## TRANSMITTA Lo f OMAH A LEA D SIT E SOI LREMEDIATIO N FIL E FOLDE R SATDJ^ ; , 2/Zx<? | Date : Q. \l ^ Address : ^^ic ^ fmr^JUfl ^ Av/
- Remediation Contractor : '^(\iA M ^/fl/ l \v\ t Year : ^ 0 | < 3 SOIL REMEDIATION PROPERT Y FIL E FOLDERDOCUMENT S 1^ Video of propert y (DVD ) 0 Executive Summar y ^ 

## EPA-providedpropert y sketc h / 

## SignedAcces s Agreemen t fo r

subjec t propert y D SignedAcces s Agrecment(s ) fo r

adjacen t propert y 0 Restoration Agreemen t D Settlemen t document s (i.e. , fo r

damj^e o r

t o replac e plants , etc. ) Confirmatio n dat a Photograph s As-buil t slcetc h Satisfector y restoration signe dby Propert y Owne r Propert y close-ou t chec k

lis t signe db y EP A n Description of areas not meetin g RO D cleanu p criteri a Utilit y clearance s 

## Propert y informatio n fromDouglas Count y Assessor' s Offic e D D D
^ ^ 3,uli > 

## "Signatur e —Dat e 3026241 8 

# iHin i Superfun dFin d Recor d Remediatio n Quer yI Lea d Remainin g Quer yI Propert yDamag e Query 

### Backfill :

Sampl e Area : 228 1 - 336 9 GRAN D AV Owner : Resident : Contract : 

# t • Owne rOccupie d Owne rName : |WES T LOS T LAKE LL C Owne rAddressl : Residen t Name : 

# 1 Propert yAddress : |336 9 GRAN D A V Contractor : |PRUDENT2009_S Contrac t Optio n OPTION S Owne rAddress2 : )132 3 WILLIA M S T City : |OMAH A Owne rPhone : State : Zi p Code : |N E |6810 8 Alternat e Phone : 

# 1 Zi p Code : |6811 1 Residen t Phon e 

# 1 

# m Assessment : Qualifyin g Grou p 

# po o Assessmen t Ma xXR F Value : 

# r 622. 8


### \

### /



### PROPERT Y SUMMAR Y Date : J/15/201 0 | Omali aLea dSite Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l | Mont hof : Q C T Propert y Address ; 336 9 GRAN D AV E A . EXECUTIV E SUMMAR Y A. l Issue s Encountered : NON E A. 2Issue s Resolved : NON E A. 3Uniqu e Findings : NON E A. 4Othe r Relevan t Information : ARE A NO T EXCAVATE D PE RP.O . REQUEST ; DZ/BUSHES (2'X l .5' ) = 44 3 PP M @ SCRAP E . CONFIRMATIO N SAMPLIN GDATA/RESULTS : B l = 33 8 PPM @ 14" ; B 2 = 324 PPM @ 14" ; D Z = 33 3 PP M @ 14" ; E A = 17 9 PPM @ SCRAPE (~1" ) ATTACHMENT S 1 ) Propert y sketchprovidedb y EP A pursuan t t o contrac t specification s 2 ) SignedAcces s Agreemen t including acces s agreement s requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l vide o clip/photograph s 4 ) Post-Excavation digita l vide o clip/photograph s 5 ) Documentation - CompletedClose-out Checklis t 6 ) As-Built sketch­ i ) Shal l include final lea dlevel s v ) Legen d ii ) Contamination lef t behindarea s vi ) Contractor identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r item s t o b e include din th e individua l propert y file, i f available , or obtainedinclude : i ) Pre-excavatio n agreemen t detail s (if an y are mad e wit hth e propert y owner ) ii ) Propert y Statu s For msignedby propert y owne r iii ) Excavation digita l vide o i n MPEG , WM V (Window s Medi aVideo ) o r SW F(FlashPlayer ) forma t and/or photograph s iv ) Signedfor mverifying satisfactor y restoratio n v ) Descriptio n of area s not meeting InterimRO D cleanu p criteria .

TEGHNOLOCIES , INC
.^HNOIOGIBS , INC . 

# EP A Propert y Clos e Ou t Propert y #: 2-2 ^ Propert y Address : SS^* ? <^><5>'w A A / Date/Time : Owner' s Name Quad s Excavated : fl ) ^2 , P ^ Contracto r Grou p p : Pruden t Technologiesnnc , Excavatio n Genera l 1 If necessary , wer e th e correct quadrant(s ) excavatedandrestored ? 2.

If necessaiy . wer e th e correct area s of drip zone excavatedandrestored ? Gradin g So dan dVegetatio n 1.Doc s the grading arounddi e perimete r of th e hous e in excavatedarea s generall y slop e awa y fro

mtlic house ? 2Has so dbee n lai d in all area s tha t wer e excavated ? 3.Doe s tli e sodappea r to be generall y healtli y andgrowing ? (Onl y evaluat e

if

inspected at a

30 da

y lim e period) 4.Ar e sodde darea s generall y finn andevenl y graded ? 5.

Ar e di e joint s betwee n tli e sodstrip s generall y tight ? (Onl y evaluat e

if

inspected at a

30 da y tim e penod ) 6Was the propert y gradedsuc htha t wate r wil l not pool on the property ? 7.Wa s damag e to landscaping or plan t material s avoided ? Gates , Fence s an dRetainin g Wall s 1.Do gate s ope n andclos e freely ? (Ifapplicable ) 2 Wer e all gate s or fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) 3 Wa s damag e to gate s or fence s avoided ? (Ifapplicable ) 4.Wa s damag e to reiainin g wall s avoided'^ (I f applicable ) Foundation , Sidin g an dGutter s 1.Wa s damag e to the siding or trimavoided ? 2. Wa s damag e to tli e foundadon avoided ? 3 Wa s damag e lo window s avoided ? 4.Wa s damag e to window s or doo r screen s avoided ? 5.Was damag e to downspout sor downspou t extension s avoided ? Sidewalk s an dDriveway s (Concrete ) 1 Wa s damag e lo drivewa y surface s avoided ? 2 Wa s damag e to walkwa y surface s avoided ? Ye s No 

## J J Ye s No 

## J / 

### J i7 

### y 

## y y Ye s No / / 

## 7 

# J Ye s No 

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## Inspectio n notes : • 1 i

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## Remova l an drestoration activate s complet e includin g th e 30-da y so dw axant y EP A Representativ e Q» - ^ Date : 

# > M t ol i 

# i( »

-;; ^ „«*.-" ' 

## Propert yCompletio n Agreemen t Thi s agreemen t document s th e completio n o f removal activitie s performe do n th e belo w liste dproperty Th e property owner' s signatur e indicate s tha t th e propert y owne r i s satisfie dwithth e restoratio n o f th e subjec t property , an dtha t n o item s ar e i n question , now , o r a t an y tim e i n th e future , excludin g an y remaimn g warrant y (3 0 day s total ) excep t thos e item s liste dbelow , ifan y PropertylD : ^^J> / Propert y Address : J^^ f ^M//7 ) >^> ^ Owne r 

## Phone : ^^^ ^ 3S^ 1 (It/ I / Wft H 3^-^6) 6 Restoratio n Item s i n Question :

Require d correction s t o complet e th e property :

^ 

### 1 agre e restoratio n i s completed
. I I d o no t agre e restoratio n i s complete d a t (note d deficiencie s above )

//-^^-^ ^ Owner' s Signatur e Dat e IPruden t Technologies , Inc . (Prudent ) i s unde r contrac t wit hth e U S . Enviixmmental Protectio n Agenc y (EPA ) t o clea n u p lead
cgqtwiinvto dsoiJ^BL anumbe r oCffropprtie s locate di n Oniaha , Nebraska , includin g th e propert y locate da t e3'f0 i (^K:7rfl/7 ) 'ff/Jf p Tli c EP A request s you r permissio n t o allo w Pruden t t o perfor masoi l cleanu p a t thi s propert y t o remov e lead-contaminate dso dB y signin g thi s form , di e propert y owne r grant s pennissio n t o Pruden t t o perfor m activitie s relate dt o th e cleanu p includin g soi l sampling , remova l o f lead-conlaminate dsoil , an drestoratio n ofth e referencedpropert y Ifyo u hav e an y question s abou t th e soi l cleanu p planne dfor you r property , pleas e contac t Prudent' s AcliniiiiMnilnu Clci k fo r th e Omah aLea dSit e cleanup . M s Siv a. S Jiiinixinii-at (402 ) 73."<- l ISX . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o th e EP A Publi c Informatio n Center s a t (402 ) 731-304 5 (South Omah aoffice ) o r (402 ) 991-9S8 3 (NorthOmah aoffice ) Propeit y Acces s Grante dBy : 

# 'FiifV7CK /(^/y^ i (Pleas e PrinrName )

. (, r leas e mpriMam^j^^. ^ Property Owne r Signatur e y ^ ' (SigDBtunj T (Date ) PROPERT Y INFOmN ; lATIO N b

yresMcB t tailwejmt ^ ipcrt y owne r — pleas e print ) RESIDEN T NAME : 

## ^f/ni^f /

7 7 £ i Owne r 

## 7£&C £ Renter
. rADORER : RESIOENTADORES J ^

I F RENTAL , PROJERTIfl^bVVNE B BY : y. .. .
OWNER ' 

# A?!^T7/^/?r W^ /^mnk ^^f^ ^ 3i<f-Sdl d 

# ^ ^^ f JXV 7 OWNER' S TELEPHON E NUMBE R - HOME : J L 

# fft
. J 1 AG E O F HOME? : YEARS
. HO W LON O HAV E YO U LIVE D HERE ? HAS TH E EXTERIO R BEE N PAINTE D O R COVERE D WrT H SIDIN G SINC E 1978 7 J L^YE S _|St

_ N O NUMBE R O F OCCUPANTS UNDE R 7 YEAR S OLD : ] ^

NUMBE R O F OCCUPANTS 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 Y I N TH E YAR D FO R S HOUR S O R MOR E PE R WEEK : COMMCNt S ORJVECIA L INSTRUtfTIONS : (I.E
. DOGS
. ENTR Y GATES , ETC.)
. „

AUTHORIT Y FO RENVIRONMENTA LRESPONS E ACTIONS , Th e activitie s t o b e implemente db y EP A unde r thi s agreemen t ar e pursuan t l o Sectio n 10 4 o f CERCLA , 4 2 U S C 960 4 EPA' s righ t ofacces s t o th e property i s provide dfo r mSectio n 104(e ) o f CERCLA , 4 2 U.S . C 960S(e) , whic hprovide s entry for "detommin g th e nee dfor response, o r choosm 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 ofth e title. "

8080 Ward Parkway , Suit e 40 5 2505 N
. 24* ^ Street , Suit e 30 8 4242 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebraska 6811 0 Sa n Antonio , T X 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7ENVIRONMENTA L & CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Addres s Date : Phone : BVID : Ite mN O Plant s & Permanen t Landscapin g T o Remai n I n Plac e O n Ma p Descriptio n & Locatio n 

# fil m

Pre-Eiistin g Conditio n o f

Structure s Doe s you r Basemen t hav e ahistory o f

leaking ? Ye s No L y Ite mN O Descriptio n & Locatio n O n Ma p

Propert y Owne r VryiAcn t Employee , Signature : Signature :
808 0 War d Parkway , Suit e 40 5 560 0 S 1 0 s t 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6810 7 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3

### #

IIF.S . IN C 

## A S - BUIL T DRAWIN G OI,S#:228 1 Dat e Kxcavatcd : 10/14/200 9 

## OMAHA LEAD SUPERFUND SIT E LSEP A Signed-Of f Date : 

## T'rT W Exterio rPain t rt n !K \ Omah a Lea d Sit e • £oo d Sit e Sketc h [7 ] Poor Samplin g Address : .^?)G.° ^ HraHr / Av • No t pan t 

# i
Sampl e Nunnbe r Lea d Sannpl e Sample s Cojiecte d Concentratio n Collecte d LA B 

### Firm : BJum7K/mmd / RYASCPXA-S S 8 / P 1 

## n Date : r^-fn-n/ ^ RYBSCPXA-22(9 / F 2 38< o pp m 

### D Time : RYCSCPXA-^2a / B l f^<9/ ° pp m 

## n Sampld s Analyze d RYDSCPXA-eca / B2 ¥Q( a pp m 

## n RDZSCPXA- SSe / D Z gflgQpp m 

## n XR F Unit : /SO^Book : nCZOOPX A 3SQ / G Z pp m 

### D 

## n Date : RPZSCPX ASSO / ^^ ' ~ pp m 

### D Time : 

### D Staff : Numbe ro f Sample s = | ^ \ Legend : F l = Fron t Left
. F 2 = Fron t Right , B l = Bac k Left , B2 = Bac k Rig M D Z = Dri p Zone , G Z = Garden , PZ = Pla y Al l quaaranl B ar e a s viewe d fro m th e street , facin g property/\ i i E V

G«!«At«i P Kv
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A = 17 9 PP M r « S C RAFF . (~1" ) CONTRAC T # : E P - R7-07-0 6 T0# 1 PRUDEN T TECHNOLOGIES , INC
.Exterio rPain t Nort h Arro w Omah a Lea d Sit e • jGoo d Sit e Sketc h 

### 0 Poo r Samplin g Acldress : 3 3 ( 

# m d A v Q Not pain t 

# 1
Sampl e Numbe r Lea d Sampl e Sample s Cojiecte d LA B Concentratio n Collecte d 

## Fimn : B7um/Kirr)m d RYASCPXA-^23 / F l 

## D 

# 2d A pp m 

## Date : Q-Id'717 ^ RYBSCPXA-225 / P 2 3Q G pp m 

## D Time : RYCSCPXA-^'^a / B l 

## _d££.pp m D Sample s Analyze d RYDSCPXA-ef<3 / B2 

## D RDZSCPXA- 22a / D Z 

## 2d.£Qpp m D XR F Unit : /^n^^Book : nozscpx ASSQ / C Z pp m 

# n D Date : pp m 

# n D Time : Staff : Numbe rp f Sample s = 

# 6^ Legend : F 1 = Fron t Lett , F2 = Fron t Right , B l = Bac k Left , B2 = Bac k Righ t D Z = Dri p Zone , G Z = Garden , P Z = Pia y Al l quadrant s ar e a s viewe d fro m th e street , facin g propert yAJ_|

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Rev20O8.DI . Created : 16-May-0 8 04(314 1 012. 1

## yfxy^ ^ GR.^Nt ) A V

### Flin t Previe w Pag e 1 of 2 

## Dougla s County-Omaha , N E

Parce l I D Owne r Nam e Propert y Addres s Cit y Zi p Owne r Addres s Owne r Addres s 2 Owne r Cit y Owne r Stat e Owne r Zi p Sec-Twn Rn g 180075000 0 WES T LOS T LAK E LL C 336 9 GRAN D A V OIVIAH A 6811 1
132 3 WILLIAIV I S T OMAH A N E 6810 8 Additio n Bloc k Lo t Lega l 1 Lega l 2 Lega l 3 Lega l 4 Acre s Treasure r Websit e Lin k Assesso r Websit e Lin k MONMOUT H PAR K 1 1 3 LT12&E1.5N94FTLT1 3

0.1 5 http://webapps.dotcomm.org:8080/TreasTax/faces/pages/taxinfo.jsp ? parc=180075000 0 littp://douglasne.mapping online.com/DouglasCoNe/static/accountinfo.jsp ? accountno=R180075000 0


### http://www.dogis.org/dogis_alias/dogis/printPreview.aspx?PrintOptData=Dougla s County-.. . 9/16/200 9

### Pag e 1 of 2

" > [ Creat e Anothe rTicke t J [ Bac k t o Irt h Interne t ] Sen d Emai l 

### YOU RTICKE T NUMBE RI S 2375366 . Origina l Cal l Date : 9/29/0 9 Time : 2:3 5 p m Op : SIVA1896 7 Wor k t o Begi n Date : 10/01/0 9 Time : 3:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 336 9 Street : GRAN D AV E Twp : 15 NRng : 13 E Sect-Qtr : 04-NW Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : SOI L LEA D REMEDIATIO NPROJEC T Locatio n o f Work : LOCAT E ENTIR E PROPERT Y Remarks : FA X AL L CLEAR S TO : (402)733-188 3 : FA X AL L CLEAR S T O (402 ) 73 3 188 3 : UNSUR E CORNER S Compan y: PRUDEN T 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 : NFront : Y Rear : Y Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N ALT87 2 CXCAT V METR O MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C
Servic e Are a Contac t Phon e Numbe r Utilit y Typ e 

### Day : 406728934 3 ALT87 2 WINDSTREA M COMMUNICATIO N 

### N A Alt : 406207149 4 Emerg : 888728934 3 Day : 402934046 9 CXCAT V CO X COMMUNICATIONS , IN C 

### HEID I Alt : 402934046 9 Emerg : 402932975 7 Day : 402457230 7 METR O METR O COMM . COLLEG E 

### CHRI S Alt : 402672703 3 Emerg : 402457231 3 Day : 402504782 3 MUDO l METROPOLITA N UTILITIE S DISTRIC T SAND Y Alt : 

### Emerg : 402504797 0
http://www.dhon.org/iithintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 9/29/200 9

## Pag e 2 of 2

OMAHACO FCIT Y O FOMAHA-TRAFFIC.SEWE RRO N 

## Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0
0PPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T N A 

## Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3 QLNN E I C QWES T LOCA LNETWOR K 

### N A 

## Day : 406728934 3 Alt : 406207149 4 Emerg : 888728934 3

http://www.dhon.org/irthintemet/DHONNoticeCr«ation/MessageText.asp?ret=<RESULTS.. . 9/29/200 9

### TECHNOLOGIES , INC
. 

# Sit e Safet yHazar d Analysi s Address : 77^ ^ rr?j^.^** J Crew : ^^ftft^tf J Lj/>^/vcsV^^ r Date : 9-^ 6 - <? ?


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. Suit e 4G 5 260 6 N
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. Suit e 30 6 424 2 Medfca l Drii/e
. Suit e 725 0 Kansa s City
. M O 6411 4 Omaha
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