TEdHKldLOCieS, INC. 

PROPERTY SUMMARY SHEET 

Omaha Lead Site Remedial Action Contract # EP-S7-10-05 

Said: 17693 PropertyAddress: 2323 S 21 ST 

Executive Summary : 

30261409 Issues Encountered: None 

Issues Resolved: None Superfund 

Unique Findings: 

Other Relevant Information: 

CONFIRMATION SAMPLING DATA/RESULTS: EA=144 PPM @>Scrape; F2=189 PPM @ 5". 

Attachments : 

Documents Included in the Property File: Yes No N/A 

Property sketch provided by EPA pursuant to contract specifications V 

Signed Access Agreement; including access agreements obtained (if required) for crossing V 

onto adjacent properties 

Pre-excavation agreement details (if any are made with the Property owner) V 

Pre-Excavation digital video clip V 

Sampling data sheet V 

Post-Excavation digital video clip V 

Documentation ­ Corhpleted EPA close-out checklist V . 

As-Built sketch V 

Oniaha Lead Site Database sample information document. V 

Signed form verifying satisfactory restoration V 

Other Documents: 

30 day SOD warranty pictures V 

Utility clearances document V 

Property information from Douglas County Assessor's office. V 

Settlement documents (i.e. for any damages, replacement of plants, etc.) V 

Site safety hazard analysis document with pictures. V 

Legend: Yes ­ Included in the File; No ­ Not included in the File; N/A ­ Does not Apply. 

Prudent Representative: EPA Acceptance: tive: ^ j 

.V 

Date: Date: QN^ 7 ^ 

^ 

Prudent Technologies, Inc. j 2505 N. 24TH Street, Suite 308 jOmaha, NE 68110 USA j TeL 402.504.1004 j 

Fax: 402.504.1005 

Environmental Engineering & Services | Remediation | Construction 
17693 

Omaha Lead Site Exterior Paint North Arrow 

Site SIcetch • Good 

• Poor f 

Samolina Address: 2323 S 21 ST Qy Notpaint f 

Sample Number Lead 

Concentration 

Sample 

Collected LAB 

Firm:

Samples Collected 

 f\)f) T^ ' Sj 

RYASCPXA-17693 Fl / B ppm D Date: ^ - Z^- 0 8 

RYBSCPXA-17693

RYCSCPXA-17693

RYDSCPXA-17693

 F2 

 Bl 

 B2 

9 & 7

15 8

2,1 A

 ppm 

 ppm 

 ppm i D 

D 

n 

Time: Z- ^ pt^ - ^ 

Samples Analyzed 

nDgscr)(A 17000—B Z " " ppm n n XRF Unit: /?v'?vr> Book: 20 ^ 

RG20CPXA-17093 6 2 — ppm D a Date: .S-/2 ' Q g 

RrZOCrXA-17093 PZ­ __=__ _ ppm D D Time: P/W 

Number of Samples = | ^ [ | Q | Staff: M^^v / 

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

All quadrants are as viewed from the street, fadng property 

ENTERED 

MAY 

15.8. '.zie. 

^ ^ 

23^S: 5 Zl S^ 3 

i-^ 

.11$. 

•/ / 

I i yz 

^\^A.iy. -V­

.Dgp6)i^K Rev 2008.N Creaied; 26-Feb-08 044701.01.2.1 
PROPERTY ACCESS FORM 

Prudent Technologies, Inc. (Prudent) is under contract with the U. S. Environmental Protection Agency 

(EPA) to clean up le^-contaminated.soils at a numtier ofproperties located in Omaha, Nebraska, including the 

property located at olf^'T.' ^ Si ' !2-\ ^ h The EPA requests your pennission to allow Prudent to 

perform a soil cleanup at this property tp remove lead-contaminated soil. By signing this form, the property owner 

grants permission to Prudent to perform activities related to the cleanup including soil sampling, removal of leadcontaminated soil, and restoration ofthe referenced property. 

Ifyou have any questions about the soil cleanup planned for your property, please contact the Prudent 

Office for the Omaha Lead Site cleanup at (402) 733-1188. General questions about the Omaha Lead Site cleanup 

can be directed to the EPA Public Information Centers at (402) 731-3045 (South Omaha office) or (402) 991-9583 

(North Omaha ofTice). 

Ifyour property has a gravel or dirt driveways or parking areas then the removal and replacement ofthe soil 

and/or gravel during the reme(|iatio[ij>rocess does not make your illegal gravel/dirt driveways or parking areas legal. 

Property Access Granted ByrT^ ­ C--f^f M

*

 rvUU>t^i ^ 

 (Please Print Name) 

Property Owner Signature: 

\6iSignature g ) . * (Date) 

Property Accessed by: / [fyr ^ r W i \ \[ \ ^\ ^ A I-'I (Pradent Employee Name) 

PROPERTY INFORMATION (To be completed by resident and/or property owner - please print) 

1. RESIDENTNAME: \ f ^t ^ (x ty \ V D {" ' • Owner Renter 

2. IF RENTAL, PROPERTY OWNED BY: C tftV-c: ^ V^i;' ^ [ C f 

3. OWNER'S MAIUNG ADDRESS: JX<^? i Z> PnAirO^; C 9. 1 Cj t^AjA'^^. ^ ^ '^^'/ C 

4. OWNER'S TELEPHONE NUMBER - HOME: nt>2.lCi > H " WORK: (^6) ) ^? J 2- " ^' ^ > } 

5. TENANT'S TELEPHONE NUMBER - HOME:V( 1 WORK: _ L 

6. AGE OF HOME?: YEARS. HOW LONG I 

7. HAS THE EXTERIOR BEEN PAINTED OR COVERED WITH SIDING^SK^E 19787 

8. # OF OCCUPANTS UNDER AGE OF 7: # OF OCCUPANTS AT OR ( 

9. # OF CHILDREN UNDER AGE OF 7 WHO PLAY IN THE YARD FOR 5 HOURS OR MORE P15R WEEK: 

10. COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, NEIGHBORING PROPERTY 

ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this 

agreement are pursuant to Section 104 of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property is 

provided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entry for "detennining the need for 

response, or choosing or taking any response action under this titie, or otherwise enforcing the provisions of the 

title." 

Prudent Technologies Inc. 5600 S. lO"* St. Omaha, NE 68107, 

402.733.1188 (Office) 402.733.1883 (Fax) 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form Date: I C> f ^^^ 5" J2- 0 f Address: 2. 3 '2 - 3 S - 2- 1 g>1'-

Phone: 4Cl-G\2-'-0Sl' ^ 

NOTICE TO BE GIVEN TO: OWNER TENANT BOTH 

HOW MUCH NOTICE IS NEEDED: 24 HOURS 48 HOURS 72 HOURS 

fVoK 

OTHER NOTICE NEEDED (PLEASE SPECIFY): 

PHONE # AND NAME TO WHOM NOTICE NEEDS TO BE GIVEN: 

WILL NEIGHBORING PROPERTY NEED TO BE USED FOR ACCESS? YES NO 

IF NEIGHBORING PROPERTY WILL NEED TO BE ACCESSED WHAT IS THE ADDRESS: 

WAS AN ACCESS FORM OBTAINED FROM THE NEIGHBOR? YES NO 

WILL A FENCE NEED TO BE TAKEN DOWN TO OBTAIN ACCESS? YES NO 

IF ANSWERED YES TO NUMBER 12 PLEASE PROVIDE LOCATION OF FENCE: 

IS THERE PRE-EXISTING FACIAL DAMAGE TO THE PROPERTY AND IF SO PLEASE PROVIDED LOCATION AND DESCRIPTION 

OFSUCH: YES NO SPECIFY: 

IS THERE PRE-EXISTING CONCRETE DAMAGE TO THE PROPERTY AND IF SO PLEASE PROVIDED LOCATION AND 

DESCRIPTION OF SUCH: YES NO SPECIFY: 

Prudent Technologies Inc. 5600 S. 10*'' St. Omaha, NE 68107, 

402.733.1188 (Office) 402.733.1883 (Fax) 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Inspection Form 

Address: (^ 1 3 S KJ = ^- If ^ % ^ Date: lOJoS J ^ , 

Phone: t/-ff,^ y (S \ ^f — ^ ^ ?-$' BVID: 

Pre-Existing Dainage: Please write in detail and included location 

and description of damage: 

Concrete Damage: 

Facial Damage Including Siding: 

JZJ/^' ^ 

Does Basement liave history of leaking or flooding? YES NO 

Does Homeowner want sod replaced in all areas? YES NO IfNO please provide what 

areas are not to be sodded and what needs to be replaced instead of sod (i.e. mulch, rock, 

leave bare) if mulch or rock please specify what type and color: 

ANY OTHER DAMAGE OR REQUESTS: 

f operty Owner Prudent Employee 

Signature Signature: 

/t^'^-A-; 

- rtf yir^..^-f4i 

DATE DATE: 
• ENi'IIiOttiMENTAL & ly^ a 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

XRF CLEARAPfCE SHEET 

PROPERTY ADDRESS: ^:.:> -2- 3 S 2 - / ^ f^ 

PROPERTYID: I Tt^ f 3 ? 

.>1AP HAS BEEN REVIEWED AND NO MISSED AREAS EXIST: (YE|; ^ NO 

WAS CONTAMINATION LEFT BEHIND? IF YES WHERE AND PIMENSIONS: 

CREW:/^e/^lyW 

DATE DEPTH QUADRANT READING 

XRF TECH:^ ^^-.y 

r..-ry ^ 

READINGS DOpyMENTED IN 

fy-2o B " 

• • : ••¥ !

••••:• . F2 ;

Bl 

 .; 

 •• . vyf. 

• . . 

LOG BOOK? TOS:>NO B2 

GARDEN 

PLAYZONE 

EASEMENT: 

Bf^ f > • •m^ . iH» tr ! 1 
' 1'.^^•m''-'y"Mifp TBCHNQIOQIES, INC. 

EPA Property Close Out 

Property #: ( 7 6?- '^3 ' 

PropertyAddress:'Ll'2^ ^ ' ^^'^ V 

Date/Time Owner'sName: <2>fi.T-u, <LCC ler ^ : Contractor Group: Pruaent Te'^hnologies, Inc, Quads Excavated: f-'2 _ 

Excavation GeneraJ 

Yes No 

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

/ 

2. If necessary, were the correct areas of drip zone excavated and restored? 

y 

Grading Sod and Vegetation - Yes No 

1. Does the gradmg around the perimeter of the house in excavated areas generally slope away 

from the house? y

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 a 30 

day time period) . / 

4. Are sodded areas generally firm aiid evenly graded? y 

5: Are tltfe joints between die sod strips, generally tight? (Only evaliiate if inspected at a 30 day y time period) 

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

y 

7. Was damage to landscaping or plant materials avoided? 

y 

Gates, Fences and Retaining Walls Yes. No 

1. Do gates open and close.freely? (Ifapplicable) 

/ 

2.. Were all gates or feiices taken down during restoration activities reinstalled? (If applicable) / 

.3. Was daniage to gates or fences avoided? (If api)iicable) . / 

. 4.- Was damage to retainiiig walls ayoided? (If applicable) :•..' ' • 7 

Foundation, Siding and Glitters Yes No 

1. Was damage to the siding or trim avoided? / : 

2. Was damage to the foundation avoided? / 

3. Wasdamageto windows avoided? 

4. Was damage to windows or door screens avoided? 

/

7 

5. Was damage to downspouts or downspout extensions avoided? 7 

Sidewalks and Driveways (Goncrete) Yes No 

1. Was damage to diiveway surfaces avoided? / 

2. Was daraage to walkway surfaces avoided? r 
Owtte«-8 CQmmeBts; 

Inspection notes: 

y 

^''' ^ ^ 

oV. 

> ; 

yy 

»> ^ 

""^y 

Xo*' 

Vt 

Removal and restoration activates complete including the 30-day sod warranty: 

EPA Representatrve ^" ^ ^ j^^^^ . ^i\^V^ 
17693 

AS-BUILT DRAWING' 

Sample Area: 17693 - TS'li S iil ST. 

Date Excavated: 10/20/2011 OMAHA LEAD SUPERFUND SITE 

Sampled By: Isaac CONTRACT #: EP-S7-10-05 

Omah Exterior Paint a Lead Site 

• Good Site Sketch 

• Poor 

Sampling Address: 2323 S 21 ST I J Not paint 

Sample Lead Sample Sanpies CoJlec'ed Number LAB Concenlration Collected Firm 

RYASCPXA- 17693 Fl 

ppm D Date Z l Q RYBSCPXA- 17693 F2 ppm n Time Z: to ^ RYCSCPXA- 17693 Bl ppm •

i 5 8 Samples Analyzed RYDSCPXA- 17693 B2 ppm D 

nDZGCPXA-i7oea ppm n XRF Unit: (hS^O Book: 2 0 3 

RGg3CPXA-17093 ppm a Date BJZ- o e 

nPZSCPXA-17093 ppm D Time _£l± 

Staff f^sy Number of Samples = | ^ \ \ Q | 

Legend: F1 = Front Left, F2 = Front Right. Bl = Back Left. 82 = Back Righl DZ = Drip Zone. GZ = Garden, P2 = Play 

All quadrants are as viewed fnm the street, facing property 

ENTEEED 

MAY: 06 

158. zia. 

I SI 

5 :5^ ) ZS^?' 2/ : 

y 

2ie scy. 9&7 

F2 = 189 PPM ® 5" yt • / / 

t A = I't t KK M @ SCRAPE 

WA.Q. ^ 

^ym\ Rev Wtt N Cceaitil: :;M-<;(H « 

Environmental Engineering & Services | Remediation | Construction 
f 

PtntJ Record ediation Query Lead Remaining Query Property Datnt -ry dose 

Property Iirfb j Clear-up Info SaiTiplle Infoj^Q^omer Calls ^ Sidewalk Repair 

Sample Area: 1769 3 - 232 3 S 21 ST 

Sa~ple Date . Quadiant ^t Parar.iete » >!RF Rt , |)gy R Exc ­ Marker Ptace Lead Remainin . in; . Sampled B -i QA Confirmee Lab Res! 

. 10/20/2011,E1 LEAD 144>^ g 1 n n ISAAC \MA 

I 10/20/2011:F2 LEAD IS.AAC IJ A 

[LEAD jpjyS3_ U: l l I • : i NyA 

Record: M < * H ••• "ij^ No Filter I Sew* EI rr 
( 

r~ aton Query Lead Remaining Query Property Damage Q^- Oose 

Property Info Clean-up Info Sampile Info | Custowef Calls j Stdewalt Rcpatr, 

Sample Area; 17693 - 232 3 S 2 1 ST 

Sampl&d B -I QA Confirmee - i Lab_Resul » Lab Result Unit' . ^•r~ar<s 

_j§AA C M'A Q mglkg 

ISAAC flA 0 .-ng-.'kg 

* :IM/A i 0, mg/kg i 

PRtcorA W 1 I % Ho filter 'Search M. 
. ^ 

•re!i»ain-Hig,w4arKaity;^3(^-days.:tofe^^^^ •,•• 

ftepttl^lWv­ mys 

g>epeyfey AdaiiessxV^ ^ J ^.5^ } -^ f 

Owoer: 

y^/f^f /^(/27M 

y^-i^i^' ytsnf 

ReslioraifKm; l(»ms in; QveestiOEit: 

Reqafeedi; cx)iririectr.ioiFis to conriptege. the proper^: 

J laigreefrestpratjbnvfe.ebFriipfeted . 

,IL_1 I^ cfoEiptvagiEee restoration isegro (noted/cfeficieheies abov^),:-

Date' 

IRTH One Call Page 1 of 1 

Diggers Hctlin* 

Of 

Nebraska iri±i 

Home Ticket 

Ticket Creation Logout 

Create Another Ticket Go to Home Page Send Email 

• YOUR TICKET NUMBER IS 2873865. 

Original Call Date: 10/11/11

Work to Begin Date: 10/13/11

 Time: 12:49 pm 

 Time: 1:00 pm 

Op: ASHLEIGH18967 

State: NE 

Address: 2323 

County: DOUGLAS 

Street: S 21ST ST 

Place: OMAHA 

Twp: 15N Rng:

Twp: Rng:

Legal Given: C 

 13E Sect-Qtr: 27-S1A( 

 Sect-Qtr: 

Type of Work: LEAD SOIL REMEDIATION PROJECT 

Location of Work: ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: UNSURE CORNERS 

Company 

Contact Name 

Alt. Contact 

PRUDENT TECHNOLOGIES 

ASHLEIGH ANIKPUTA 

NONE 

Phone: (402)733-1188 

Work Beina Done For: EPA 

http://www.dhon.org/IRTHOneCall/Ticket/TicketCreation.aspx?ViewTicketID=858262 10/11/2011 
IRTH One Call Page 1 of 1 

(hn- iMi 

Di39«rB Hotlin* 

Of 

Nebraska 

Home Ticket 

Ticket Creation Logout 

Create Another Ticket Go to Home Page Sentd Email 

• YOUR TICKET NUMBER IS 2879610. 

Original Call Date: 10/18/11 Time: 9:31 am

Work to Begin Date: 10/20/11 Time: 9:45 am 

State: NE 

Address: 2323 

County: DOUGLAS 

Street: S 21ST ST 

 Op: ASHLEIGH18967 

Place: OMAHA 

IWi 

Twp: 15N Rng: 13E

Twp: Rng:

Legal Given: C 

 Sect-Qtr: 27-SW 

 Sect-Qtr: 

Type of Work: LEAD SOIL REMEDIATION PROJECT 

Location of Work: ENTIRE PROPERTY 

Remarks: FAX ALL CLEARS TO: (402)733-1883 

: UNSURE CORNERS 

Company 

Contact Name 

Alt. Contact 

PRUDENT TECHNOLOGIES 

ASHLEIGH ANIKPUTA 

NONE 

Phone: (402)733-llf 

Work Beina Done For: EPA 

http://www.dhon.org/IRTHOneCall/Ticket/TicketCreation.aspx?ViewTicketID=865771 10/18/2011 

'^l^ICXifflOSQ 

N 2323 S21 ST <; 

A Printed: Sep 27. 201! 

www.dcgis.org/'dogis 
Site Job Hazard An ysis 

adress •^i^> ' ^ 3 - f / ^ / 0> "ZT Date 

Analysis Completed By L O /"T y ryC/^ J t Z 2 C r Prudent Technologies Health and Safety Officer 

Item 

Overhead Power Lines 

Gas Lines 

Water Lines 

Sewer Line 

Septic Tank 

Propane/Butane 

Foundation (DZ) 

Driveway 

Side walk 

Trees 

Plants/Garden GZ 

Access to Property 

Busy Street (need to close 

off Lane) 

Hand Dig 

Pets /bees/wasps/ticks/red 

ants/spiders 

Poison Ivy/Poison Oak 

Miscellaneous 

Location 

F1F2 

B1B2 Condition 

f9. Underground 

Utilities r y 

H)^ 

((»;slfiCr| 

^4 0 dn 

H^i^vc 

\v^COC 

KO ?V iat5/(,ia>'' 

fvCn'v 5 .^rst 

HO 

N 0 

\^OAt \ iol-cd 

isclxd \\Ci n<^ 

Hazards 

Electrocution 

Gas, water 

leaks 

io-^ 

' 

Corrective Action 

Call Digger Hotline Prior to perform locates prior to 

beginning work on property 

If utilities are not located contact Supervisor, Safety 

Personnel to notify them of issue 

Go to another property to work as directed 

Time Print Name ofeach Signature ofeach Changes in conditions resulting in additional 

Date Reviewed Reviewed crew member. creyupembCT safety assessment if applicable 

B -IB-II \?Z6 ^ /urZp jSi y^'^— 

O^Ui/>f/a ^ Ty- g12^^'y ^n *'&L.ty^1f*vy7^^ 

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Audited by V..^ ' , Date ^O O/ML IL 
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