SAID# : 

### 4920 3 

### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R DATE : 1/1 5 ADDRESS : 461 5 N 3 4 A V REMEDIATIO N CONTRAaOR : PRUDEN TTECHNOLOGIES . INC . YEAR : 

### 201 ^ 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S ri PR E AN D POS T VIDE O O F PORPERT Y (DVD ) 3023750 3 a EXECUTIV E SUMMAR Y 

# un m Q EPA-PROVIDE D PROPERT YSKETC H Superfun d U SIGNE D ACCES S AGREEMEN T FOR SUBJEC TPROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FOR ADJACEN TPROPERT Y E i RESTORATIO N AGREEMEN T n SETTLEMEN T DOCUMENTS (I.E. , FOR DAMAG E O R TO REPLAC E PLANTS , ETC. ) o f CONFIRMATIO N DAT A a PHOTOGRAPH S H AS-BUIL T SKETC H m SATISFACTOR YRESTORATIO N SIGNE D BYPROPERT YOWNE R m PROPERT YCLOSE-OU TCHEC KLIS TSIGNE D B YEP A D DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A C

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### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLeadSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address ; 461 5 N 3 4 A V A . EXECUTIVESUMMAR Y A. 1Issue s Encountered : NON E A. 2Issue s Resolved : NON E A. 3Uniqu e Findings : NON E A. 4Othe r Relevan t Information : CONTAMINATIO N LEF T BEHIN D PE RP.O . REQUEST : F1/FLOWERS (2'X40' ) = 40 6 PP M @ SCRAP E CONFIRMATIO N SAMPLIN GDATA/RESULTS : F l = 36 7 PP M @ 10" ; DZ= 64 3 PP M @ 13" ; E A = 187 PP M @ SCRAPE(~1" ) ATTACHMENT S 1 ) Propert y sketchprovidedb y EP A pursuan t to contract specification s 2 ) SignedAcces s Agreemen t including acces s agreement s requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l video clip/photograph s 4 ) Post-Excavation digita l video clip/photograph s 5 ) Documentation - CompletedClose-ou t Checklis t 6 ) As-Buil t sketch
i ) Shal l includ e fina l lea dlevel sv ) Legen d ii ) Contamination lef t behindarea svi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r items t o b e includedi n the individua l propert y file, i f available , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (ifan y ar e mad e wit hthe propert y owner ) ii ) Propert y Statu s For msignedb y propert y owne r iii ) Excavation digita l vide o i n MPEG , WM V (Window s Medi aVideo ) or SW F(FlashPlayer ) forma t and/or photograph s iv ) Signedfor mverifying satisfactor y restoration v ) Description of area s not meeting InterimRO D cleanu p criteria .

TECHNOLOGIES , INC .Fin d Recor d Remediatio n Quer y] ijea d Remainin g Quer y| Propert yDamage Quer y 

### Backfill :

Sampl e Area : 4920 3 - 461 5 N 3 4 A V Owner : Use rProvide d Owne rInformatio n Resident : n Owne rOccupie d Owne rName : Owne rName : Residen t Name : fCLU B INCORPORATE D [ "^•TM " jCLUBINCORPORATE D Owne rAddressl : Owne rAddress : Propert yAddress : 

# 1 J461 5 N 3 4 A V Owne rAddress2 : Zi p Code : 1461 5 N 3 4 AV E J68111 - City : state : Zi p Code : City : State : Zi p Code : Reslden t Phon e [oMAH A JNE ^

J68111 ­ 

# 1 ••' • 1 ' 1 •"" " ! Owne rPhon e j(402 ) 451-981 5 Altemat e Phone : 

# " r Owne rPhone : Alternat e Phone :

Contract : Assessment :

• ! Contractor : , |PRUDENT2010_S Qualifyin g Grou p |40 0 I Contrac t Optio n (BASE " Assessmen t Ma xXR F Valu e J 480.1 3TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Propert y # : ^'^^ ^ Propert y Address : '4<o\'^

_M "^ 4 A\re - Date/Time : Owner' s Name : Ok t \r

€ *~ C ) ov>-a> ~ Quad s Excavaterf : p ( ^ Q 2 Contracto r Group : PrucSent Technologies , Inc . Excavatio n Genera l Ye s N o I I f necessarv . wer e th e correc t qLiadrant(s ) excavate daii drestored' ^ / 2 . If necessary , wer e th e correc t area s o f dri p zon e e.xcavate dan drestored ? / Gradin g So dan dVegetatio n 1 Doe s Lli e gradin g aroun dtli e perimete r ofth e hous e i n e.xcavate darea s generall y slop e awa y fromth e house' ' Ye s / N o 2 3 Ha s so dbee n lai dmal l area s tliat wer e excavated ? Doe s th e so dappea r t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte dat a3 0 day tim e period ) / / 4 Are sodde darea s generall y firmai\devenl y graded ? / 5 Ar c Ui e joint s betwee n th e so dstnp s generall y light ? (Onl y evaluat e if inspecte dat a3 0 day tim e penod ) / 6 Wa s (h e property grade dsuc htliat wate r wil l no t poo l o n lli e property ? / 7 Wa s damag e l o landscapin g o r plan t material s avoided' ' / 1 Gates , Fence s an dRetainin g Wall s Ye s N o 1 D o gate s ope n an dclos e freely' ' (I f applicable ) 

### / 2 Were al l gate s or fence s take n dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) 

# '7 1 Wa s damag e to gate s o r fence s avoided ? (I f applicable ) 

# 7 Wa s damag e t o retainin g wall s avoided ? (I f applicable ) Foundation , Sidin g an dGutter s Ye s No 1 Wa s damag e l o th e sidin g o r tri mavoided ? / 2 Wa s damag e l o tli e foundatio n avoided ? / Wa s damag e t o window s avoided' ' / 4 Wa s damag e l o window s o r doo r screen s avoided ? / 5 Wa s damag e l o downspout s o r downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s N o Wa s damag e l o dnvewa v surface s avoided' ' 

# 7 Wa s damag e t o walkwa y surface s avoided' ' 

# 7

## Owner s comments :

Inspectio n notes :

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e '^ ^ ^ ^Date; \t\i\[ 0RnTNOL(X;iF,S . INC 

### A S - BUIL T DRAWIN G OL S # 4920 3 Dat e Excavated : 10/28/201 0 

### OMAH A LEA D SUPERFUN D SIT E I SEP A Signed-OI T Date : 

### 4920 3 Exterio rPain t Omah a Lea d Sit e H Owne rName : CLU B INCORPORATE D ^ Goo d Sit e Sketc h Address : ••61 5 N 3 4 /V V _ • Poo r Phone : " W : n No t pain t Sampl e Numbe r RYASCPXA-4920 3 F 1 RYBSCPXA-4920 3 F 2 RYCSCPXA-4920 3 B l RVDOCrXA''4920 3 —BS RDZSCPXA-4920 3 D 2 -nogocr'XA4oro3—s£ ­ RPZOGr)(A-<9g0 3 -P2 - La

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# «En V Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio no 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 dwithth e restoratio no f th e subjec t property , an dtha t n o item s are in question , now , o r a t an y tim e i n th e future , excludin g an y remainin g warranty (3 0 day s total ) excep t thos e item s liste dbelow , ifany . Propert y ID : Propert y Address : l^^ f t ; f^ ^ 2 ^ ^V E Owner : 

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# //-3.<?-/< g Dat e

### TFC-H^OiiK^iFs . ivr : Pruden t [echnologies . Inc . (Prudent )is under contrac t wit hth e U. S. Environmental Protectio nAgenc y (EPA ) tn clean up lead
­ contaminate dsoil s at anumbe rof propertie s locate d in Omaha , Nebraska , includin g th e property locate d at Vi^^S ^ A / 3""/* ^ /WJt . Th e EP A request s you r permissio n to allo w Pruden t to perfor masoi l cleanu p at

thi s properl yto remov e lead-contaminate dsoi l By signin g thi s form , tli e property owner grant s permissio nto Prudent to perfor m activitie s relate dto th e cleanu p includin g soi l sampling , removal of lead-contaminate dsoil , an drestoratio nof :he reference dpropert y If

yo u hav e an y question s abou t th e soi l cleanu p planne dfor your property , pleas e contac t Prudent •• • '• ' r i ,: <.. ' .i,\
- fo r the Omah a LeadSit e cleanup , at (402 ) 733-1188 ; 733-1455 . General question s abou t th e Omah aLea dSit e cleanu p ca n b : directe d lo the EP A Publi c Informatio nCenter s at (402 ) 731-304 5 (Sout hOmah aoffice) . Property Acces s Grante d By (ll_\{Jfl L'0[79feV ^ i*^ ^ ' •• (Pleas e Print Name ) Property Owne r .Signature 

# £z^=B'/ o (Date ) PROPERT YINFORMATIO N (T o be complete d byresiden t and/o rpropert yowne r~ pleas e print ) RESIDEN T NAME : Itl ^

^Od B Owne r Rente r RESIDEN T ADDRESS : 

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IF RENTAL , PROPERT Y OWNE D BY :
OWNER' S MAILIN G ADDRES S 

# '^ hi - J¥^f^ ^ ' OWNER' S TELEPHON E NUMBE R - HOME : (TI M > Hit ) / "000 ^ WORK : 

### J \ \ AG E OF HOME? : 

# ^72 L 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 WIT H SIDIN G SINC E 1978 ? C—^ S NO NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : Mf ^ NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDE R ^ NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YIN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUT»miT Y FO RENVIRONMENTA LRESPONS EACTIONS , Th e activitie s to be implemente d by EP A .inder thi s agreement ar e pursuan t to Sectio n10 4 of CERCLA . 42 U S.C . 9604 . EPA' s righ tof acces s to th e propertyis provide dfo
- in Sectio n104(e)of CERCLA , 42 U.S . C 9605(e) , whic hprovide s entry fo r "determinin g th e nee dfo r response , or choosin g or takin g any respons e actio n under thi s title , or otherwis e enforcin g th e provision s ofth e title. "

808 0 War d Parkw/ay , Si ' Kansa s City . MO 641"- : :s.:ii . (^iMo-'M o '•) < '"Ai2\ - Dhone : («16 ! 353-:-"'" ' •••• • '•' • .T'l " r';;:Ais?; >E^vTROl^^vrE^TAL & CONSTRUCTIO N TECHNOLOGIES , INC . SERVICE S 

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# •p/cy^^^s^ Signature : 808 0 War d ParttWay . Suit e 4 f 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 San Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-968 8

## 4920 3 Exterio rPain t Nort h Arrow / 

### Omah a Lea d Sit e Owne rName : CLU B INCORPORATE D 0 Goo d 

### Sit e Sketc h Address:46l5N34A V 

### • Poo r 

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# A Printed : No v 30 . 201 0 \\\vv\. dcgis.org/dogi s

### 10/27/201 0 kWww.dhon.org/irthinternet/DHONNotic. . . Creat e Anothe rTicke t Bac k t o Irt h Inteme t Send . E mai k



## • YOURTICKE T NUMBE RI S 2627913 . Origina l Cal l Date : 10/27/1 0 Time : 2:5 0 p m Op : SIVA1896 7 Wor k t o Begi n Date : 10/29/1 0 Time : 3:1 5 p m State : N E County : DOUGLA S Place : OMAHA Address : 461 5 Street : N34T H AV E Twp : 15 NRng : 13 E Sect-Qtr : 04-N W Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : Lea d Soi l 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 Company: 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 : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N ALT87 2 CXCATV METR O MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C 

## Servic e Are a Contac t Phon e Nunibe r 

## Utilit y Typ e ALT87 2 WINDSTREAM COMMUNICATIO N EL M LOCATIN G Day : 406728934 3 Mt : 406207149 4 Emerg : 888728934 3 

## CXCATV CO X COMMUNICATIONS , IN C HEID I Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 

## METRO METRO COMM . COLLEG E CHRI S Day : 402457230 7 AH: 402672703 3 Emerg : 402457231 3 MUDOl METROPOLITAN UTILITIE S DISTRIC T S/ySTD Y Day : 402504782 3 Alt : Emerg : 402504797 0 dhon.org/irthinternet/.../MessageText.as. , 

### 1/ 2

### 10/27/201 0 kWww.dhon.org/irthinternet/DHONNotic.. . 

## OMAHACO F CIT YO F OMAHA 

## TRAFFICSEWE R RICHTRAFFI C Day : 402444719 7 Al : 402444516 1 Emerg : 402444516 0 0PPDGPR 5 OMAH A PUBLI C POWE R DISTRIC T EL M LOCATIN G Day : 406728934 3 AH : 406207149 4 Emerg : 888728934 3 

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

dhon.org/irthinternet/.../MessageText.as.. . 2/ 2

### ENVIRONMENTAL ENGINEERBV GAN D CONSTRUCTIO N 

## lEeMNoukoes, mc . SOLUTION S 

## SIT ESAFt:T Y HAZAR D ANALYSI S Address : .i{4l5._^ . Jf ZMj/„^ . Crew : J^l^i f JJ-lilj.QJC^—— .

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 Driveway Sprinkle r Syste m Othe r Cre w Forema n Conditio n PaOc A (^LurveA '^uuTi-e^A . 

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Sit e Safet y Offic e Date : 

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808 0 WMtffiariany , Suit B 40 5 5600S10S t 424 2 Medica l Drive , Suit e 725 0 Kansa s OHv . IIO«411 4 OmAfia , Netaask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363^370 3 Phone : (402)733-118 8 Phone : (210)822^.958 8 f^x : (816)363470 7 Pax : (402 ) 733-188 3 Fax : (210)579-657 7

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