### PROPERT Y SUMMAR Y Date : 09/28/200 7 Omah aLea dSite Remedia l Actio nContrac t #EP-R7-07-0 6 Mont hof : Augus t Propert y Address ; 155 6 N 1 9 S t A . EXECUTIV ESUMMAR Y A. I Issue s Encountered : Ma p Error . Ne w ma p Drawn . A. 2 Issue s Resolved : Re-See dwil l occu r i nNovembe r o nan y dea dspot s t o encourag e sprin g growth . A. 3 Uniqu e Findings : A. 4 Othe r Relevan t Information : CONFIRMATIO NSAMPLIN GDATA/RESULTS : Easemen t 6 8 @ Scrap e Fl - 14 6 @ 6 " F 2 - 19 2 @ 6 " B 2 - 12 3 @ 6 " 

### Dl-34@14 " ATTACHMENT S 1 ) Propert y sketc hprovide db y EP Apursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfo r crossin g othe r propertie s 3 ) Pre-Excavatio ndigita 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-Buil t sketc h­ i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contaminatio nleft behin darea s vi ) Contracto r identificatio n iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include di nth e individua l propert y file , i f available , o r obtaine dinclude : i ) Pre-excavatio nagreemen t detail s (i f an y ar e mad e wit hth e propert y owner ) ii ) Excavatio ndigita l vide o i nMPEG , WM V (Window s Medi aVideo ) o r SW F(Flas hPlayer ) forma t and/o r photograph s iii ) Signe dfor mverifyin g satisfactor y restoratio n iv ) Descriptio no f area s no t meetin g Interi mRO D cleanu p criteria .

:CHNOLOCIES , INC .1 

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## & & \ PropertyTo^e^nduc t Easemen t Sit e Remedia l * v¥P v£ Samplin g an d Cleanu p Actio n V^-^/Xv. ^

.. < Under Contrac t EP-R7-07-06 , th e U . S . Environmenta l Protectio n Agenc y (EPA) ha s Contracte dPrudent Technologies , Inc . (Prudent) , to cleanu p lea dcontaminatio n o n variou s residential propertie s includin g you r property . Yo u can help wit hthi s activit y b y givin g permissio n t o conduc t easemen t samplin g an d conduc t cleanu p o n you r property . I f yo u sig n thi s form , Prudent will return i n afe w week s an dperform th e work . W e will coordinat e samplin g an dcleanup wit h yo u prio r to commencement I f

yo u hav e an y question s abou t th e propose dwork , pleas e contac t Dan Garvey , EPA' s Projec t Office r fo r ou

r Omah aLea dSit e Contrac t Mr . Garvey ca n b e reache da t (402 ) 731-0788 . 

### Propert y Acces s Grante dBy : %/S7/ 7 /& . [A/ f

////*?/X ) (PUutPnutNamt ) 

### Propert y Owner Signature : /y^Ui ? /C^i-^L^M-^^t^*^^ 2 . ' (Dnt» ) 

### PROPERT YINFORMATIO N (T o b e completedb y residen t and/o r property owne r - pleas e print) <-p ) n . Q en1e r RESIDEN TNAME : 4<v.\ L ff i yi'U- A Hr^Jl ^ [g3¥?ne r dt

W RESIDEN TADDRESS : |«g . ^ Q M ~ ^ i ^ V ^"^ ~ <^WN<^Q L AJ £ G^/ / f I F RENTAL . PROPERTYOWNE D BY : OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBE R -HOME : {HcQ l r^D§ > ~ *£>G>° 3 WORK : AG E O F HOME? : YEARS . HO W LON G HAV E Y O LIVE D HERE ? YEARS . HA S TH E EXTERIO R BEE N PAINTE D O R COVERDE D WIT H SIDIN G SINC E 1978 7 YES HA S TH E INTERIO R BEE N PAINTE D O R COVERE D SINC E 1978? V ^

YE S N O NUMBE R O F OCCUPANT S UNDE R 6 YEAR S OLD : )

_NUMBE R O F OCCUPANTS 6 YEAR S OL D AN D OLDE R NUMBE R O F CHILDREN TUNDE R C YEAR S OL D WH O PLA YI 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 YGATES . ETC. ) AUTHORIT Y FO RENVIQRMMENTALRESPONS EACTION S Th e activitie s to b e implement s b y EPA unde r thi s agreement are pursuan t to Sectio n 10 4 o f CERCLE . 4 2 U . S.C . 9604 . EPA' s right o f acces s to the propert y i s provide dfor i n Sectio n 104(e ) o f CERCLE , 4 2 U.S . C 9605(e) , whic h provide s entr y fo r "determinin g th e nee dfo r response , o r choosing o r takin g any respons e actio n unde r thi s title , o r otherwis e enforcin g th e provision s o f th e title. "

# &EP A EP A Propert y Clos e Ou t Propert y # : £ Propert y Address : iSS £A > /9- M jy . Date/Time : Owner' s Name : /j><.y> >*J.u.//vn » Quad s Excavated : Contracto r Grou p Pruden t Technologie s Excavatio nGenera l Ye s N o 1 . I f necessary , were th e correc t quadrant(s ) excavate dan drestored ? 

### / 2 .I f necessary , wer e th e correc t area s o f dri p zon e excavate dan drestored ? 

# y Gradin g So dan dVegetatio n Ye s N o 

## 1 . Doe s th e gradin g aroun dth e perimete r o f th e hous e i nexcavate darea s generall y slop e awa y 

### S fro mth e house ? 

### 2 . Ha s so dbee nlai di nal l area s tha t wer e excavated ? 

### i / 3 . Doe s th e so dappear to b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte dat a3 0 

### t / da y tim e period ) 

### 4 . Ar e sodde darea s generall y firman devenl y graded ? 

### i / 5 . Ar e th e joint s betwee nth e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 day tim e period ) LS 

### 6 . Wa s th e property grade dsuc htha t wate r wil l no t poo l o nth e property ? 

### \ s 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? i / Gates , Fence s an dRetainin g Wall s Ye s N o 1 .D o gate s openan dclos e freely ? (I f applicable ) 

### i/ 2 .

Wer e al l gate s o r fence s take ndow ndurin g restoratio nactivitie s reinstalled ? (I f applicable ) 

### , / 3 .

Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) iS 4 .Wa s damag e t o retainin g wall s avoided ? (I f applicable ) 

### ^ 

### Foundation , Sidin g an dGutter s Ye s N o 1 .Was damag e to the sidin g or tri mavoided ? ( / 2 .Wa s damag e t o th e foundatio navoided ? </ 3 .

Wa s damag e t o window s avoided ? 

## S 4 .

Wa s damag e t o window s o r doo r screen s avoided ? 

## i/ 5 .Wa s damag e t o downspout s o r downspou t extension s avoided ? 

## </ Sidewalk s an dDriveway s (Concrete )Ye s N o 1 .Was damag e to drivewa y surface s avoided ? 

### « / 2 .

Wa s damag e t o walkwa y surface s avoided ? 

### ( /

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. 4613 0

### 46T30 "

### Print Previe w Pag e 1 o f L 

## Dougla s County-Omaha , N E

Parce l I D Owne r Name Propert y Addres s Cit y 

### Zi p Owne r Addres s Owne r Addres s 2 Owne rCit y Owne r Stat e Owne rZi p 222930000 2 HODG E RUBY L 1556N19S T OMAH A 6811 0 1556 N 1 9 ST OMAH A N E 6811 0 Sec-Twn-Rn g Owne r Address Additio n Bloc k 

### Lot Lega l 1 Legal 2 Legal 3 Legal 4 Assesso r Websit e Lin k 15-15-1 3 SMITH S -EV - AD D 1 7 3 1/

2 VA C ALLE YAD J & S 1 F T& AL L LT2&N33FTLT3BLK1 7 http://douglasne.mapping online.com/DouglasCoNe/static/accountinfo.jsp ? accountno=R222930000 2 Disclaime rMa p an d parce l data ar e believed to b e accurate , bu t accurac yi s no t Ma p Scal e guaranteed . Thi s i s not a lega l documen t an d shoul d not b e substitute d fo ra titl e search , 1 inc h = 3 1 fee t appraisal , survey , o rfo rzonin g verification . 

### http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 7/16/200 7

# SER A PropertyCompletio n Agreemen t Thi s agreemen t document s th e completio no f remova l activitie s performe do nth 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 no f th e subjec t property , an dtha t n o item s ar e i nquestion , now , o r a t an y tim e i nth e future , excludin g an y 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 : 

### Owner : Phone : Restoratio n Item s i n Question :

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



### LJ I agre e restoratio n i s completed , excep t a s note d above . E H I d o not agre e restoratio n i s complete d

Owner' s Signatur e Dat e

### Pag e 1 of2

Creat e Anothe rTicke t Bac k t o Irt h Internet Sen d Emai l ~ [ 

### YOU RTICKE T NUMBE RI S 1846454 . Origina l Cal l Date : 7/20/0 7 Time : 11:2 1 a m Op : CYNDIE1896 7 Wor k t o Begi n Date : 7/24/0 7 Time : 11:4 5 a m State : N E County : DOUGLA S Place : OMAH A Address : 155 6 Street : FLORENC E BLV D Twp : 15 NRng : 13 E Sect-Qtr : 15-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : Soi l Excavatio n - Lea d Locatio n o f Work : LOCAT E ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)504-100 5 Company: PRUDEN T TECHNOLOGIE S Contac t Name : CYNDI E Phone : (402)504-100 4 Wor k Bein g Don e For : EP A Dept h o f Excavation : 13 " Ma x Corne r Lot : N Front : NRear : N Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V LEVEL S MAGELLANMUD0 1 OMAHACO F OPPDGPR 5 QLNNE1 C

Servic e Are a Contac t Phon e Numbe r Utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C 

### HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 LEVEL S LEVEL 3 COMMUNICATIONS , LL C 

## N A Day : 877366834 4



## Alt : Emerg : 877366834 4 MAGELLA NMAGELLA N MIDSTREA M PARTNER S L PTONY A 

### Day : 918574709 8 Alt : 

### Emerg : 918574709 8 MUD0 1 METROPOLITAN UTILITIE S DISTRIC T EDWTN A Day : 402504782 3 Alt : 

### Emerg : 402504794 6 Day : 402444719 7 http://www.dhon.org/irmmternet/DHONNoticeCreatiori/MessageText.asp?ret=<RESULTS.. . 7/20/200 7

### Pag e 2 o f 2

OMAHACO FCIT Y O FOMAHA-TRAFFIC,SEWE RRO N 

## Alt : Emerg : 402444516 1 402444516 0 OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T N A 

### Day : 406728934 3 

## Alt : Emerg : 888728934 3 QLNNE1 C QWES T LOCA LNETWOR K 

### N A 

### Day : 406728934 3 

## Alt : Emerg : 888728934 3

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### Sampl e Area : 2655 3 - 1556 N 1 9 S T Owner : Resident : Contract :

' ; Owne rOccupie d Residen t Name : Contractor : Owne rName : HODG E RUBYL JPRUDENT200 7 I HODG E RUB YL Propert yAddress : Group : Owne rAddressl : 

### 155 6 N

### 1 9 S T Owne rAddress2 : Zi p Code : [6811 0 

### Assessment : 1155 6 N

### 1 9 S T Residen t Phon e Qualifyin g Grou p 

### City : State : Zi p Code : I [80 0 jOMAH A NE T J6811 0 I Assessmen t XR F Date : Owne rPhone : Alternat e Phone : I | | ' 

### |(402 ) 734-163 2 | ; Assessmen t Ma xXR F Value :

. . 881

_ 1 5