TEdHKldLOCieS , INC . PROPERT Y SUMMAR Y SHEE T Omah aLea dSit e Remedia l Actio n Contrac t #EP-S7-10-0 5 Said : 1769 3 PropertyAddress : 232 3 S 2 1 S T Executiv e Summary : 3026140 9 Issue s Encountered : Non e Issue s Resolved : Non e Superfun d Uniqu e Findings : Othe rRelevan t Information : CONFIRMATIO N SAMPLIN G DATA/RESULTS : EA=14 4 PP M @>Scrape ; F2=18 9 PP M @ 5" . Attachments : Document s Include d i n th e Propert yFile : Ye s N o N/ A Propert ysketc h provide d b yEP Apursuan t t o contrac t specification s V Signe d Acces s Agreement ; includin g acces s agreement s obtaine d (i f required ) fo rcrossin g V ont o adjacen t propertie s Pre-excavatio n agreemen t detail s (i f an yar e mad e wit h th e Propert yowner ) V Pre-Excavatio n digita l vide o cli p V Samplin g dat a shee t V Post-Excavatio n digita l vide o cli p V Documentatio n ­ Corhplete d EP Aclose-ou t checklis t V . As-Buil t sketc h V Oniah a Lea d Sit e Databas e sampl e informatio n document . V Signe d for m verifyin g satisfactor yrestoratio n V Othe rDocuments : 3 0 da ySO D warrant ypicture s V Utilit yclearance s documen t V Propert yinformatio n fro m Dougla s Count yAssessor' s office . V Settlemen t document s (i.e . fo ran ydamages , replacemen t o f plants , etc. ) V Sit e safet yhazar d analysi s documen t wit h pictures . V Legend : Ye s ­ Include d i n th e File ; N o ­ No t include d i n th e File ; N/ A ­ Doe s no t Apply . Pruden t Representative : EP AAcceptance : tive : ^ j

. V Date : Date : QN ^ 

# 7 ^ ^

Pruden t Technologies , Inc . j 250 5 N . 24TH Street , Suit e 30 8 jOmaha , N E 6811 0 US A j Te L 402.504.100 4 j Fax : 402.504.100 5 Environmenta l Engineerin g & Service s | Remediatio n | Constructio n

## 1769 3 Omah a Lea d Sit e Exterio rPain t Nort h Arro w 

### Sit e SIcetc h • Goo d • Poo r f Samolin a Address : 2323 S 2 1 S T QyNotpain t 

# f Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Collecte d f\)f ) T^ ' S j RYASCPXA-1769 3 F l / B pp m 

## D Date : ^ - Z^ - 0 8 RYBSCPXA-1769 3 RYCSCPXA-1769 3 RYDSCPXA-1769 3F2 B l B 2 9 & 7 15 8 2, 1 A pp m pp m pp m 

# i D D 

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# n n XR F Unit : /?v'?vr > Book : 20 ^ RG20CPXA-1709 3 6 2
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## D D Time : P/W Numbe ro f Sample s = | ^ [ | Q | Staff : M^^v / 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 viewe d fro m th e street , fadn g propert y 

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# PROPERT Y ACCES S FOR M Pruden t Technologies , Inc . (Prudent ) i s unde r contract wit hthe U . S . Environmenta l Protectio n Agenc y (EPA ) to clea n u p le^-contaminated.soil s a t anumtie r ofpropertie s locatedi n Omaha, Nebraska , including the propert y locate da t olf^'T.' ^ Si ' !2- \^hTh e EP A request s you r pennission to allow Pruden t t

o perfor masoi l cleanu p a t thi s propert y t

p remove lead-contaminatedsoil . B y signin g thi s form, th e propert y owne r grant s permission t o Pruden t t

o perfor mactivitie s relatedt o the cleanu p includin g soi l sampling , remova l o f leadcontaminate dsoil , an drestoration ofth e reference dproperty . Ifyo u have an y question s abou t the soi l cleanu p planne dfo r you r property , pleas e contact the Pruden t Office fo r th e Omah aLeadSit e cleanup at (402 ) 733-1188 . Genera l question s abou t the OmahaLea dSit e cleanu p ca

n b e directedto the EP A Public Informatio n Centers a t (402 ) 731-3045 (Sout hOmah aoffice ) o r (402 ) 991-958 3 (Nort hOmah aofTice) . Ifyour propert y has agrave l o

r dir t driveway s o r parking areas the n the remova l an dreplacemen t ofth e soil and/o r grave l during the reme(|iatio[ij>roces s doe s not mak e you r illega l gravel/dir t driveway s o r parking areas legal . Propert yAccess Grante d ByrT^ ­ C--f^f M * rvUU>t^i ^ (Please Prin t Name ) Propert yOwne rSignature : \6i g Signature ) . * (Date ) Propert yAccessed by : / [fyr ^ rW i \ \[ \ ^\ ^ AI-' I (Praden t Employe e Name ) PROPERT YINFORMATIO N (T o b e complete d b yresiden t and/o rpropert yowne r- pleas e print ) 1 . RESIDENTNAME : \ f ^t ^

( xt y\ V D {" ' • Owne rRente r 2 . I F RENTAL , PROPERT Y OWNE D BY : C tftV-c: ^

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### 3 . OWNER' S MAIUN G ADDRESS : JX<^? i Z > PnAirO^; C 9. 1 C j t^AjA'^^ . ^ ^ '^^'/ C 4 . OWNER' S TELEPHON E NUMBER - HOME : nt>2.lCi > H " WORK : (^6) ) ^ ? J 2- " ^' ^ > } 5 . TENANT' S TELEPHON E NUMBER - HOME:V ( 1 WORK : _ L 6 . AG E O F HOME? : YEARS . HO W LON G I 7 . HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDING^SK^ E 1978 7 8 . # O F OCCUPANT S UNDE R AG E O F 7 : # O F OCCUPANT S A T O R ( 9 . # O F CHILDRE N UNDE R AG E O F 7 WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E P15R WEEK : 10 . COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , NEIGHBORIN G PROPERT Y ETC. ) AUTHORIT YFO R ENVIRONMENTA L RESPONS E ACTIONS : Th e activitie s t o b e implemente d byEP Aunde rthi s agreemen t ar e pursuan t t o Sectio n 104 o f CERCLA , 42 U.S.C . 9604 . EPA' s righ t o f acces s t o th e propert yi s provide d fo ri n Sectio n 104(e) o f CERCLA , 42 U.S . C 9605(e) , whic h provide s entryfo r"detenninin g th e nee d fo r response , o rchoosin g o rtakin g an yresponse actio n unde rthi s titie , o rotherwis e enforcin g th e provision s o f th e title. " 

## Pruden t Technologie s Inc . 5600 S . lO" * St . Omaha , N E 68107 , 402.733.118 8 (Office) 402.733.188 3 (Fax )ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

## Propert y Statu s Form Date : I C > f ^^ ^

5 " J2- 0 f Address : 2. 3 '2 - 3 S - 2- 1 g>1' - Phone : 

# 4Cl-G\2-'-0Sl' ^ NOTIC E T O BE GIVE N TO : OWNE R TENAN TBOT H HO W MUC H NOTIC E I S NEEDED : 2 4 HOUR S 4 8 HOUR S 7 2 HOUR S 

# fVo K OTHE R NOTIC E NEEDE D (PLEAS E SPECIFY) : PHON E # AN D NAM E T O WHO M NOTIC E NEED S T O B E GIVEN : WIL L NEIGHBORIN G PROPERT Y NEE D T O B E USE D FO R ACCESS ? YE S N O I F NEIGHBORIN G PROPERT Y WIL L NEE D T O B E ACCESSE D WHA TI S TH E ADDRESS : WA S A N ACCES S FOR M OBTAINE D FRO M TH E NEIGHBOR ? YE S N O WIL L AFENC E NEE D T O B E TAKE N DOW N T O OBTAI N ACCESS ? YE S N O I F ANSWERE D YE S T O NUMBE R 1 2 PLEAS E PROVID E LOCATIO N O F FENCE : I S THER E PRE-EXISTIN G FACIA L DAMAG E T O TH E PROPERT YAN D I F S O PLEAS E PROVIDE D LOCATIO N AN D DESCRIPTIO N OFSUCH : YE S N O SPECIFY : I S THER E PRE-EXISTIN G CONCRET E DAMAG E T O TH E PROPERT YAN D I F S O PLEAS E PROVIDE D LOCATIO N AN D DESCRIPTIO N O F SUCH : YE S N O SPECIFY :



### Pruden t Technologie s Inc . 560 0 S . 10*' ' St . Omaha , N E68107 , 402.733.118 8 (Office ) 402.733.188 3 (Fax )ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

## Propert y Inspectio n For m Address : ( ^ 1 3 S K J = ^- I f

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

# Pre-Existin g Dainage : Pleas e writ e i n detai l an dinclude dlocatio n an ddescriptio n o f

damage : Concret e Damage :

Facial Damag e Includin g Siding : 

# JZJ/^' ^ Doe s Basemen t liav e history of leakin g o r flooding ? YE S N O

Doe s Homeowne r wan t so dreplace di n al l areas ? YE S N O IfN O pleas e provid e wha t area s ar e no t t o b e sodde dan dwhat need s to b e replace dinstea do f

so d(i.e . mulch , rock , leav e bare ) i f

mulc ho r roc k pleas e specif y wha t typ e an dcolor :
AN Y OTHE RDAMAGEO RREQUESTS : 

# f operty Owne r Pruden t Employe e Signatur e Signature : /t^'^-A- ; 

# - rt f yir^..^-f4i DAT E DATE :• ENi'IIiOttiMENTA L& CONSTRUCTIO N 

# ly ^ a TECHNOLOGIES , INC . SERVICE S 

# XR FCLEARAPfC E SHEE T PROPERT Y ADDRESS : ^:.: > -2- 3 S 2 - / ^ f ^ PROPERTYID : I Tt^ f 3 ? .>1A PHA S BEEN REVIEWE D AN D N O MISSE D AREA S EXIST : (YE|; ^ 

# N O WA S CONTAMINATIO N LEF T BEHIND ? I FYE S WHER EAN D PIMENSIONS : CREW:/^e/^lyW DAT E DEPT H QUADRAN T READIN G 

# ^^-. y XR FTECH: ^ r..-ry ^ 

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### ' 1'.^^•m''-'y"Mif p TBCHNQIOQIES , INC . 

# EP A Propert y Clos e Ou t Propert y # : ( 7 6?- '^3 ' PropertyAddress:'Ll'2 ^ ^ ' ^^'^ V Owner'sName : <2>fi.T-u , <LC C 

### ler ^ Date/Time : Contracto r Group : Pruaen t Te'^hnologies , Inc , Quad s Excavated : f-'2 _ Excavatio n Genera J Ye s N o 1 . I f necessary , wer e th e correct quadrant(s ) excavatedan drestored ? / 2 . I f necessary , wer e th e correct area s o f drip zone excavatedandrestored ? 

# y Gradin g Sodan dVegetatio n - Ye s N o 1 .

Doe s th e gradm g aroundth e perimete r o

f th e hous e in excavatedarea s generall y slop e awa y 

# y fro mth e house ? 2 .Has sodbee n lai din all area s tha t wer e excavated ? 

## y 3 .

Doe s th e sodappea r to.b e generall y health y an dgrowing ? (Onl y evaluat e i

f inspecteda t a3 0 da

y tim e period) . / 4 .

Ar e soddedarea s generall y firmaiidevenl y graded ? 

# y 5 :

Ar e tltf e joint s betwee n di e so dstrips , generall y tight ? (Onl y evaliiat e if inspectedat a3 0 da y 

# y time period) 6 . Wa s th e propert y gradedsuc htlia t wate r wil l not pool on th e property ? 

# y 7 . Wa s damag e t o landscaping o r plan t material s avoided ? 

# y Gates , Fence s an dRetainin g Wall sYes . N o 1 . D o gate s ope n andclose.freely ? (Ifapplicable ) / 2. . Wer e al l gate s o r feiice s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) / .3 . Was daniag e to gate s or fence s avoided ? (I f api)iicable ) . /

. 4. - Was damag e t o retainiii g wall s ayoided ? (I f applicable ) :•..' ' 

# • 7 Foundation , Sidin g an dGlitter sYe s N o 1 .

Wa s damag e to th e siding o r trimavoided ? / : 2 .Was damag e t o th e foundation avoided ? / 3 .

Wasdamaget o window s avoided ? 4 .

Wa s damag e to window s o r door screen s avoided ? / 

# 7 5 .Wa s damag e t o downspouts o r downspou t extension s avoided ? 

# 7 Sidewalk s an dDriveway s (Goncrete ) Ye s N o 1 .

Wa s damag e to diivewa y surface s avoided ? / 2 .

Was daraag e t o walkwa y surface s avoided ? 

# r

## Owtte«- 8 CQmmeBts ;

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### 1769 3 AS-BUIL T DRAWING ' Sampl e Area : 1769 3 - TS'l i S ii l ST . Dat e Excavated : 10/20/201 1 

### OMAH A LEA D SUPERFUN D SIT E Sample dBy : Isaa c 

### CONTRACT # : EP-S7-10-0 5

Exterio rPain t Omah a Lea d Sit e • Goo d Sit e Sketc h • Poo r Samplin g Address : 232 3 S 2 1 S T IJ No t paint Lead Sampl e Sanpie s CoJlec'e d Sampl e Numbe r LA B Concenlratio n Collecte d Fir m RYASCPXA - 1769 3 F l pp m 

### D Dat e 

### Z l Q RYBSCPXA - 1769 3 F 2 pp m 

# n Tim e Z : t o ^ RYCSCPXA - 1769 3 B l pp m 

# • i 5 8 Sample s Analyze d RYDSCPXA - 1769 3 B 2 pp m 

### D nDZGCPXA-i7oe a pp m 

# n XR F Unit : (hS^ O Book : 2 0 3 RGg3CPXA-1709 3 pp m 

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• YOU R TICKE T NUMBE R I S 2873865 . Origina l Cal l Date : 10/11/1 1 Wor k t o Begi n Date : 10/13/1 1 Time : 12:4 9 p m Time : 1:0 0 p m Op : ASHLEIGH1896 7 State : N E Address : 232 3 County: DOUGLA S Street : S 21S T S T Place : OMAH A Twp : 15 NRng : Twp : Rng : Lega l Given : C 13 E Sect-Qtr : 27-S1A ( Sect-Qtr : Typ e o f Work : LEA D SOI L REMEDIATIO NPROJEC T Locatio n o f Work : ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : UNSUR E CORNER S Compan y Contac t Nam e Alt . Contac t PRUDEN T TECHNOLOGIE S ASHLEIG H ANIKPUT A NON E Phone : (402)733-118 8 Wor k Bein a Don e For : EP A



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• YOU R TICKE T NUMBE R I S 2879610 . Origina l Cal l Date : 10/18/1 1 Time : 9:3 1 a m Wor k t o Begi n Date : 10/20/1 1 Time : 9:4 5 a m State : N E Address : 232 3 County: DOUGLA S Street : S 21S T S T Op : ASHLEIGH1896 7 Place : OMAH A IW i Twp : 15 NRng : 13 E Twp : Rng : Lega l Given : C Sect-Qtr : 27-S W Sect-Qtr : Typ e o f Work : LEA D SOI L REMEDIATIO NPROJEC T Locatio n o f Work : ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : UNSUR E CORNER S Compan y Contac t Nam e Alt . Contac t PRUDEN T TECHNOLOGIE S ASHLEIG H ANIKPUT A NON E Phone : (402)733-ll f Wor k Bein a Don e For : EP A



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