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

## SAID# : r^^ia^i o Date : 1 T 15 " \ U 

# Addtess : Ni O M H SJ
Remediatio n Contractor : Pp,- , rypr^i- y T^/'-f t N/'yioc , K^<i ^ ir>jc,'i Year : 

## SOI LREMEDIATIO N PROPERT Y FIL EFOLDE RDOCUMENT S [ ^ Vide o ofpropert y (DVD ) ^ ExecutivesTM ^ Executiv e Summary aEPA-provide dpropert y sketc h 0 Signe dAcces s Agreemen t for subjec t propert y D Signe dAcces s Agreement(s ) fo r adjacent property aRestoratio n Agreemen t 

## 3023752 4 1111111111 1 Superfun d



### D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) 1* 5 Confirmatio n dat a dPhotograph s d

f As-btiil t sketc h aSatisfectory restoratio nsigne db y Property Owne r 

## [/

Propert y close-out check lis t signedb y EP A D Descriptio n o f area s no t meeting RO D cleanu p criteri a B Utilit y clearance s
• Propert y information fromDougla s Covint y Assessor' s Office D D D 

# 9A'y\8l«*> " Signatur e Dat e

### PROPERT Y SUMMAR Y Date : 11/15/201 0 Omah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Monti i of : Novembe r Propert y Address ; 141 0 N1 7 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 Information : NON E CONFIRMATIO NSAMPLIN GDATA/RESULTS : B l = 34 1 PP M @ 4" ; B 2 = 36 8 PP M @ 4" ; N O EASEMEN T ATTACHMENT S 1 ) Property sketc hprovide db y EP A 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 digita l vide o clip/photograph s 4 ) Post-Excavatio ndigita l 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 lea dlevel s v ) Legen d ii ) Contaminatio nlef t behin darea s vi ) Contracto r identificatio n iii ) Property addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include di n th e individua l property file , i f available , o r obtainedinclude : i ) Pre-excavatio n agreement detail s (ifan y ar e mad e withth e property owner ) ii ) Property Statu s Formsigne db y property owne r iii ) Excavatio n digita l vide o i nMPEG , WM V (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 .

TECHNOLOGIES , INC .Fin d Record 

### Backfill :

Sampl e Area : 2565 6 - 141 0 N 1 7 S T Owner :
n Owne rOccupie d Owne rName : lOT YO F OMAH A Owne rAddressl : 

# I Owne rAddress2 : 1181 9 FARNAM ST#111 1 City : State : Zi p Code : OMAH A |N E |68183 - Owne rPhon e Alternat e Phon e )(402 ) 441-515 0

Contract :
contractor : |PRUDEMT2010_S Contrac t Optio n [OPTIO N 1 Remediatio n QueryI Lea d Remainin g QueryI Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : Owne rAddress :

City : State : Zi p Code : Owne rPhone : Alternat e Phone :

Assessment : Qualifyin g Grou p |4o 6 Assessmen t Ma xXR F Valu e | 530. 4 Resident : Residen t Name : 

# r Propert yAddress : |1410N17S T Zi p Code : |68102 - Residen t Phon e 

# I

### i^ ^ .-^l i V TECHNCtLOGIBS b UMC . 

# EP A Propert y Clos e Ou t Propert y #:' ^ 5^^ ^ Propert y Address : \41 0 A-' 1 7 $ ^ . Date/Time : Owner' s Name : c ^^'-^ o ^ C i»^»<»
- ^ 6 \ Quad s Excavated : 2>( , ^"2
- Contracto r Croup : Pruden t Technologies , Bnc , £.\cavatio n Genera l Ye s No 1 .

I f necessary , wer e th e correc t quadrant(s ) excavatedandrestored ? / 

### 2If necessarv , wer e th e conrec t area s o f drip zone excavatedandrestored ? 

# y Gradin g So dan dVegetation i Ye s N o 1 Doe s tli e gradin g aroundth e perimete r o

f th e hous e inexcavate darea s generall y slop e awa y fro mthe house ? 

# y 2 .

Has sodbeenlaidin al l area s tlia t wer e excavated ? 

# y 3 Doe s th e sodappea r to b e generall y health y andgrowing ? (Onl y evaluat e i

f inspecte da t a3 0 da

y time period) / 

### 4 .

Ar e soddedarea s generally fir man devenl y graded ? 

# y 5 .Ar e th e joint s betweenth e sodstrip s generall y tight ? (Onl y evaluat e i

f inspecteda t a3 0 da y tim e period ) ^ 

### 6 .Wa s th e propert y grade dsuchtlia t wate r wil l not poo l o n tli e property ? 

# X 7 .

Wa s damag e t o landscapin g o r plan t material s avoided ? 

# y Gates , Fence s an dRetainin g Wali s Yes^N o 1 .

Do gate s ope n an dclos e freely ? (I f applicable ) 2 .

Wer e a U gate s o r fence s taken dow nduring restoratio nactivitie s reinstalled ? (I f applicable ) / ' 

### Wa s damag e lo 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 ) 

# A Foundation , Sidin g an dGutter s Ye s N o 1 . Wa s damag e t o th e siding o r trimavoided ? ^ 2 Was damag e t o tli e foundationavoided ? / .3 , Wa s damag e l o window s avoided ?

• ^ 

# A\ 4 . Wa s damag e to window s or doo r screen s avoided ? / 5 Wa s damag e f o downspout s o r downspou t extension s avoided ? / Sidewallli s an dDriveway s (ConcreUe) Ye s N o 1 . Wa s damag e lo drivewa y surface s avoided ? / 2 . Was damag e to walkwa y surface s avoided ? 

## y

## Owner s co mments :

Inspectio n notes :

Remova l andrestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e JSL^ > ^ Date : lojisli o:CHN0L0(J1ES , INC . 

## A S T #UJI. T DRAWIN G OL S #2565 6 Dat e Excavated : 9/29/201 0 

## OMAHA LEAD SUPERFUND SIT E USEP A Signed-Of T Date :

Omah a Lea d Sit e Address : 141 0 N1 7 S T Owne rName : crt YO F OMAH A Sit e Sketc h Phone : " • •MISiS O W : Sampl e Numbe r Lea d Sampl e LA B Concentratio n Collecte d RYASCPXA-2565 6 F 1 pp m 

### D 

## y RYBSCPXA-2565 6 F 2 

# n o pp m 

### D RYCSCPXA-2565 6 B l pp m 

### D 

# m RYDSCPXA-2565 6 8 2 H3 Q pp m 

### D RDZSCPXA-'iMS e DZ - pp m Rr!7grPYA.9IWI« i G2 _ pp m 

# n D D RPZSCPXA.256S 6 PZ - pp m 

### D D D Numt>e ro f Sample s = , ^ Legend : F 1 = Fron t Left , F 2 : Fron t Right , B l = Bac k Left . B 2 = Bac k Ri g A n quadrant s af B a s viewe d from tti e etreet , ( 

## 2565 6 Exterio rPaint NoithAmi w • Good • Poo r B^o t paint Sample s Collecte d Finn : H^ ^ ' M^^tJ Q Date : 0* 4 I t'>^\o< a Time : *? : O ? Q« M Sample s Analyze d XR F Uni t (pS' J Book : li b

Date : ^•Jg-ot / Time : 

# Aa . Staff : M^V. / D Z = Dri p Zone , G Z = Garden , P Z = Pla y propert y

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

# EP A Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f remova l 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 propert y owne r i s satisfie dwit hth 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 in th e future , excludin g an y remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , ifany . PropertyID : PropertyAddress : /y^ ^ ^^^^ ^ 11 ^

S4r-^- h Owner : C , U J C>r^K A Phone : ^ u,e(v.| . ^)^K\ X Restoratio n Item s i n Question :

Item : Item : item : Item : Item : Item : Required correction s t o complet e th e property :

^ ^ 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 )



## ./T-Or(-yfO/ 0 Owner' s Signatur e Date IPruden t Technologies , Inc . (Prudent ) i s unde r contrac t withth e U . S . Environmenta l Protectio nAgenc y (EPA ) t o clea nu p lead
contaminate dsoil s at anumbe r ofpropertie s locate din Omaha , Nebraska , includin g th e propert y locate da t /T/ Q A A //" * S/~ ^ . Tli e EP A request s you r permissio n t o allo w Pruden t t o performasoi l cleanu p a t thi s property 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 perfor m 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 dfor you r property , pleas e contac t Pruden t southoffic e fo r th e Omah aLea d Site cleanup-a t (402 ) 733-1188 . Genera l question s atxjut th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informatio n Center s a l (402 ) 731-304 5 (SouthOmah aoffice ) o r (402 ) 991-958 3 (NorthOmah aoffice) . Property Acces s Grante dBy : > Q A<///0^>» 7 L-y</ H ^ I . (PI leas e Prin t Name ) Property Owne r Signature : 

# ^^/^7\IZL ^ ^i^Sr^^-^Ol O (Signature ) (Date ) 

# T PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r —pleas e print ) RESIDEN TNAME : C^// ] c/ 7 Ay/yyO^A ^ (owner ^ Rente r ' " ^ RESIDEN TADDRESS : 

## I m p O tn-H y,^i ^ I P RENTAL , PROPERT YOWNE D BY :
OWNER' S MAILIN G ADDRESS ; 

# ip ^ fi^r^a ^ a.^SuiJc^ ml , 0(^ ^ Ay & adh 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 FO R 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 ar e pursuan t t o Sectio n10 4 ofCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f

acces 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 hprovide s entry for "determinin g th e nee dfor response , or 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. " 808 0 War d Parkway . 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 Onrtaha . Nebrask a 6810 7 Sa n Antonio , T X 7822 9 Ptione : (816 ) 363-370 3 Ptione : (402)733-118 8 Phone : (210)822-968 8 Fax:(816)363-370 7 Fax : (402 ) 733-188 3 Fax : (210 ) 579-657 7ENVrROkXMEL\TAL & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : Phone : BVID : 

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Propert y Owne r Pruden t Employe e Signature : Signature : 808 0 War d Parkway , Suit e 40 5 560 0 S 1 0 S t edica l Drive , Suit e 425 0 KansasCity , M O 6411 4 Omaha , Nebrasli a 6810 7 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 C^v . I»nt \ T4 1 400- 4 C^v - <9in t «T0Jt«T 7

# 2565 6 Owne rName : CIT YO F OMAH A Address : 141 0 N 1 7 S T Phone : H : fHISiS O Sampl e Numbe r RYASCPXA-2565 6 F 1 RYBSCPXA-2565 6 F 2 RYCSCPXA-2565 6 B l RYDSCPXA-2565 6 B 2 

### RnzsrpxA.?5fi96—DZ Bn7.SnPXA-?fififif i GZ RPZSCPXA.?56 ^ PZ W : Lea d Concentratio n 

## 17 3 pp m _LKi_Pp m 5 3 0 pp m =^PP m _^pp m pp m

Omah a Lea d Sit e Sit e Sketcl i Sampl e LA B Collecte d 

## M 

## D D D D D D D D D D Numbe ro f Sample s = ^ Legend : F 1 = Frcn t Left . F 2 = Fron t Right , B l = Baci cLeft . B 2 = Bac k R

k Al t quadrant s ar e a s viewe d firo m th e street ,



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## Ki A' \6 t Rev 4 Exterio rPain t Nottt i Arro w 

### • Goo d • Poo r Q^o t pain t Sample s Coiiecte d 

### Firm : Ht » ' t^^ftl Q Date : 0< 4 I ty^lo ^ Time : *?' . O g Cic/v> Sampie s Analyze d XR F Unit : L S ^ Book : /f b Date : H 

# Miou . Time : A, M 

### Staff : MS V D 2 = Dri p Zone , G Z = Garden . P Z = Play propert y



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# ENTERE D AP R 15^ 200 6

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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 

## YOURTICKE T NUMBERI S 2592082 . Origina l Cal l Date : 9/14/1 0 Time : 5:2 3 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 0 Street : IS l 17T H S T Twp : 15 NRng : 13 E Sect-Qtr : 15-NW-S W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lea d remediatio n project 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: 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 : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V LEVEL 3 MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C



### Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL S COMMUNICATIONS , LL C N A Day : 877366834 4 Alt : Emerg : 877366834 4 MUDO l METROPOLITA NUTILITIES DISTRICT SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFICSEWE RRICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0 

### Day : 406728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/14/201 0

### Pag e 2 of 2
OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T EL M LOCATIN G Alt : 406207149 4 Emerg : 888728934 3 QLNNEI C QWES T LOCA LNETWOR K Day : 406728934 3

EL M LOCATIN G. Alt : 406207149 4 Emerg : 888728934 3

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

### ENVIRONMENTA L ENGINEERIN GAS W GON&TRUCTIO N 

# m;jm ^ TtraeHNotneflEs , mc . SOLUTION S 

## SIT ESAFET Y HAZARD ANALYSI S Address : I^ie.„.4/.-(2]^.^t . Excavatio n Date : J-Mr_L2 > Crew : —^tc^.£^^St^:r: ^ 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 Structure s Drivewa y Sprinkle r Syste m Othe r 

## Cre w Forema n 

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## Hazard s Correctiv e Actio n



## Sit e Safet y Offic e Date :

S08O1Mlaftf«arfiN9y;BiM»4O 5 iS6005:iaS t 4242Medica t Drtve/.Stiite ' 725 0 Kaaas.ia|yj\|l056411 4 Omaha , NaboM a «810 7 5San'Antonio,iT) ( 7822 9 PFhona : i f<02r733.118 8 t?hone : ((210^^822)968 8 Fax:(81«)^^363«3707 Tax : ft02)733<ia8 3 !lrax;t210)r5r»«S7 7