CONTRAC T # EP-R7-06-0 4 AS W Associate s Inc . Omah a Lea d Sit e Remediation , Omaha , N E 

### EPA 

### AS W Associate s In c Certificatio n fo rPropert yCloseou t BVI D Fiel d Wor k

Starte d 2020 6

23-Jun-0 6 Propert yAddres s Fiel d Wor k

Complete d 140 8 Sout h 11 m Stree t t h , 

## 17-jui-o e Summary : Th e excavatio n wa s performe d i n complianc e wit h th e wor k plan s an d specifications . Th e F 2 quadran t wa s excavate d t o a dept h o f 6 inch . Th e B 1 quadran t wa s excavate d t o a dept h o f 6 inch . Th e B 2 quadran t wa s excavate d t o a dept h o f 1 2 inch . Th e dri p zon e was not excavated . Verificatio n sample s confirme d tha t th e cleanu p standard s wer e met . Th e site wa s backfille d wit h material s whic h meet s contrac t specifications . Th e backfil l wa s compacte d t o acceptabl e standards . So d placements an d sit e restoration s wer e conducte d i n complianc e wit h wor k plan s an d 

### specifications . Comments : Garden i zone^asjxcavatej d to a degthjr f jjjncj r



### " r

Ja n Prawd7i k Nam e AS W Projec t Manafle i Titl e 

# /o/'s///£ > _A ^ ^-^ ^ 

### Signatur

e 4026196 1CONTRAC T # EP-R7-06-0 4 AS W Associate s Inc . Omah a Lea d Sit e Remediation , Omaha , N E EP A 

### Analytica l Resul t Summar y OL S ID : 2020 6 Propert y Address : 140 8 South11 t h

### Stree t Sa mpi e 

### I D 20206-DE-F2-0 6 20206-DE-B1-0 6 20206-DE-B2-1 2 20206-DE-GZ-1 2 XR FResult s 

### Avg . (ppm ) 16 2 ±53. 3 185. 3 ±53. 6 21 1 ±55. 3 

### 14 8 ±4 9 | La b Result s



### (Ppm ) 

### N A N A N A N A

Ja n Prawdzi k Nam e AS W Projec t Manage r Titl e 

## Date Sampl e Designatio n OLSlD-DE-Location-d d OI.S1 D i s aparticula r

residentia l property I D fro mwhic hth e sampl e i s collected . D E- During an dPost

Excavatio n Locatio no f th e sampl e a s follows ; F I- Fron t Yar d(I aQuadrant ) B l - Bac k Yard(l u Quadrant ) F 2 = Fron t Yard(2ndQuadrant ) B 2 - Fron t Yard(2 n dQuadrant ) D7 , - Dri p /on e P / - Pla y Zon e G A= Garde n E A= Easemen t d ddescribe s th e depthfro mwhic hth e sampl e wa s collected . N A-NotApplicabl e

# EP

A

Propert y # : £ Date/Time : Quad s Excavated : 

# Remediation/Excavatio n Contrac t (ASW ) EP A Propert y Clos e Ou t Form Propert y Address : //JQf t «3 . Owner' s Name : Contracto r

Grou p Excavatio n Genera l Ye s N o 1 . I f necessary , wer e 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 ? 

### / 

# s Gradin g So dan dVegetatio n 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 fro mth e house ? 2 . Ha s so dbee n lai di n al l area s tha t wer e excavated ? 3 . Doe s th e so dappea r

t o b e generall y health y an dgrowing ? (Onl y evaluat e i f inspecte da t

a3 0 da y tim e period ) 4 . Ar e sodde darea s generall y fir man devenl y graded ? 5 . Ar e th e joint s betwee n th e so dstrip s generall y tight ? (Onl y evaluat e i f inspecte dat

a3 0 day tim e period ) 6 . Wa s th e propert y grade dsuc htha t wate r wil l no t poo l o nth e property ? 7 . Wa s damag e t o landscapin g o r plan t material s avoided ? Gates , Fence s an dRetainin g Wall s

Foundation , Sidin g an dGutter s Ye s N o

Ye s N o 1 . D o gate s ope n an dclos e freely ? (I f applicable ) 2 . Wer e al l gale s o r

fence s take n dow n durin g restoratio n activitie s reinstalled ? (I f applicable ) 3 . Wa s damag e t o gate s o r fence s avoided ? (I f

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

# s

s s s Ye s N o I. Wa s damag e t o th e sidin g o r tri mavoided ? 2 . Wa s damag e t o th e foundatio navoided ? 3 . Wa s damag e t o window s avoided ? 4 . Wa s damag e t o window s o r doo r screen s avoided ? 5 . Wa s damag e t o downspout s o r downspou t

extension s avoided ? 

### • • / 

# s / Sidewalk s an dDriveway s (Concrete ) Ye s N o 1 . Wa s damag e t o drivewa y surface s avoided ? 2 . Wa s damag e t o walkwa y surface s avoided ? 

### i / «/

### Owner s comments :

Inspectio n notes :



## Removal an drestoratio nactivate s complete includin g th e 30-day so dwarranty : EP A Representativ e x&«^ ? Date :

# 1 Contract No : E P - R 7 - 0 6 - 0 4 PropertyCloseou t Agreemen t Omah a Lea d Superfun d Sit e 

### ® OLSI D j-i/J/lJflOUlP'f l £fl\}ftft A 

### Propert y Owne r -M » c L , Complianc e Statement : U.S . Environmenta l Protectio n Agenc y (EPA ) o r it s a u an dconduc t

environmental restoratio n service s fo r th e You r cooperatio n i n givin g EPA/AS Wpermissio n t o a phas e i s sincerel y appreciated , Thi s documen t certifie s complete di n accordanc e wit hth e contac t specificatio n I f yo u hav e question s o r

nee dadditiona l informatio n p i (402 ) 7 3 1-304 5 o r

(402 ) 991-958 3 o r

th e EPA Offic e c Propert y Addres s r ^ 4 k

> C~ * t

=J * ' t^/v-/^ / ^^> . l | *" " * ^ • I s th e Residen t

th e Owne r

D Ye s J* J N o thorize drepresentatives , (o r it s contractors) , t o ente r Omah aLeadSite . :ces s you r

property durin g th e removal/restoratio n tha t al l work performe dat

thi s property wa s s an dEP A requirements . eas e contac t

th e EP A Publi c Informatio n Center s at f Externa l Program s at

1-800-223-0425 . Additiona l Comment s b y EP A and/o r ASW :

CONTRACTO RCERTIFICATIO N Ja n Prawdzi k

AS WProjec t

Manage r Nam e Titl e Dat e



## Propert y Owne r

Sectio n Signatur e 

### Thi s agreement

document s th e completio no f remedial/restoratio neffort s at th e property t o my satisfactio n G3 - 1 agre e that

restoratio ni s complete da

t m y property D I D o No t

Agree : Comments :



### <i £%}#A/<?t

L £ i <c*c*if

« Property Owner' s Signatur e 

## ^ 8A&A-A.CXf^MA ^ 'S\&

j iffvyv . / PP A Representativ e Signatur e 

# fiJ^/^-o b Dat e 

# 6* y // y 04 > I ' * Dat ePag e 1 of .

U.S . Environmenta l Protectio nAgenc y Regio n VI I Omah aLeadSit e Omaha , N E Residentia l YardSoil s 

### Environmenta l Restoratio n Service s Granto r (the propert

y owner) , consents to an dauthorize s the Unite dSate s Environmental Protectio n Agency (USEPA ) o r it s authorize drepresentative s (o r it s contractors) , th e Grantee , t o ente r an dperfor mcertai n environmenta l respons e activitie s upo nth e followin g describe dpremises . Fo r furthe r informatio npleas e contac t EPA^at 1-800-223-0425 . Propert y Acces s Grante dB y (Pleas e Print Name ) {Propert y Owner Signature ) (Date ) NOTE : Grantin g permissio n DOES NO T necessaril y imply you r

propert y will b e remediate da

t thi s time . Residen t Name : Residenc e Address : / A Q 0 % / / f» ' D Owne r

O Fl A H A D Rente r (CITY ) (STATE ) (ZIP ) 

### Property owne dby :



# . : v Owner s mailin g addres s Owner' s telephon e number—Home : / 3 5 ' " * ^ * ^

—Work : Ag e o f Home ? / Q year s Ho w lon g hav e yo u live dhere ? __ Ha s th e exterio r

been painte do r

covere dwithsidin g sinc e 197 8 Ha s th e interio r

bee n painte do r

covere dsinc e 1978 ? Total numbe r

o f occupants : ^- > Lis t Ages : _year s r YE S 

### ffl^YES D 

### N O

D 

### N O 

### Lis t age s o f occupant s under

6 year s ol dwh o pla y i nth e yar dfo r 5 o r mor e hour s pe r

week : Comments : AUTHORIT Y FO RENVIORNMRNTA LRESPONS EACTION S Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t

are pursuan t

t o Sectio n 10 4 o f

CERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f acces s t o th e property fo r

i n Sectio n 104{e

) o f CFRCLA , 4 2 U.S.C . 960

4 (e) , whic hprovide s entry for . "determinin g th e needfo r response , o r

choosin g o r

takin g an y respons e actio n unde r

thi s title , o r

otherwis e enforcin g th e provision s o f thi s title. " Acces s Attempts : First : Second : Third :

# Lis t o f existin g Condition s 

# p g . 1 o f Property Address : . 

## ° $ S / / Owner : Date : 6 '£"0 4 QLS # Description : 

## A

Owne r Signature ' Prin t & Sig n AS WAssocite s In c Prin t < S SName : C

Address : j Phone : Omah a Lea d Sit e Site Sketc h Date : "

Time : l a NorthArro w 

### X

Tea m BVI D # XR F Cod e Sampl e Numbe r Lea d Concentratio n 

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### pp m Confirmatio n Sampl e



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