CONFIRMATIO N DAT A 1 3 PHOTOGRAPH S \

^

AS-BUIL TSKETCH 0 SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R d PROPERT YCLOSE-OUTCHEC KLIS TSIGNE D B YEP A

• D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A d UTILIT YCLEARANCE S [ ^

PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR'S OFFIC E 

### D D D

SIGNATUR E DAT E 3026082 6 

# l i Superfun dFin d Record 

### Backfill :

Sampl e Area : 2909 4 - 141 9 OHI O S T Owner : D Owne rOccupie d Owne rName : jCFTYO F OMAH A Owne rAddressl : |c/ 0 PUNNIN G DEPf i kRTN lEN T Owne rAddressZ : J181 9 FAR N A M S T# 1 

### 11 1 City : state : Zi p Code : loMAH A JN E [68183 ­ owne rPhon e Alternat e Phone : 

# 1 

# r

Contract : Contractor : |PRUDENT2010_ S Contrac t Optio n jOPnO N 1 Remediatio n Quer y| Lea d Remainin g Quer y9 Propert yDamag e Quer y 

### Use rProvide d Owne rInformatio n

owne rName : 

# i Owne rAddress : City : State : Zi p Code : 1 • J - ­ ^ 

# 1 1 Owne rPhone : Alternat e Phone : 

# 1 • 1

Assessment : Qualifyin g Grou p |40 0 Assessmen t Ma xXR F Valu e | 

### 522 Resident : Residen t Name : Propert yAddress : J141 9 OHI O S T Zi p Code : |68110 - Residen t Phon e

### PROPERT Y SUMMAR Y Date : 12/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Decembe r Propert y Address : 141 9 Offl O S T A . EXECUTIV ESUMMAR 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 Infonnation : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : B l = 30 9 PP M @ 6" ; B 2 = 25 7 PP M @ 6" ; N O EASEMEN T ATTACHMENT S 1 ) Property sketc hprovide dby EPA pursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfor crossin g othe r propertie s 3 ) Pre-Excavatio n digital vide o clip/photograph s 4 ) Post-Excavatio n digital vide o clip/photograph s 5 ) Documentatio n - Complete dClose-ou t Checklis t 6 ) As-Built sketc h­ i ) Shal l includ e final leadlevel s v ) Legen d ii ) Contaminatio n lef t behin darea s vi ) Contracto r identificatio n iii ) Property addres s vii ) Date iv ) BVI D numbe r 7 ) Othe r item s t o b e include di n th e individual property file, if available , o r obtaine dinclude : i ) Pre-excavatio n agreemen t detail s (i f an y ar e mad e wit hth e property owner ) ii ) Property Statu s For msigne db y property owne r iii ) Excavatio n digita l vide o i n MPEG , WMV (Window s Medi aVideo ) o r SWF(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio n o f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC .TECHNOLOGIES , BMC . 

### Propert y #:2'^i ^ 4 Date/Time : Quad s Excavated : ^7^9"Z ­ 

### ••i:"^t~: f 

# EP A Propert y Clos e Ou t Propert y Address ^ |i- f \f

LOv>.v< i Owner' s Name : Cv^ > .'^Ct.v-'^* ^ Contracto r Group : Pruden t Technologies , Inc. , Excavatio n Genera l Ye s N o I . I f necessary , wer e th e correc t quadrant(s ) excavatedandrestored ? 

## y 2 . I f necessary , wer e the correct area s o f drip zon e excavatedan drestored ? 

# y Gradin g Sodan dVegetatio n Ye s N o 1 . Doe s di e gradin g aroundthe perimete r o

f th e hous e in excavatedarea s generall y slop e awa y 

# y fro mdi e house ? 2 . Has so dbeen laidi n ali area s dia t wer e excavated ? 

# y 3 . Doe s tli e sodappea r to b e generall y health y an dgrowing ? (Onl y evaluate i f inspecte da t a30 

# y da

y tim e period) 4 . Ar e soddedarea s generally fimi an devenl y graded ? 

### y 5 . Ar e the joint s between the sodstrip s generall y tight ? (Onl y evaluat e if inspecteda t a3 0 da y 

# y tim e period ) 6 . Wa s (h e properr y grade dsuc hdia t wate r wil l not pool on the property ? 

# y 7 . Wa s damag e to landscapin g o r plan t material s avoided ? 

## y Gates , Fence s an dRetainin g WalJ sYe s N o 1 . D o gate s ope n an dclos e freely ? (I f applicable ) 

# y 2 . Wer e all gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) y 3 . Wa s daniag e l o gate s o r fence s avoided ? (I f applicable ) 

### y 4 . Wa s damag e to relainin g wall s avoided ? (I f applicable ) 

## y Foundation , Sidin g an dGutter s Ye s N o ! , Wa s damag e t o the sidin g o r trimavoided ? 

### y 2 . Wa s damag e t o di e foundation avoided ? 

## y 3 . Was damag e t o window s avoided ? 

### y 4 . Wa s daniag e to window s o r 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 )Ye s N o I .

Wa s daniag e t o drivewa y surface s avoided ? 

# y X

y 

### 2 . Wa s daniag e t o walkwa y surface s avoided ?

## Owner s comments :

Inspectio n notes :

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarrant y EP A Representativ e .gL. , ^ ^ Date : /o/^ ?/ /HJHNULOGIES , [NC . 

### A S - BUIL T DRAWIN G OL S #2909 4 Dat e Excavated : 9/24/201 0 

### OMAH A LEA D SUPERFUN D SIT E USEP ASigned-Or rDate : 

# iimillll l 2909 4 Exterio rPain t Nort h Arrow Omah a Lea d Sit e • Goo d Sit e Sketc h • Poo r Samolin a Address : 141 9 OHI O S T 0 * No t pain t Sampl e Numt>e r Lea d Sampl e Sample s Cotlecte d LA B Concentratio n Collecte d Firm:1»' . tVg rCH'*'R W RYASCPXA-2909 4 F l .^3^ ^ pp m 

### 0* . D Date : S-lSSt^/ e RYBSCPXA-2909 4 F 2 

### 0 * D Time : I/:0 0 AM . RYCSCPXA-2909 4 B l -52 2 pp m 

### D B

* Sample s Analyze d RYDSCPXA-2909 4 B 2 ^(rxO i pp m 

### B " D RDZ3CPXA-2909 4 B * " • pp m 

### D D XR F Uni t fOfiV' > Book : l/^i R ROZOCP)(A-i!000 4 62 '

—pp m 

# n Date : fn-O H -IC ) 

# n rXPZCOPXA-gOOO t pa ­ ___=_

_ pp m Time : P M 

# n staff : M^U / Numtje ro f Sample s = / j \ \ ^

| Legend : F l = Fron t Left , F 2 = Fron t Right , B 1 = Bac k Lef t B 2 = Bac k Righ t D Z = Dri p Zone , G Z = Garten , P Z = Pla y Al l quadrants ar e as viewe d fro m th e street , facin g propert y 

## EUTTERE D MAY19'201( | 

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B l = 2-S 7 PP M @ 6 " ^ 

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# MOST . Rt x:00 8 ! Ai-fj'-' - l.1-M3r-a S 

### ^O^fi<;gmfc=TS T CONTRA a # : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

### / 2 ^ 

## Propert yCompletio n Agreemen t Thi s agreemen t documents th e completio n o f remova l activitie s perfonne d o n th e belo wliste d property . Th e propertyowner' s signature indicate s tha t th e propertyowne ri s satisfie d wit h th e restoratio n ofth e subjec t propert)' , an d that n o item s ar e i n question , now , o ra t an ytim e i n th e future , excludin g an y remainin g warrant y(3 0 day s total ) except thos e item s liste d below , i f any . PropertyID : Propert y Address : /y^o ; ^;^^^ ^ <^'lrc^4 - I Owner ; (^(•1- ^ ••-'' / Oytn:^-l-A . Phone : 

### ^ ^y/'-i-'-/3H) r Restoratio n Item s I n Question :

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

[^ , I agre e restoratio n i s cotnpieted . \_ J I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above )



### c^' S -Ock/>-a ^ -.<PO/ Q rtti>noi-> cCinnoViit-. / /

' V Owner' s SignaiureC / Dat e

# w RUDE N

Pniden t Technologies , Inc . (Prudent ) i s unde r contrac t wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o clean u p lead conlaminate dsoil s a t anumbe r ofpropertie s locate di n Omaha , Nebraska , includin g th e property locate da l • il l C^/I/ Q . Tli e EPA request s you r permissio n t o allo w Pruden t t o perfor masoi l cleanu p a t thi s property t o remov e lead-contaminale dsoil . B y signin g thi s form , th e property owne r grant s penrussio n l o Pruden t t o perform activilie s relate dl o th e cleanu p includin g soi l sampling , remova l o f lead-contaminate dsoil , an drestoratio n ofth e reference dproperty . Ifyo u hav e an y question s abou t th e soi l cleanu p planne dfor you r property , pleas e conlac l Pruden l southoffic e for th e Omah aLea d Site cl«anup-a l (402 ) 733-J I %% . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e direae dt o th e EPA Publi c Informatio n Center s ai (402 ) 731-304 5 (Sout hOmali aoffice ) or(402 ) 991-958 3 (NorthOmali aoffice) . Property Acces s Granle dBy : 

### yilifiiyy i LryicA\ h (Pleas e Prin t Name ) Property Owne r Signature : 

# My ^ gnature ) (Date ) PROPERT YINFORMATIO N (T o be complete d b yresiden t and/o rpropertj ' owne r— pleas e print ) RESIDEN TNAME : d!w'> f c/ T^•>->i» ^ (Owne r Rente r RESIDEN TADDRESS : I F RENTAL , PROPERT YOWNE D BY : OWNER' S MAILIN G ADDRESS ; /fl ^ rfJQr^Ayy i ^/ ^ Suil c(lll ^ Ol ^ hfi - A/ & Co m 6 OWNER' S TELEPHON E NUMBE R - HOME : J L WORK : 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 NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R O F CHILDRE NUNDE R 7 YEAR S OL D WH O PLA Y I NTH E YAR D FOR 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTRY GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t are pursuan t l o Sectio n 10 4 o f CERCLA , 4 2 U.S.C . 9604 . EPA'srigh t o f

acces s t o th e propert y i s provide dfor in Sectio n 104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entj- y fo r ""detenninin g th e nee dfor response , or choosin g or takin g an y respons e actio n under ilii s title , o r otherwis e enforcin g th e provision s ofth e title. " 808 0 War d Parkv/ay . Suit e 40 5 560 0 S 1 0 S 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 7EN\T;RO.M\JEiVT.AL & 

# mmm ' CONSTRLiCTrO N 

### TECHNOLOGIES , INC . S£RVICE. S 

# Propert y Statu s For m Address : 

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IPropert y Owne r I Signatur e

808 0 War d Parkway , Suit e 40 5 560 0 S 1 0 s t edica 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 C.. . ro^C \ .. O OTA ? Phone : (402)733-118 8 

# V Pttone : Co» . (210)822-958 8 Iinn\e7«J5«T 7

# illllllillllillll i 2909 4 Exlerto rPain t Kforth ! Arro w 

### Omah a Lea d Sit e • Good 

### Sit e Sketc h • Poo r 

# V Samplin g Address : 141 9 OHI O S T 0*1^0 1 poin t Sampl e Numbe r Lea d Sampl e Sample s Collecte d LA B Concentratio n Collecte d 

### Firm:"^/^ . -Q/C yO:!'*'R W RYASCPXA-2909 4 F l 

### ri"^ ^ pp m 

# D Date : 5yg'Z0/ C RYBSCPXA-2909 4 F2 

# E * D Time ; l/.-O Q /{./j . RYCSCPXA-2909 4 B 1 

### 522 . pp m 

# D Sample s Anafyza J RYDSCPXA-2909 4 8 2 

### HCrtG i ppm 

# D RDZ3CPXA-2909 4 BS " " ^ pp m 

# n D Book : 7L9 i XR F Unff : RGZGCPX A2000 4 G *

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# D 

# • Date : RPZOCPXA ' 2900 4 P2 - « ~ pp m 

# D Tinr>e ; 

# 2n . Staff : 

# ns w Numbe rof Sampte s - ^ [ Q | Legend : F 1 = Fron t Left , F 2 = Fron t Right , B 1 = Bac k Left , B 2 = Bac k Righ t D Z = Drt p Zone , G Z = Garden , P Z pray Al l quadrant s ar e a s viewed - frorr rth e street , facin g property 

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### Pag e 1 of 2

" > Creat e Anothe rTicke t Bac k t o Irt h Inteme t Sen d Emai l



### • YOU RTICKE T NUMBE RI S 2592083 . Origina l Cal l Date : 9/14/1 0 Time : 5:2 4 p m Op : SIVA1896 7 Wor k t o Begi n Date : 9/16/1 0 Time : 6:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 141 9 Street : OHI O S T Twp : 15 NRng : 13 E Sect-Qtr : 10-S E • Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lea d remediatio n projec t Locatio n o f Work : LOCAT E ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : UNSUR E CORNER S Compan y: PB.UDEN 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 : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCAT V MCINE B MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Utilit y Servic e Are a Contac t Phon e Numbe r Typ e 

### Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , INC HEID I 

### Alt : 402934046 9 Emerg : 402932975 7 Day : 800289342 7 N O CAL LPER MCINE B MC I 

### Alt : MEM O 

### Emerg : 800289342 7 Day : 402504782 3 METROPOLITA N UTILITIE S MUDOl SAND Y 

### Alt : DISTRJC T 

### Emerg : 402504797 0 Day : 402444719 7 OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C 

### Alt : 402444516 1 Emerg : 402444516 0 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/14/201 0

### Pag e 2 of 2

0PPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T ELM LOCATIN G 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES T LOCALNETWOR K EL M LOCATIN G 

### Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/14/201 0• j^.mpi » • 

### SOLUTION S 

## SIT E SAFET Y HAZARD ANALYSI S Address : 

# l(kL£LMhL.±L . Excavatio n Date : (nj^^ O Crew : 

## Backfi U Date : '^jMlQ. .

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 Structure s Drivewa y Sprinkle r Syste m Othe r Cre w Forema n Conditio n c:>/ ^ 

# (h^ ' ^ 

# w

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## Hazard s Correctiv e Actio n /_«i*i J /M^-W^ . _ . t^Si= > /P""/ ^



## Sit e Safety Offic e Date :

n o Waftf^earimsy , Sut e 40 S 5S0 0 S 1 0 S t 424 2 Medica l Drive , Stdt e 725 0 insasCify;ABa«4ll 4 Oui^JU rNeliush a 6Siu / Sa n Antonio , TX 7822 9 : f018)'363-37O 3 nuiie : (402)733-113 8 Phone : (210)822^58 8 : (8 ^

363-370 7 Fax : (402 ) 73»>1«a 3 Fax : (210 ) 579-657 7^^•• t "^* ^ 

# F /^/ ^ OHI O S yi^CAv r lo r 

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