TRANSMITTAL of OMAHA LEAD SITE 

SOIL REMEDIATION FILE FOLDER 

SAID#: 35979 Date: 

Address: 5013 N 22 St 

Remediation Contractor: Environmental Restoration, LLC_ Year: _2011 

SOIL BIEMEDIATION 

PROPERTY FILE FOLDER DOCUMENTS 

X Video of property (DVD) ^^^a^fore DAfter 0 Basement D 

Executive Summary (Final Report) 

EPA-provided property sketch 

Signed Access Agreement for subject property 

D Signed Access Agreement(s) for adjacent property 

Restoration Agreement 

D Settlement documents (i.e., for damage or to replace plants, etc.) 

Confirmation data 

Photographs yfatioxQ DCrewPhotos-'flDuring Excavation D Sod 

,0^-da y Sod D 

As-built sketch 

Completion Agreement signed by Property Owner 

Property close-out check list signed by EPA 

D Description of areas not nieeting ROD cleanup criteria. Contamination left behind 

y ^ Utility clearances 

/ U Property information from Douglas County Assessor's Office 

Property access checklist 

^ , ^T 30262341 

Contact Log 

y ^ y^r^^-h W l Superfund 

J yO--/<^ 

Date 

.,_ , ^ _3yysyy^ 

EPA COR signature y ^ Date 
EPA 

EPA Property Close Out Form 

Omaha Lead Site 

Property*: 35979 Property Address: 5013 N 22 St 

Date/Time: Owner's Name: Anne Brutsche 

Quads Excavated: Fl Contractor Group: Environmental Restoration (ER) 

Excavation General Yes No 

1. If necessary, were the correct quadrant(s) excavated and restored? y y 

2. If necessary, were the correct areas ofdrip zone excavated and restored? ^Cif}JQi^{\X (o T "OT 

Grading Sod and Vegetation Yes No 

1. Does the grading around the perimeter ofthe house in excavated areas generally slope away from the 

y house? 

2. Has sod been laid in all areas that were excavated? \ y 

3. Does the sod appear to be generally healthy and growing? (Only evaluate if inspected at 30-day time 

period). 

4. Are sodded areas generally firm and evenly graded? " ^ 

5. Are the joints between the sod strips generally tight? (Only evaluate if inspected at 30-day time period). 

6. Was the property graded such that water will not pool on the property? y 

7. Was damage to landscaping or plant materials avoided? *• ' 

Gates, Fences and Retaining Walls Yes No 

1. Do gates open and close freely? (if applicable) A//4 

2. Were all gates or fences taken down during restoration activities re-installed? (if applicable) A//i 

3. Was damage to gates or fences avoided? (if applicable) 

4. Was damage to retaining walls avoided? (if applicable) 

Foundation, Siding and Gutters 

1. Was damage to siding or trim avoided? 

2. Was damage to the foundation avoided? 

3. Was damage to windows avoided? 

4. Was damage to window screens or door screens avoided? 

5. Was damage to downspouts or downspout extensions avoided? 

Sidewalks and Driveways (Concrete) 

1. Was damage to driveway surfaces avoided? 

2. Was damage to walkway surfaces avoided? 

Inspection notes: / / 

^ ^ 

A ^ 

Yes No 

>J(yQ^y [Q L 

AW 

Yes 

y 

Y 

No 

Remedial and restoration activities complete including 30-day sod warranty: 

EPA Representative;.y^7^..^ _ y^y^^ . V^X^ ^ Date: 11/^/^. ( 
X 

OMAHA LEAD SITE — EP-R7-09-05 

ENVIRONMENTAL RESTORATION, LLC 

WWW.ERLLC.COM 

y^"^^,, 

\ 

' \ PHO^*'' 

EXECUTIVE SUMMARY 

35979 5013 N 22 ST 

NO ISSUES OR CONCERNS ISSUES/CONCERNS 

DETAIL EXPLANATION: 
IRTH One Call 

Page 1 of 1 

Ticket Information for Ticket 2879328 

Below Is The Ticket Text Followed By A List Of Members Affected 

Printer Friendly Version 

Original Call Date: 10/17/11 Time: 10:31 pm Op: TIM24186 


Work to Begin Date: 10/20/11 Time: 7:00 am 


State: NE County: DOUGLAS Place: OMAHA 


Address: 5013 Street: N 22ND ST 


Twp: 15N Rng: 13E Sect-Qtr: 03-NW 


Twp: Rng: Sect-Qtr: 


Legal Given: C 


Type of Work: LEAD REMOVAL 


Location of Work: LOCATE THE ENTIRE PROPERTY. 


Remarks: FAX ALL CLEARS TO: (402)451-1069 


: 35979 


Company ENVIRONMENTAL RESTORATION 


Contact Name TIM SUTTON 
 Phone: (402)451-1314 x2267 


Alt. Contact 	CELL 
 Phone: (402)306-2347 


Work Being Done For: EPA 


Depth of E.xcavation: 24 INCHES Corner Lot: N Front: N Rear: N 


Involves Tunneling or Horizontal Boring : N Explosives: N 


COXCATV MUDOl OMAHACOF 0PPDGPR5 QLNNEIC 


Service Area 

Utility Service Area Name Contact 

Phone Numbers Code 

Type 

COXCATV 

COX COMMUNICATIONS INC ELMCOX ELMCOX Day: (406)728 - 9343 

Alt: (406) 327 - 2936 

Emerg: (888) 728 - 9343 

MUDOl 

METROPOLITAN UTILITIES SANDY MUDOl Day: (402)504 - 7823 

DISTRICT 

Emerg: (402) 504 - 7970 

OMAHACOF 

CITY OF OMAHA- RICH/TRAFFIC OMAHA Day: (402) 444 - 7197 

TRAFFICSEWER 

Alt: (402) 444 - 5161 

Emerg: (402) 444 - 5160 

0PPDGPR5 

OMAHA PUBLIC POWER CONSOLIDATED Day: (800) 575 - 5587 

DISTRICT CONSOLIDATED 

Emerg: (800) 575 - 5587 

QLNNEIC QWEST LOCAL NETWORK ELM QLNNEIC 

Day: (406)728 - 9343 

Alt: (406) 207 - 1494 

Emerg: (888) 728 -9343 

View Map 

http://www.dhon.org//IRTHOneCall/TicketA^iewTicket.aspx?ticketID=865423 1/9/2012 
ENVIRONMENTAL 

RESTORATIO N 

Questions to answer at the house 

1 Does the map match the property? \ | L ^ 

2 Is there a dog? r\cr>

3 Is there anything that need to be moved? like a car or boat? f\ o

4 Does the property have easy access? M^.' ^ 

5 Is the property Easy, Normal or Hard? r\C>r~rr>0^ l 

5 If no. is there a property we can get access from?_ 

7 Is soil going to have to be shuttled out? (Ncs 

8 Is the property ail hand work? A o 

9 Is there a retaining wall? fVo 

10 Is it in bad shape? 

11 is there under ground line to the garage? (\ o 

12 is there a sewer clean out? f\ o 

13 Is there any hazards in the yard? r\c? 

14 Is the siding old on the house? V Q- V 

15 Try to leave the time frame oper\ when we will be there? v/g_f^ 

. 

 L-V'"0-'S>V\ CJQJN -^^Lfscj^ 

i s If they need a notice Mark it big on the map. Try to leave it at a 24 hour notice onlyl 

17 What kind materials are need for replacement? (\or\ ^ 

IS Is there zoysia grass at the property ( Red rla.g this propertY)?_ 

19 Is this property boarder line on routine? C\Oi 

20 Is there sentimental item be aware of? •VvjOQ -W-ejt.-^ 

21 Can we use the driveway? \jCS> 

2 Is the property line marked in the excavation areas? sj 4. ^ 

Sign \^,: ^ ^'^jSX^t^r ^ 
Contact Information Log 

SAID# 5^A"1^ 

Owner's Name: Anne . "^vx-V^jcV^e , Daytime Phone: L^Ol. - »A&& -Cj>ZH \ 

Property Address: 50\' b Ki . "ZZ ^+ . 

Attempt to contact Date/time Name 
Property Access Checklist 

SAID: 55^1S D WORK STARTED ON: / / 

Property Address: 5C:5\^^ K^ . ZT-* ^ S ^ D WORK COMPELTED ON: __/__ / 

Owner: ftr^nc ly^^^tC^ ^ Renter: 

Address: Phone: 

Fax: 

Cell/Pager: 

Phone: Additional Information: 

Fax: 

Cell/Pager: 

13 Access Agreement Siened: ? / ^ / U By: 13 ^ 

S Restoration Agreement Signed: *2 l ^ / K By^Tj ^ 

^ Video Property Before On : ? /J^/H By: TU 3 

H Digital Photos Before On : ^ l^ l W By: -r j 3 

1 1 Video Property After On : / / By: 

D Digital Photos After On : / / By: 

S , Property Completion Agreement Siened: ^o P ^ I |( By:(ejO 

• Final Report Siened: / / By: 

Additional Video or Digital Photo's Taken: 

n Video n Digital Photo On : / / By: 

Reason: 

D Video D Digital Photo On : / / By: 

Reason: 

D Video D Digital Photo On : / / By: 

Reason: 

n Video n Digital Photo On : / / By: 

Reason: 
Consent for Access to Property SAID#_^^3 ? 

RIGHT OF ENTRY TO PREMISES 

Grantor (the property owner), consents to and authorizes the United States Environmental 

Protection Agency (USEPA) or its authorized representatives, collectively the Grantee to enter 

and perform certain environmental response activities upon the following described premises: 

Owner's Name: ftt^rse. "St^cv-V^cV* ^ Daytime Phone: HOX-'AS^-Cp'2H \ 

Address: ^^\ S U ZT.^^ '^ . 

Address: 

Addresses of Properties 

covered by this Address: 

Agreement: Address: 

Address: 

PURPOSE OF INVESTIGATION 

The purpose of the remedial activities is to remove all soils at the property which are 

contaminated with hazardous substances, in particular lead at concentrations greater than or equal 

to 400 parts per million (ppm). 

REMEDIAL ACTIONS 

The environmental response actions to be performed on said property may include the following 

activities: 

a. Taking photographs and/or video of the property before, during, and after remedial 

activities; 

b. Locating equipment and machinery on-site in preparation for and in the course ofthe 

environmental response; 

c. Planning and implementing the removal action on or near Grantor's property. 

d. Obtaining samples from Grantor's property; . 

AGREEMENT NOT TO INTERFERE 

The Grantor agrees not to interfere or tamper with any of the activities or work done, or the 

equipment used to perform the activities, or to undertake any actions regarding the use of said 

property which would tend to endanger the health or welfare ofthe Grantees or the environment, 

or to allow others to use the property in such 

IKI I grant access to my properties O I do not grant access to my properties 

(JM/^D, 1^^k^!ilU. i W ^ P-Oi/ 

Signature ' Date Signature Date 
^1^-'- ^ 

Additional Comments / Instructions: 

*4o ''^)OiQ£rf\xX\'V 

^ Check this box if owner does not want E.R. to enter the residents to document interior 

foundation walls and possible preexisting damage. By checking this box E.R. is not responsible 

for any damage done to the interior of house, including foundation cracks or fissures. 

KI I agree Q I do not agree S i agree O I do not agree 

Owner's Signature Date Contractor's Signature Date 
E2:^sc:^^^:;i»5 

Restoration Agreement 

The purpose of this agreement is to provide a mutual agreement as to conditions of property prior to 

contractor activities. This will also serve as documentation for the purpose of assuring that restoration 

activities are completed to the satisfaction ofthe property owner and the United States Environmental 

Protection Agency (EPA). 

SAID: ss^ns 

Property Address: ^ON* ^ VA. 17-'^*2»-V 

Owner: firNp,^ "^^OIVSJCVN C 

Phone: i^CTL - v\S^ - Ci>7.^V 

On the attached diagram(s) indicate area(s) to be excavated and depth of e.xcavation, location of all known 

utilities, subsurface features, surface structures and landscaping features, access location(s) to be used by 

contractor, and the direction of North. Indicate distances, depths, material types, etc. Indicate digital photos 

by referencing the photo-log number with an arrow indicating direction of view. 

Items to be removed by Contractor and not replaced: 

Item: 

PAOVC or^d^uc V bor^k ^ejf\c£. *for--Wo5yr> 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Page 1 of 2 
Additional Comments / Instructions: 

[ 3 I agree n I do not agree |S<] I agree n I do not agree 

^>.oCtt&- ^-M-\l 

Owner'ss Signatur Signaturee Date Contractor's^Sienat Signatur u e Date 

Attachment 

Page 2 of 2 
Property Completion Agreement 

This agreement documents the completion of remedial activities performed on my property. My 

signature will designate that 1 am satisfied with the restoration of my property, and that no items are in 

question, now, or at any time in the future, except those items listed below, if any. 

SAID: ^^I S 

Property Address: 5Ci\?. U. Z^*^ SA-. Owner: f\r\T\L "fer-u.-V^.cWe. 

Phone: 

Restoration Items in Question: 

Item: 

Item: 

Item: 

Item: 

Item: 

Item: 

Additional Comments: 

l/X I agree restoration is completed, except as noted ^J^'HI agree restoration is completed, except as noted 

I I I do not agree restoration is completed | | I do not agree restoration Is completed 

y^. y (^..^.yptfcT id-^^-i\ C . ^ '"''-^-'f 

Owner's Signature Date Contractor's Signature Date 
Uougias County Account Intormation Page I of2 

Douglas County, Nebraska Property Record - R2004920000 

Print Report 

View Interactive GIS Mao Information is valid as of 2011 -7-15 Treasurer's Tax Report 

New Feature ->*->-* Subdivision Sales Search 

Owner 

BRUTSCHE ANNE M 

1 5011 N 22 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 0492 0000 20 

Account Type: Residential 

\ Parcel Number: 2004920000 

Parcel Address: 5013 N 22 ST 

OMAHA NE 68110-0000 

Legal Description: PATRICKS 2ND SARATOGA ADD LOT 9 BLOCK 7 53 X 128 

Value Informatio n 

2011 

2010 

2009 

2008 

2007 

2006 

Land 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

Show All Transactions 

Improvement 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Total 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

Land Informatio n 

Acres 

0.15 

SF 

6784.0 

Units 

0.0 

Depth 

128.0 

Width 

53.0 

Vacant 

Yes 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R20... 7/26/2011 
4 

Uougias County Account Intormation Page 2 ot 2 

* X * 

^ ^ 

The above map is powered bv Gooqie, and is intended to provide a general idea of a property's location. If 

vou reauire a more exact orooertv location, vou mav use the Interactive GIS Maps that are maintained bv our 

office. 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R20... 7/26/2011 
9 

ENVIRONMENTA L 

AS-BUILT DRAWING *>« " "-"1- . 

OMAHA LEAD 

SUPERFUND SITE 

'%^^^~ RESTORATIO N Contract* EP-R7-09-05 

33S79 

Omah Exterior Paint North Arrow a Lead Site 

rCKGood Site Sketch r~l Poor 

Samplin g Address: . 

I I Not paint 

Sampl Lead Sample 

Samples Collected e Number 

Concentration Collected LAB 

Firm: t^&g^ I AM j D A 

RYASCPXA-3S'97 9 F l _ ppm • Date; _ 10/|g7c3J4 -

RYBSCPXA-3S9T 9 1^2 H3 > _ ppm Q^ n Time: 

o 9 .-^-S 

RYCSCPXA-3S97 ^ B1 2X>Ot Dom 

n Samples

 Analyzed •RYDSCPXA TSSyT g Bg — ppm D •RDZeCPXA liCi'T^ f DZ — ppm • D

• XRF Unit: >=^»2. Book: 9P > 

•RGZOCPXA-'3S9T9 Q g — ppm • 

Date: lcy2Q/oi4 ­ •

RPZQCPXA-aS97 » Pg - m ppm • 

Time: __ • 

_0£3Q_ 

Staff: F^4\/ : fPJ M Number of Samples • 3 I

 Li 

Legend: F1 = Front Left, F2 = Front Rigtit, B1 = Back Left, 8 2 = Back Rigtit DZ = Drip Zone, GZ = Garden, PZ = Play 

A It quadrants are as viewed from the street, facing property f Sf \ ^ *^ 

ENTERED : SAID # 35979 tSAF S;/^C=>E:. . 

DATE EXCAVATED 10-27-11 

DATE EPA SIGNED OFF 11-4-11 

: OCT 1 ^ 1 m

AREA SODDED 1472 SQ FT 

1

/ / f ^ 

3 - - .US. 

(X. 

F2; 

F l =158 PPM e 4 ­

,\

\

 v\ . • • • \ \ ' ' 

FZ: 

: 5 • 

> 

Q 

> FZ, 

; , EZ s128 PPM G 1 " - - ) 

N -2.2. €»+ 

^ -=""^ ^ ; 

Rev^ 2008 BL Created 16.May-08 

046141 0)23 

LEGEND 

Quadrant Excavated Drip Zone Excavated Lead Soil Remaining Easement Excavated 
lO-^^"^ ^ uy 

3S979 

Sampling Address: 50L ^ Isl 2 Z S-fOmah a Lea d Site 

Site Sketc h 

Exterior Paint 

g^Good 

• Poor 

r~| Not paint 

North Arrow 

Sample Number 

RYASCPXA-35979 F1 

Lead 

Concentration 

7Sft ppm 

Sample 

Collected 

Q^ 

LAB 

n 

Fimi:

Date:

Samples Collected 

 M£S : AM j D A 

 k3/l2./o ^ 

RYBSCPXA-3S979

RYCSCPXA-3S979

RYDSCPXA-35979

 F2 

 B1 

 B2 

i3. 2JCX D

•—

ppm 

 ppm 

 ppm 

\ ^ 

0" 

D 

D 

D 

D 

Time: Q 9 '.•Z. S 

Samples Analyzed 

•RDZSCPXA 3C;979 DZ .j = ppm a D XRF Unit: gl2 . Book: _2a _ 

•ROZQCPXA--39979 GZ­ — ppm D D Date: _ lO/gQ/oM -

• RPZOCrXA 3597 9 PZ — ppm n D Time: _am _ 

Number of Samples = 3 Staff: R^V : DJ M 

Legend: Fl = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

ENTERED 

0C1 u 

> 

f t 

fzl 

768 F2. 

>^ALkh4 2.2.: €>+ ; 

Rev2i:i08.BL Created: 16-May­
3S979 

Omah Exterior Paint North Arrow a Lead Site 

g^Goo d Site Sketch • Poor 

Samplina Address: 50l5 i M Z2 . S-f- • Not paint 

Sample Number Lead Sample Samples Collected LAB Concentration Collected Fimi: M£S : AM j D A 

RYASCPXA-B5979 Fl 7Sft ppm D Date: 10/|2./Q ^ 

RYBSCPXA-3S979 F2 13 ppm D Time: o 9 ;7. S 

RYCSCPXA-3S979 B1 ZOO ppm D 

Samples Analyzed •RYD6CPXA-35979 Bg- ppm n D 

-RDZSCPXA 3G97'9 DZ ppm D D XRF Unit: ^12. Book: _2a_ 

•ROZOCPXA-39979 GZ­ ppm D D Date:_ lO/2e>/o^ • RPZOCPXA 3597 9 PZ ppm D D Time: aiT> 

Number of Samples • 

Staff: R4^V: PJ M 3 O 

Legend: Fl = Front Left, F2 = Front Right, B1 = Back Left, B2 = Back Right DZ = Drip Zone, GZ = Garden, PZ = Play 

All quadrants are as viewed from the street, facing property 

y c— ^\# A\. ^ , ^ 

i5AP^A'^F; ENTERED

OCl \ k t m 

/ ^ ^ / [ 

Bl FZ: 

D.. . ..im.. 

Ul' 

> 

Q f 2 ; 

i p 

y ^ F Z k 

; : -UU5» 

•VO ft,.. ­ rZ3 y>»K. 5 i a F Z 

" 

^ \jji.i.t< -

N 2.2. s-v 

Rev2iXiS.BL Created: I6-May-08 (M6I41.0123 
ENVIRONMENTAL XRF DATA ENTRY LOG 

RESTORATION 

sAiD# ^^^-r \ DATE \c>\"n\\\ — 

PROPERTY ADDRESS TIME o^w 

'C)0\5 Si . 2 Z ^>V. 

XRF S/N 

QUADRENT OR SAMPLE AREA 

DEPTH AVERAGE OF RESULTS SHOT #s 

redig 

D 

Fl H" \6%t z\ 3)3V?)^U 

D F2 

n 81 

n 82 

n DZ 

n PZ 

n GZ 

n EZ1 \2% t \^ ^1)1-^^D 9^ 

D EZ2 

r 

n OTHER 

SAMPLER NAME 
Thermo Fisher Scientific Thermo 900 Middlesex Turnpike 

Billerica, MA 01821 

SCIENTIFI C 

A\KRA(;K ADDKKSS SAMI'I K ARKA OPKRAIO R DKPI H 

'

2

 |: 

 )i 

2011-10-27 09:09 

2011-10-27 09:09 

Avg of 337-339 5013n22st 

5013n22st 

^ 

«• 

EZ. 

EZ. 

TIM 

TIM 

/Si*rfeot 

/^uHbc c 

final clearance 

final clearance 35979 

128.14 

131.26 

± 19.07 

± 19.25 

3 • 1 2011-10-27 09:08 5013n22st y t EZ. TIM /Su<-4%tciL final clearance 35979 136.37 ± 19.66 

4 : 2011-10-27 09:08 5013n22st w ei TIM >&VLr4baC final clearance 35979 116.78 ± 18.29 

'

6

 ^

 ^ !' 

1 2011-10-27 09:01 

2011-10-27 09:01 

Avg of 333-335 5013n22st 

5013n22st 

Fl 

Fl 

TIM 

TIM 

4 

4 

final clearance 

final clearance 35979 

157.59 

143.81 

± 21.27 

± 20.46 

7 2011-10-27 09:00 5013n22st Fl TIM 4 final clearance 35979 171.47 ± 21.91 

8 2011-10-27 09:00 5013n22st Fl TIM 4 final clearance 35979 157.49 ± 21.46 

Page 1 of 1 10/27/11 13:11:53 
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