### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 28949 DATE : 1/1 5 ADDRESS : 252 3 MIAM I S T REMEDIATIO N CONTRACTOR : PRUDENTTECHNOLOGIES . INC . YEAR : 201( t 

### SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENT S m PR E AN D POS T VIDE O O F PORPERT Y (DVD ) 0 EXECUTIV E SUMMAR Y 0 EPA-PROVIDE D PROPERT YSKETC H T

Z SIGNE D ACCES S AGREEMEN TFOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT{S ) FOR ADJACEN TPROPERT Y tZ i RESTORATIO N AGREEMEN T D SETTLEMEN TDOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) (^CONFIRMATIO N DAT A m PHOTOGRAPH S [p^AS-BUIL T SKETC H D^SATISFACTORY RESTORATIO N SIGNE D B Y PROPERT Y OWNE R D

T PROPERT YCLOSE-OU TCHECKLIS TSIGNE D B Y EP A n DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A [ Z UTILIT YCLEARANCE S T

Z PROPERT YINFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E D D D

SIGNATUR E DAT E 

### 3021836 6 

# Mun i Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Oinah aLea dSit e Remedia l Actio n Contrac t #EP-R7-07-0 6 TO# l Montl i of : Propert y Address : 252 3 MIAM I 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 Infomiation : NON E CONFIRMATIO N SAMPLIN GDATA/RESULTS : B l = 19 0 PP M @ 13" ; B 2 = 51 0 PP M @ 13" ; E A = 15 0 PP M @ SCRAP E (~1" ) 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 n digita l vide o clip/photograph s 5 ) Documentatio n - Complete dClose-ou t Checklis t 6 ) As-Buil t sketc h­ i ) Shal l includ e final lea dlevel s v ) Legen d ii ) Contaminatio n lef 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 din th e individua l property file , i f available , o r obtaine dinclude : i ) Pre-excavatio n agreement detail s (i f an 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 n MPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio n ofarea s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES . INC .Fin d Record i 

### Backfill : Remediatio n Quer y Lea d Remainin g Query Propert yDamag e Query .^ J 

### Sampl e Area : 2894 9 ­ 252 3 MIAM I S T Owner : Use rProvide d Owne rInformatio n Resident : n Owne rOccupie d Owne rName : Owne rName : Residen t Name : !|WYN N MARL AM Owne rAddressl : 

# r ^^ Owne rAddress2 : |624 4 REA D S T City : [OMAH A Owne rPhon e State : Zi p Code : N E J68152 - Alternat e Phone : Owne rAddress : 

# r City : I • Owne rPhone : State : Zi p Code : 

# "i— )

Alternat e Phone : Propert yAddress : (252 3 MIAM I S T ZlpCod ^ 

## jesnT ­ ~ Residen t Phon e 1(402)571-467 6

Contract : Assessment : Contractor : jPRUDENT2010_S Qualifyin g Grou p |40 0 I Contrac t Optio n foPTlOI N 2 Assessmen t Ma xXR F Valu e 485.6 4, • , .. . -"•' . ;J^'X ; TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Propert y # : ^^^ ^ Propert y Address : Z.^Z' ^ <^-i<x.xv^ X Sf- . Date/Time : Owner' s Name ; M^i^l, ^ COt^^wir x Quad s Excavated : ^t , S2 _ Contracto r Group : Pruden t Technologies , Inc. , 

### Excavatio n Genera l Ye s I .

I f necessarv . wer e the correct quadrant(s ) excavatedandrestored ? / 2 .

I f necessary , wer e the correct area s o f drip zone excavatedan drestored ? / Gi-ading So dan dVegetatio nYe s 1 .

Doe s the gradin g aroundthe perimete r o

f the hous e i n excavatedarea s generally slop e awa y fro mthe house'^ / 2 .

Has so dbeen laidi n all area s tha t wer e excavated ? / 3 .

Doe s di e so dappea r t

o be generall y health y andgrowing ? (Onl y evaluat e i f inspectedat a3 0 / da

y tim e period) 4 Ar e soddedarea s generall y firmandevenl y graded ? / 5 .Ar c tlie joint s between the sodstrip s generall y tight ? (Onl y evaluat e i

f inspecte da l a3 0 da y lim e period) / 6 .

Wa s th e propert y gradedsuc hdia t wate r wil l not pool o n the property'^ / 7 .

Wa s diunag e to landscaping o r plan t material s avoided ? / Gates , Fence s an dRetainin g WaUsYe s 1 .

Do gate s ope n andclos e freely ? (I f apphcable ) / 2 . Wer e al l gate s o r fence s take n dow n dming restoratio n activitie s reinstalled ? (I f applicable ) / 3 .

Wa s damag e t o gate s or fence s avoided ? (I f applicable ) / 4 .

Wa s damag e t o retaining wall s avoided ? (I f applicable ) / Foundation , Sidin g an dGutter s Ye s 1 .

Wa s damag e t o the sidm g o r trimavoided ? / 2 .Wa s damag e t o the foundation avoided ? / 3 .

Wa s damag e to window s avoided' ? /

I 

### / ' 4 .Wa s damag e t o window s o r doo r screen s avoided ? / 5Was damag e t o downspout s o r downspou t extension s avoided ? Sidewalk s an dDriveway s (Concrete ) I W;i s d;miag e (o djivewn y surface s avoided ? Wa s damag e t o walkwa y surface s avoided ? 

# T N o

N o

N o

N o

No

## Owner s comments :

Inspectio n notes : ^* < 

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# yy 

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Remova l an drestoratio n activate s complete includin g th e 30-da y sodwarranty : EP A Representativ e Saa-^oi ^ Date : ilzr/ nEUHNULOGIES . INC . A S - BUIL T DRAWIN G OL S #2894 9 Dat e Excavated : 11/15/201 0 I SEP A Signcd-Of T Date : OMAH A LEA D SUPERFUN D SIT E 2894 9 Exterio rPain l Omah a Lea d Sit e Owne rName : MARL AM WYNN _ • Goo d Sit e Sketc h Address : 252 3 MIAM I S T • Poo r Phone : H ^ No t pain t Sampl e Numbe r RYASCPXA-2894 9 RYBSCPXA-2894 9 F l F 2 Lea d Concentratio n

25 3 pp m Z.'\~ \ pp m Sampl e Collecte d LA B D D Sample s Collecte d Fir

m ^-^U^y^ ' < ^ Date : 

# 'TVT' Time : >'I J RYCSCPXA-2894 9 RYDSCPXA-2894 9 B l 8 2 H3' i HPiC e pp m pp m D D Sample s Analyze d -RS£SCPXA-2«949
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­ -OS ­ pp m pp m pp m D D D Numbe ro f Sample s = '- j 

# n D D XR F Unit : I OO l Book : Date : Time : Staff : ft -ZS-Ofo MSv / lCc 9
Legend : F l = Fron t Left , F2 = Fron t Right , B l = Bac k Left , B2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pla y A n quadrant s ar e a s viewe d fro m th e street , facin g properl y 

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# M (CCi'rttS t E A = 15 0 PP M ( dSCRAP E(~l" )

04< > I I CONTRAC T# : EP-S7-10-0 5 PRUDEN TTECHNOLOGIES , INC .

# SEP A Propert yCompletio n Agreemen t Thi s agreemen t documents th e completio n o f removal activitie s performe do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth 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 at an y tim e i n th e fiiture, excludin g any remainin g warranty (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Propert y ID : Propert y Address : ^ ^^ ^ ^ ^^ ^ ^ ^ -^ ^ 

## ^"^•• ^ ^ A g t/vls h ^J=> - Phone : ^ ^ ^ , ^n \ - ^ J-^Ll L 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 I 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 ) 

# rVcyu/ a3^'y^^^yw ^ Owner' s Signatur e Date ' I.\ \



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## fXIHNkJIOCili N t Pruden t Technologies , Inc . (Pnident ) is unde r contrac t withth e U. S. Environmenta l Protectio n Agenc y (EPA ) to clea nup lead
contanjinate dsoite at anim^cxja f propetties'locatB d in Omaha , Nebraska , includin g ih e imtperty locate dat y ^ S"^ ^ ' ^ /I'lJ'A/VlJfht EP A request s you r pennissio n to aUo w Pniden t to perfon n asoi l cleanu p at thi s propert y to removFlead-contaminate dsoil . By signin g thi s fonn, th e property owne r grant s pennissio n to Pruden t to perfin m activitie s relate d to th e cleanu p includin g so U samplmg , lemova l of lead-contaminate dsoil , ui drestoratio n ofth e reference dproperty . If

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 Pruden t SouthOmah aOffic e for th e Omah a Lea dSit e cleanup,,at (402 ) 733-1188 ; 733-1455 . General question s abou t th e Omah aLea dSit e cleanu p ca n be directe d to th e EP A Publi c InfoimatiQn Center s at (402 ) 73 1 •304 5 (Sout hOmah aoffice) . Property Acces s Grante dBy: . 

# /VUrIc M^ \M\j7\ n (Pleas e Pri mName ) Property Owne r Signature : 

# ^^'-^^ ^ ^^Mh (Date ) PROPERT Y INFORMATIO N yfr^h t complete d bvresiden t amyo rpropert yowne r— pleas e print ) RESIDEN TNAIHE : Rente r RESIDEN T ADDRESS : 

# '^"77.-^ l/CiAU^i IF RENTAL . PROPERT YOWNE D BY :
OWNER' S MAILIN JU G ADDRESS ; AODR I -i j ._ OWNER' S TELEPHON E NUMBE R • HOME :

# . .d ^ 'fT/ya c««« . J 1 AG E OF HOME? : YEARS . HO W LON G HAV E YO U LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D OR COVERE D WTT H SIDIN G SINC E 1978 ? 

### YE S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R OF CHILDREN 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 SPEO ^ INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORrr Y FO RENVIRONMENTA LRESPONS EACTIONS ; Tb e activitie s to be implemente dby EPA unde r thi s agreemen t ar e pursuan t to Sectio n 104 ofCERCLA , 42 U.S.C . 9604 . EPA' s righ t ofacces s to th e property is provide dformSectio n 104(e)o f CERCLA , 42 U.S . C 9605(e) , whic hprovide s enti y for "determinin g th e nee dfor response , or choosin g or takin g an y respons e actio n unde r thi 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. IO* " Stree t 424 2 Medica l Drive , Suit e 425 0 Kartsa s City , MO 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 383-370 3 Phone : (402)733-145 5 Phone : (210)822-958 8

## 2894 9 Owne rName : MARL AMWYN N Address : 252 3 MIAM I S T Phone : ^• Sampl e Numt)e r RYASCPXA-2894 9 RYBSCPXA-2894 9 RYCSCPXA-2894 9 RYDSCPXA-2894 9 RDZOCrXA-2004 0 ROZOCPX A2004 0 RPZSCPX A280^1 9 F l F 2 B l B 2 DZ GZ P Z - 

## Omah a Lea d Sit e Sit e Sketc h W : Lea d Concentratio n 

## Z 5 3 pp m 2.*^ ! pp m HB" ^ pp m Hfl ^ pp m pp m pp m pp m Numbe ro f Sample s = Sampl e Collecte d ^ . 

# a D D D ^ LA B 

## D D D 

# n n D D Exterio rPain t Nort h AfTo w • Goo d • Poo r gf'No t pain t Sample s Collecte d Firm : Date : 

# S Time : yi l
XR F Unit :

Date : Time : Staff : Sample s Analyze d 100 7 Book : lL> ^ flr'Zb-Oi o Krr \ MS W Legend : F l = Fron t Left . F 2 = Fron t Right , B l = Bac k Left , B 2 = Bac k Righ t D Z = Dri p Zone . G Z = Garden , P Z = Pla y Al l quadrant s ar e a s viewed fro m th e street , facin g propert y 

# lENTEBE R i m2 1 200 6 ;

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### Dougla s County Pag e 1 o f 1

http://www.dcgis.org/dogis / 11/2/201 0

### Ticke t Tex t an dMa p displa y fjMJ'icket : #263236 4 Pag e 1 of 2 Origina l Cal l Date : 11/02/1 0 Wor k t o Begi n Date : 11/04/1 0 Time : 12:0 1 p m Time : 12:3 0 p m Op : SIVA1 8 96 7 State : N E Address : 252 3 County : DOUGLA S Street : MIAM I S T Place : OMAH A Twp : 15 NRng : 13 E Sect-Qtr : 09-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: 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 : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N CXCATV . MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C



### Servic e Are a Contac t 

### Phon e Number Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIES DISTRICT SAND Y Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE RRICH/TRAFFI C Day : 402444719 7

Alt : 402444516 1 Emerg : 402444516 0 OPPDGPR 5 OMAH A PUBLI C POWE RDISTRICT EL M LOCATIN G Day : 406728934 3

Alt : 406207149 4 Emerg : 888728934 3 QLNN E1 C QWES T LOCA LNETWOR K EL M LOCATIN G 

### Day : 406728934 3

Alt : 406207149 4 Emerg : 888728934 3

Vie wMa p : ; Clos e Ma p


### http://www.dhon.org/irthintemet/MessageText/MessageTextAndMap.asp?NoticeID=DHO. . . 11/2/201 0TBOHN ! laLO^i , 

### CONSTRUCTIO N 

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## SIT E SAFfeT Y HAZARD ANALYSI S 

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- & - Address : Excavatio n Date : Crew : Backfi U Date :

Ite m Overliea 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 Driveway Sprinkle r Syste m Othe r Cre w Forema n Conditio n Hazard s Correctiv e Actio n c^<
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08 0 Waitf^RartgNay . 5ul B 4( B SSOOSIOS t 424 2 Medica l Drive , StJtt e 72S 0 Caisasia)^illO««11 4 l€810 7 Sa n Antonto , T X 7822 9 4iane : (819 ) SSS-aTO S (402 ) 733-110 8 Phone : (2t0 ) 822458 8 ?« : ^16)363.4710 7 Paor . (4Q2)73»>1<8 3 Fax : (210)679-657 7

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