### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 

### 2822 8 DATE : 12/15/201 0 ADDRESS : 230 9 N 2 7 ST REMEDIATIO N CONTRACTOR : PRUDEN TTECHNOLOGIES
. INC
. YEAR : 

### 201 0 

### SOI L REMEDIATIO N PROPERT YFIL E FOLDE R DOCUMENT S [T i PR E AN D POS TVIDE O O F PORPERT Y(DVD ) 

## E f EXECUTIV E SUMMAR Y EPA-PROVIDE D PROPERT YSKETC H SIGNE D ACCES S AGREEMEN TFO R SUBJECTPROPERT Y SIGNE D ACCES S AGREEMENT(S ) FO R ADJACEN TPROPERT Y RESTORATIO N AGREEMEN T SETTLEMEN TDOCUMENT S (I.E. , FO R DAMAG E O R T O REPLAC E PLANTS , ETC. ) 

# o i CONFIRMATIO N DAT A PHOTOGRAPH S AS-BUIL TSKETC H SATISFACTOR YRESTORATIO N SIGNE D B YPROPERT YOWNE R PROPERT YCLOSE-OU TCHEC KLISTSIGNE D B YEPA 

# a DESCRIPTIO N O F AREA S NO TMEETIN G RO D CLEANU P CRITERI A 

# i UTILITYCLEARANCE S PROPERT YINFORMATIO N FRO M DOUGLA S COUNT YASSESSOR' S OFFIC E
D D
^\x M C V y y SIGNATUR E DAT E 

### 3021861 3 

# mi l Superfun dFin dRecor d Remediatio nQuer y Lea d Remainin g Quer yPropert yDamage Quer y Backfill :



### Sampl e Area : 2822 8 ­ 230 9 N 2 7 S T Owner : Use rProvide d Owne rInformatio n Resident : n Owne rOccupied Owne rName : JOT YO F OMAH A Owne rName : Residen t Name : 

### P-OT Owne rAddressl : Ic/ O CTT YRNANC E Owne rAddressZ : 1181 9 FARNAM S T City : JOMAHA Owne rPiion e ]C402 ) 441-515 0 State : ZipCode : JN E J68183 - Alternat e Phone : 1(402 ) 444-518 0 Owne rAddress :

City : 

### 1 • Owne rPhone : State : Zi p Code : Alternat e Phone : 

# r—^— " Propert yAddress : J2309N27S T ZipCode : 168111 - Residen t Phon e \ " '



### Contract : Assessment :
Contractor : PRUDENT201 0 S i Qualifyin g Grou p |40 0 Contrac t Optio n jOPTlO N 2 Assessmen t Ma xXR F Valu e f 

### 494

### PROPERT Y SUMMAR Y Date : 12/15/201 0 Omah aLea dSit e Remedia l Actio nContrac t t

t EP-R7-07-0 6 TO# l Montl i of : Decembe r Propert y Address ; 230 9 N2 7 S T A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : NON E A. 2 Issue s Resolved : NON E A. 3 Uniqu e Findings : NON E A. 4 Othe r Relevan t Information : NON E CONFIRMATIO NSAMPLIN GDATA/RESULTS : B l = 28 4 PP M @ 3" ; E A = 12 4 PP M @ SCRAP E(~1" ) ATTACHMENT S 1 ) Property sketc hprovide db y EP A pursuan t t o contrac t specification s 2 ) Signe dAcces s Agreemen t includin g acces s agreement s require dfor crossin g othe r propertie s 3 ) Pre-Excavatio n digita l vide o clip/photograph s 4 ) Post-Excavatio n digita l vide o clip/photograph s 5 ) Documentatio n - Complete dClose-ou t Checklis t 6 ) As-Built sketc h­ i ) Shal l includ e final lea dlevel s v ) Legen d ii ) Contaminatio n lef t behin darea s vi ) Contracto r identificatio n iii ) Property addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include dinth e individual property file , i f available , o r obtaine dinclude : i ) Pre-excavatio nagreement detail s (i f an y ar e mad e withth e property owner ) ii ) Property Statu s Formsigne db y property owne r iii ) Excavatio ndigita l vide o in MPEG , WM V (Window s Medi aVideo ) o r SWF(Flas hPlayer ) forma t and/o r photograph s iv ) Signe dfor mverifyin g satisfactory restoratio n v ) Descriptio no f area s no t meetin g Interi mRO D cleanu p criteria .

TECHNOLOCIES , INC
.

# '^!tLhju i TECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Propert y # : 25 " >^ ^ Propert y Address ^ 5^'* 1 ^ ^ ^ ^ ^ Date/Time : Owner' s Name : Csi-H \c-^L^yyuxi^t^ Quad s Excavated: ^ / Contracto r Group : PrudeniTechnologies , Inc. , Excavatio nGenera l Ye s N o I If necessary , wer e th e correc t quadrant(s ) excavate dan drestored ? 

### y 2 I f necessary , wer e th e correc t area s o f dn p zon e excavate dan drestored' ^ ^ Gradin g So dan dVegetatio n 1 2 3 4 5 6 Doe s th e gradin g aroun dth e penmete r ofth e hous e mexcavate darea s generall y slop e awa y fro mth e house' ^ Ha s so dbee nlai di n al l area s that wer e excavated ? Doe s tli e so dappea r t o b e generall y health y an dgrowing' ? (Onl y evaluat e if inspecte da t a3 0 da

y tim e penod ) Ar e sodde darea s generall y fim i an devenl y graded' ? Ar e th e joint s betwee n th e so dstnp s generall y tight ? (Onl y evaluat e i f inspecte dat a3 0 da y tim e penod ) Wa s lh e propert y grade dsuc htliat wate r wil l no t poo l o n th e property* ? Ye s 

### y y 

### y y y 

### y N o

7 Wa s damag e t o landscapin g o r plan t material s avoided' ? y Gates , Fence s an dRetainin g Wall s 1 D o gate s ope nan dclos e freely• ? (I f apphcable ) Ye s 

### y N o 2 Were al l gate s o r fence s take ndow n dunn g restoratio nactivitie s reinstalled ? (Ifapplicable ) 

### y 3 Wa s damag e t o gate s o r fence s avoided ? (I f applicable ) 

# y 4 Wa s damag e t o retainin g wall s avoided" ? (Ifapplicable ) 

### y Foundation , Sidin g an dGutter s 1 2 Wa s damag e t o th e sidin g o r tri mavoided ? Wa s damag e t o di e foundatio n avoided' ? Ye s ^ ^ N o

1 4 Wa s damag e t o window s avoided ? Wa s damag e t o window s o r doo r screen s avoided ? 

# y
5 Wa s damag e t o downspout s o r downspou t extension s avoided" ? i ^ Sidewalk s an dDriveway s (Concrete ) I Wa s damag e lo drivewa y surface s avoided' ? Ye s N o 2 Wa s damag e t o walkwa y surface s avoided" ? 

# y

## Owner s comments :

Inspectio nnotes :

Remova l an drestoratio n activate s complete includin g th e 30-da y so dwarrant y EP A Representativ e /9c ^ J& , Date : lofnli o

# m CHNOLOGIES , INC 

### A S - BUIL T DRAWIN G OL S #2822 8 Dat e Excavated : 10/08/201 0 USEP A Signed-OffDate : 

### OMAH A LEA D SUPERFUN D SIT E

Name ; C^V+ A<rrO*'»v<3K a Omati a Lea d Sit e Date ; Nort h Arro w Address ; 7 ^c ^

/< i 2.r ^

S t Sit e Sicetc h Time ; Phone ;
Tea m 

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PH f A)oi> ^ OmahaLea dSit e 4613 0 EA=124PPM ® I "
CONTRAC T # : EP-S7-10-0 5 PRUDEN T TECHNOLOGIES , INC
.

# ffSfCjTjHi Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n of remova l activitie s perfonne d onth e belo w liste dproperty . Th e propert y owner' s signatur e indicate s tha t th e propert y owne r is satisfie dwithth e restoratio n of th e subjec t property , an dtha t no item s ar e inquestion , now , or at an y tim e inth e future , excludin g an y remainin g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , if any . Propert y ID : Propert y Address ; ^y^^K > ,f/„„> . j ; J i' <./.,. / Owner : 

# yyj-y y K Phone : ^ /'/' / '/J'/} " Restoratio n Item s In Question :

Item : Item : item : Item : Item : Item : Require d correction s to complet e th e property :

lSf \ agre e restoratio n Is completed
. L J I do no t agre e restoratio n is complete d at (note d deficiencie s above )



### ..^ \ (I >Ll. l r/jy O tvner' Sienatur e y Owner' s s Signat Dat e

# ¥

Prudent Technologies , tn c(Prudent ) i s unde rconlrac i wil h (he U S Environmenia l Proleciio n Agenc y(EPA) l o clea n u p lead conlaminale d soil s a t a nunibe rofpropertie s located i n Omaha
. Nebraska , includin g th e propert ylocated a l 1^,10' ^

A J pl- ^ Kyrv-' t The EP Arequest s you rpcmiissio n l o allowPruden t t o perform a soi l cleanu p a l Ihi s propert yl o remov e lead-conlaminated soi l B ysignin g Ihi s form , lh e properl yowne rgrant s permissio n l o Pruden t l o perform activiiie s relate d l o Ih e cleanu p includin g soi l sampling , removal o f lead-coniammate d soil , and resloralio n ofth e referenced property . Ifyo u hav e anyquestion s abou t lh e soi l cleanu p planned fo ryou rproperty , pleas e conlac i Pruden i soul h offic e .fo rIh cOmaha Lea d Su e cleanup-a l (402 ) 733-1188
. Genera l queslion s abou t Ih e Om.^ a Lea d Su e cleanu p can b e directe d l o th e EP APubli cInformalio n Center s a l (402 ) 731-304 5 (Soul h Omaha ofTice ) o r(402 ) 991-938 3 (Nort h Omah a ofHcc ) Propert yAcces s Granted By ; A^ / //' / »

^ / ^

Lvt4r \ J ^ (Pleas e Prin I Name ) Propert y0>vne rSignatur e 

# yi/M
. 

# iJy L 5-Oc l -Po/ v (Signature) (Date) PROPERT YINFORMATIO N (T o b e complete d byresiden i and/o rproperl yowne r- pleas e print ) RESIDEN TNAME : Owne r Rente r RESIDEN TADDRESS : 

## 2.^ 0 ^ /\ / 5L 7 e ^ I F RENTAL , PROPERT YOWNE D BY :
OWNER' S MAILIN G ADDRESS ;
OWNER' S TELEPHON E NUMBE R - HOME : J L WORK :
AG E O F HOME? : YEARS
. HO W LON G HAV E YO U LIVE D HERE ? YEARS
. HA S TH E EXTERIO R BEE N PAINTE D O R COVERE D WIT H SIDIN G SINC E 1978 7 YE S N O NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : . NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDE R NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E
. DOGS , ENTR YGATES , ETC. )

AUTHORITYFO R ENVIRONMENTA L RESPONS E ACTIONS , The aclivmes l o b e implemented byEP Aunde rihi s agreemen t ar

e pursuant t o Seclio n 10 4 ofCERCLA , 4 2 U S. C 960 4 EPA' s righ l o f acces s l o Ih 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 enlr> ' fo r"delermmin g Ih e nee d fo rresponse , o rchoosin g o rtakin g an yrespons e actio n unde rthi s title , o rotherwise enforcin g ih e provision s ofth e ml e " 808 0 War d Parkway , Suit e 40 S seoosios t 424 2 Medica l Drive , Suit s 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , T X 7822 9 Phone:(816)363-370 3 Phone : (402)733-118 8 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7Name : ^^'^<^^**^ ^

^ Omah a Lea d Sit e Date : ^/n/b^- j Nort h Arro w Address : 2--^ q A/ 2.y ^ ^ Sit e Sicetc h Time : 'y^O ^ Phon e Tea m 5^kxX^> > l\i.t\\\=.^< i BVI D # ;:?

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# A)ci> ^ Omah aLea dSit e 46130

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### Printed : Oct 25 , 201 0 www.dcgis.org/dogi s 

# 230 1 K l ^ 7 SL "

### Pag e 1 o f 1

" > Bac k t o Irt h Interne t Sen d Emai l 

### Creat e Anothe r Jicket YOURTICKE T NUMBERI S 2609462 . Origina l Cal l Date : 10/05/1 0 Time : 4:3 4 pm Op : SIVA1896 7 Wor k t o Begi n Date : 10/07/1 0 Time : 5:0 0 pm State : N E County : DOUGLA S Place : OMAH A Address : 230 9 Street : N27T H S T Twp : 15 NRng : 13 E Sect-Qtr : 09-S E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : SOI L LEA D REMEDIATIONPROJEC 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 Compan y: PRUDENT 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 : N Front : Y Rear : Involve s Tunnelin g o r Horizonta l Borin g : N Explosives : N CXCAT V

MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Phon e Nunibe r utilit y Typ e CXCAT V CO X COMMUNICATIONS , IN C HEIDI 

### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7
MUDO l METROPOLITA NUTILITIE S DISTRICT SANDY 

### Day : 402504782 3 Alt : Emerg : 402504797 0
OMAHACOFCITY OFOMAHA-TRAFFIC,SEWE R RICH/TRAFFIC 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0
0PPDGPR 5 OMAH A PUBLIC POWE RDISTRICT EL M LOCATING 

### Day : 406728934 3 Alt : 406207149 4 

### Emerg : 888728934 3 QLNN E1 C QWES T LOCA LNETWOR K EL M LOCATING 

### Day : 406728934 3 Alt : 406207149 4 

### Emerg : 888728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 10/5/201 0

### CONSTKUCnC W TEDHNOUieni , mc . 

### SOLUTION S 

## SIT ESAFET Y HAZARD ANALYSI S 2 7 ^ 

## Address : -^21iJl—U . Excavatio n Date : Jii-t/JiSJi , Crew : Backfil l Date : —C^jL/jiauiL
.



## Ite m Overhea dLine s Ga s Lin e Wate r Lin e Sewe r Lin e Septic/Leecl i Fiel d Propane/Butan e Sidewal k Foundatio n Retainin g Wall s Fence s Tree s Structure s Drivewa y Sprinkle r Syste m Othe r Cre w Forema n Conditio n Hazard s Correctiv e Actio n CP/ ^ 

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### seoosios t 424 2 Medica l Drive , Suit s 725 0 KjmaKGQy ; IK>«411 4 OiitiAa , Nataosk a «St0 7 Sa n Afitsnio , T X 7822 9 Ptiaiw:(81«)36»370 3 1>liefW : (402)733-110 8 Phone : (2t0 ) 822.-0S88 Ftf : {S16 ) 363>47D 7 i=aK : (402)733^108 3 Fax:(210)«r«-<57 7

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