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### TRANSMITTA L O F OMAH ALEA D SIT E SOI L REMEDIATIO N FIL E FOLDE R SAID# : 33309 DATE : 1/1 5 ADDRESS : 391 8 N 2 5 S T REMEDIATIO N CONTRACTOR : PRUDEN T TECHNOLOGIES . INC . YEAR : 201( ( 

### SOI L REMEDIATIO N PROPERT Y FIL E FOLDE R DOCUMENT S 0

^

PR E AN D POS T VIDE O O F PORPERT Y (DVD ) Q EXECUTIV E SUMMAR Y

EPA-PROVIDE D PROPERT Y SKETC H [f l SIGNE D ACCES S AGREEMEN T FOR SUBJEC T PROPERT Y D SIGNE D ACCES S AGREEMENT(S ) FOR ADJACEN T PROPERT Y Ca^RESTORATIO N AGREEMEN T D SETTLEMEN T DOCUMENTS (I.E. , FOR DAMAG E O R T O REPLAC E PLANTS , ETC. ) ^

CONFIRMATIO N DAT A E

^

PHOTOGRAPH S 0

^

AS-BUIL T SKETCH H SATISFACTOR Y RESTORATIO N SIGNE D B Y PROPERT Y OWNE R a PROPERT Y CLOSE-OU T CHECKLIS T SIGNE D B Y EP A D DESCRIPTIO N O F AREA S NO T MEETIN G RO D CLEANU P CRITERI A n UTILIT Y CLEARANCE S ^

PROPERT Y INFORMATIO N FRO M DOUGLA S COUNT Y ASSESSOR'S OFFIC E D D D

SIGNATUR E DAT E 3021885 9 

# m m Superfun d

### PROPERT Y SUMMAR Y Date : /15/201 0 Omah aLea dSit e Remedial Actio n Contrac t #EP-R7-07-0 6 TO# l Mont hof : Propert y Address : 391 8 N 2 5 S T A . EXECUTIV E SUMMAR 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 N SAMPLIN GDATA/RESULTS : B 2 = 380PPM(g6";E A = 31 8 - Q S PP M @ SCRAP E H" ) '^ P|t » r "Sa o fP" ^ ^6 ^ ATTACHMENT S 1 ) Propert y sketc hprovidedb y EP A pursuan t to contract specification s 2 ) Signe dAcces s Agreemen t including acces s agreements requiredfo r crossing othe r propertie s 3 ) Pre-Excavation digita l vide o clip/photograph s 4 ) Post-Excavation digita l video clip/photograph s 5 ) Documentation - CompletedClose-ou t Checklis t 6 ) As-Buil t sketch
i ) Shal l includ e fina l lea dlevel s v ) Legen d ii ) Contamination lef t behin darea s vi ) Contracto r identification iii ) Propert y addres s vii ) Dat e iv ) BVI D numbe r 7 ) Othe r items to b e includedi n th e individua l propert y file, ifavailable , o r obtainedinclude : i ) Pre-excavation agreemen t detail s (if an y ar e mad e wit hth e propert y owner ) ii ) Propert y Statu s For msignedb y 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/o r photograph s iv ) Signedfor mverifying satisfactor y restoration v ) Description of area s not meeting Interi mRO D cleanu p criteria .

TECHNOLOGIES . INC .Fin d Record | 

### Backfill :

Sampl e Area : 3330 9 - 391 8 N 2 5 S T Owner : n Owne rOccupie d Owne rName : JFUERTE S JOS E Owne rAddressl : jC/ O RAU L CHAIDE Z Owne rAddress2 : 

### |430 6 S 2 1 S T City : state : Zi p Code : [OMAH A 

### ^ JN Y 168107 - Owne rPhon e Aiternat e Phone : 

# r

Contract : Contractor : |PRUDENT2010_S Contrac t Optio n JOPTTON T Remediatio n Quer y] Lea d Remainin g Quer yj Propert yDamag e Quer y

Use rProvide d Owne rInformatio n Owne rName : 

# r Owne rAddress : 

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

# I

Assessment : Qualifyin g Grou p J40 0 Assessmen t Ma xXR F Valu e \ 498.7 6 Resident : Residen t Name : 

# I — Propert yAddress : |391 8 N 2 5 ST ZipCode : 168111 - Residen t Phon e 

# ITECHNOLOGIES , INC . 

# EP A Propert y Clos e Ou t Property# : '^'3>^C> \ Propert y Address : ^"^ ^ ^ ' ^ ^ '^^ - Date/Time : Owner' s Name : ^«Uc \0\aXA-^~l- ^ Quad s Excavated : < ^ Contracto r Group : Pruden t Technologies , Inc. , 

### Excavatio n Genera l Ye s 1 .

I f necessary , wer e the correct quadrant(s ) excavatedandrestored ? 

# y 2 .

I f necessary , wer e the correct area s o f drip zone excavatedandrestored ? 

# y Gradin g So dan dVegetatio n Ye s 1 .

Doe s th e gradin g aroundth e perimete r o

f th e hous e i n excavatedarea s generall y slop e awa y fro mIh e house ? 

# y 2 .

Has sodbeen lai di n all area s Uia i wer e excavated ? / 3 .

Doe s the so dappea r to b e generall y health y an dgrowing ? (Onl y evaluate i f inspecteda t a3 0 da

y tim e period) / 4 .Ar e soddedarea s generall y fir man devenl y graded ? 

# y 5 .Ar e tlie joint s between the sodstrip s generall y tight ? (Onl y evaluat e i f inspecteda t a3 0 da y 

# y tim e period) 6 .

Wa s th e propert y gradedsuc htlia t wate r wil l not pool o n di 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 s Ye s 1 .

D o gate s ope n andclos e freely' ? (I f applicable ) 

# y 2 .

Wer e al l gate s o r fence s taken dow n during restoratio n activitie s reinstalled ? (I f applicable ) / 3 .

Was damag e t o gate s o r fence s avoided ? (I f applicable ) 

# y 4 .Was damag e t o retainin g wall s avoided ? (Ifapplicable ) / Foundation , Sidin g an dGutter s Ye s 

### 1 .

Wa s damag e t o the stdm g o r trimavoided ? / 2 .Wa s damag e t o tlie foundation avoided ? / 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 lo downspout s o r downspou t extension s avoided ? / Sidewalk s an dDriveway s (Concrete ) Ye s IWa s damag e t o diivewa v surface s avoided ? 2Wa s damag e t o walkwa y surface s avoided ? 

### N o

N

o

N

o

N o

N o

## Owner s comments :

Inspectio n notes :

/ . 

## cT , ,\o<

Remova l andrestoratio n activate s complete includin g th e 30-da y so dwarranty : EP A Representativ e ^' ^ ^ . ^Date: i|»| »

# 1 ^ (.'HNOLOUIES , FNC, 

### A S - BUIL T DRAWLIN G OLS#3330 9 Dat e Excavated : 11/03/201 0 

### OMAH A LEA D SUPERFUN D SIT E liSEP A Signed-Of f Date : 3.330 9 Exterio rPain t Omah a Lea d Sit e Owne rName : RAU L CHAIDE 2 • Goo d Sit e Sketc h Address : 3918_N 2 5 S T -£:i> . • Poo r Phone : H : W : ^ ' Not pain t Sampl e Numbe r Lea d Concentratio n Sampl e Collecte d LA B Firm : Sample s Collecte d P E T /VV v- ^ U ^ RYASCPXA-3330 9 F l \ 7 ? pp m 

### D Date : C A•Xk-n5 ' RYBSCPXA-3330 9 F 2 "2-3 1 pp m 

### D Time : / OC O •^•-' V RYCSCPXA-3330 9 RYDSCPXA-3330 9 B l 8 2 ^2-£ , ppr " 

### B" " 

### D D Sample s Analyze d RDZSCPX A3330 0 B Z " pp m 

### D D XR F Unit : /05 1 Book : /g 2 RCg&GPX A•3330 0 -G2 ­ ~ pp m 

### D D Date : / a -Zff-a ^ RPZSCPXA-3330 9 P Z V^' ? pp m 

### D Time : P m Numbe ro f Sample s = C Staff : L - A 

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OmahaLea dSit e •tfil.^ O E A= 31 8 PP M ff S ( RAPt : {~\" \ CONTRAC T # : EP-S7-10-0 5 PRUDEN T TECHNOLOGIES , INC .

# %1S ^ Propert yCompletio n Agreemen t Thi s agreement document s th e completio n o f remova l activitie s performe do n th e belo w liste dproperty . Th e property owner' s signatur e indicate s tha t th e property owne r i s satisfie dwithth e restoratio n ofth e subjec t property , an dtha t n o item s ar e i n question , now , o r at an y tim e i n th e future , excludin g an y remainin g warranty (3 0 day s total ) excep t thos e item s liste dbelow , i f any . Propert y ID : Propert y Address ; 'P^C\ \g t O P,S^ ^ ^j^U
Phnne ; 0 

### Restoratio n Item s i n Question :

Item : Item : Item : Item : Item : Item :

1/

3 I agre e restoratio n i s completed . [_ ] 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

• & SPruden t Technologies , Inc . (Prudent ) i s under contrac t wit hth e U . S . Environmental Protectio n Agenc y (EPA ) to clean u p lead
containina(ed'toil s a t anumbe f o f

propertie s locate di n Omaha , Nebraska , includin g th e propetty locate dat ^ n 1 5 " ^ '2^~ > \ . -T " Th e EP A request s you r permissio n t o allo w Pruden t to perfor masoi l cleanu p at thi s property to remov e lead-contaminate dsoil . B y signin g thi s form , th e property owne r grant s permissio n t o Pruden t t o perfor m activitie s relate dt o th e cleanu p includin g soi l sampling , removal o f lead-contaminate dsoil , an drestoratio n ofth e reference dpropeity . Ifyo u hav e an y question s abou t th e soi l cleanu p planne dfo r you r propetty , pleas e contac t Pruden t sout hoffic e .fo r th e Omah aLead Site cleanup-a t (402 ) 733-1188 . General question s abou t th e Omah aLeadSite cleanu p can b e directe dt o th e EP A Publi c Informatio n Center s at (402 ) 73 1 -304 5 (Sout hOmah aoffice ) o r (402 ) 99 1 -958 3 (NorthOmah aoffice) . Propert y Acces s Grante dBy : (Pleas e Prin t Name ) Property Owne r Signature : r - ^ C (Signature s ^ ^ | (Date) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y own e r ~ pleas e print ) RESIDEN T NAME : Owne r Rente r RESIDEN T ADDRESS :

:9iLFcr i I Auur\c9o : , / * c1 1 ~ L
I F RENTAL , PROPERT Y OWU^ D BY : 

### ^ OWNER' S MAILIN G ADDRESS ; , ^
OWNER' S TELEPHON E NUMBER - HOME : _£ L WORK : 

### J 1 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 CHILDRENUNDE R 7 YEAR S OL D WH O PLA Y I NTH 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 Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente dby EPA under 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 i s provide dfo r i n Sectio n 104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry fo r "determinin g th e nee dfo r response , or choosin g o r takm g any respons e actio n under thi s title , o r otherwis e enforcin g th e provision s ofth e title. " 808 0 War d Paricway , 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 Phone : (402)733-118 8 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)733-188 3 Fax : (210 ) 579-657 7

### TECHNOLOGIES , INC . ENVIRONMENTA L & CONSTRUCTIO N SERVICE S


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Pruden t Employ e 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 , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)733-118 8 Phone : (210)822-968 8Owne rName : RAU L CHAIDE Z Address : 391 8 N 2 5 S T Phone : H: Sampl e Numbe r RYASCPXA-3330 9 F l RYBSCPXA-3330 9 F 2 RYCSCPXA-3330 9 B l RYDSCPXA-3330 9 B 2 RDgeCPX A3330 0 B Z nOilSGPX A3330 0 62 - RPZSCPXA-3330 9 P Z 

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### • YOU RTICKE T NUMBE RI S 2632417 . Origina l Cal l Date : 11/02/1 0 Time : 12:3 3 p m Op : SIVA1896 7 Wor k t o Begi n Date : 11/04/1 0 Time : 1:0 0 p m State : N E County : DOUGLA S Place : OMAH A Address : 391 8 Street : N25T H S T Twp : 15 NRng : 13 E Sect-Qtr : 04-S E Twp : Rng : Sect-Qtr : Lega l Given : C Typ e o f Work : soi l lea d remediatio n projec 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: 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 : Involve s Tunnelin g o r Horizonta l Borin g : NExplosives : N ALT87 2 CXCAT V MUDO l OMAHACO F 0PPDGPR 5 QLNNEI C Servic e Are a Contac t Phon e Numbe r Utilit y Typ e ALT87 2 WINDSTREA M COMMUNICATIO N 

### EL M LOCATIN G Day : 406728934 3

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### Day : 402934046 9 Alt : 402934046 9 Emerg : 402932975 7 MUDO l METROPOLITA N UTILITIE S DISTRIC T SAND Y 

### Day : 402504782 3 Alt : Emerg : 402504797 0 OMAHACO FCIT Y O F0MAHA-TRAFF1C,SEWE R RICH/TRAFFI C 

### Day : 402444719 7 Alt : 402444516 1 Emerg : 402444516 0 Day : 406728934 3 http://www.dhon.org/irthintemet/DHONNoticeCreation/MessageText.asp?ret=<RESULTS. . . 11/2/201 0

### Pag e 2 of 2
OPPDGPR 5 OMAH A PUBLI C POWE RDISTRIC T Alt : 406207149 4

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# wm i SAFET Y HAZAR D ANALY S 

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