### TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID : 2513 4 Date : 12/22/200 8 Address : 322 4 Myrtl e Av e Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S g

f Vide o o f propert y (DVD ) 0 Executiv e Summary l /

Signe dAcces s Agreemen t fo r subjec t property 0 ^ Paintin g Agreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D Photograph s [?

f Satisfactory restoratio n signe db y Property Owne r aProperty close-ou t chec k lis t signe db y EP A H

^ Property informatio n fromDougla s County Assessor' s Offic e D D D


### Signatiu- e J ^ Dat ePROPERT Y SUMMAR Y Date : 12/22/0 8 LB P STABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address : 322 4 Myrtl e Av e SAID : 2513 4 

### A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : None A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 11/18/0 8 Wor k Began : 11/20/0 8 Closeou t Date : 12/10/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio n For m 6 . Pain t Matc hFor m 7 . Trackin g For m 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES . INC .ENVIRONMENTA LA CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Property Statu s Form Address: 393 4 rn\^rV\ f nU € Date : |,^i^^c?l J 

# Phone : <^3;i-33? V ^^ = St)\^ M T Plan t & Pennanen t Landscapinf r j n Rmwii n In Plyi » Iteoi # Descriptio nan dLocatio n OnMq ) r\<fc .

Pfe.T^y^grin g Cr^nditjo no f Structure s Doe s you r Basemen t hav e ahistor y o f leaking ? Ye s — No ^ Item ^ Descriptio n & Locatio n O nMa p 'J^SCS ­ " ^ '



### Propeit y Owne r Pruden t Employe e Signatuie;.,^^^^^'^ ^ Signature : ^^.^,>>.^ ' 424 2 Medica l Dilvft , SuK e 428 0 260 5 N . 24* ^ Street , Sittf t 30 8 808 0 Ward PaikMiy . Sut e 40 6 Omaha , Nebraska 6811 0 Sa n Antonio , TX7822 9 Kans8 S Cily . H O 0411 4

# 5^513 ^

Pruden t Technologies , Inc . (Prudent ) i s unde r

contract (Contract #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o stabiliz e Lea dBasedPaint (LBP ) at anumbe r

of propertie j locatedi nOmaha, Nebrasica , includin g tiie propert y locateda t ^^^c^ M Tfi^ . \f \\- e rkj ^ The EP A requests your permissio n t o allo w Pruden t t o perfor mLB P Stabilizatioiii t tiiis property . B y signing tiiis form, tiie propert y owner grant s permissio n to Prudent t o perfor mactivitie s relatedt o LB P Stabilization including scrapin g pain t an dpaintin g ofth e reference dproperty . Furtiier , tiie owner/tenen t verifie s tiiattiiey hav e receive dth e LB P pamphle t "Renovat e Right. " I f

you have an y question s abou t tiie LB P stabilizatio n plannedfo r

your property , pleas e contac t Prudert' s i^d^iniiiftnitiv e Cler k

fo r

th e Lea dBase dPaint Stabilization , Mrs . Debora hAkereie-Johnson , a

t (402) 504-1004 . Cienera l question s about tiie Omah aLea dSit e cleanup can b e directedto th e EP A Publi c Infonnation Center s a t (402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nort hOmaha . office) . ProiiBtyAeceMOfaitedBv : J ^ OL\//X WA ) < . /V\o- ^ C OvA . (Pleas e Prin t Name ) Propert y Ome r SigutDte : 

# n - i t -o z (Date ) PROPERT Y INFORMATIO N (T o b e coaplctt dhr f rciidn t tBd/o r propat r owne r - pkaa e priat ) RBSDENTNAIIE : ^CLV/O^/^ V S^o^\(y ^ 6^ ^ Rente r RESIDEN TADDRESS : ^73~ H /YNwr-lr U As/ff' . WRENTAL , PROPERT Y OVVNE D BY : SiCiJirr\' ^ 0IIVNER! 8 HAUN O ADDRESS ; OWNERrSTELBPHONENUMBER.HOME : f JO ^ > 93;2 - 33f^yyoRK. . t \ NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : ^ NUMBE R O P OCCUPANT S 7 YEAR S OL D AN O OLDER : NUMBE R OFCHILDRE N UNDE R 7 YEAR S OL D WH O PLAYI N TH E YAR D FO R 6 HOUR S O R MOR E PE R WEEK : , ^ COMHENTSORSPeCIALiNSTRUCnONS : (L E DOGS , ENTR YGATES , ETC. ) 

### >2^ ^
AOTHOWr y TOR ENVnwyNMBbn'A LRESPONS EACTTOO ; Tl w actMlie i t o b e faytea^^ O

f CEROA . 4 2 U.S. C 9604 . EPA' I righ t o f

woei s t o (h e property to provide d fi)r i nSectio a104(e ) o f CBRO ^ 4 2 U.S . C 960 ^ flir

"deliniiiBiagt e iwe d(b r letpoiiM , o r duosni g ortddn g an y lespoos e acdo nifflde r (ht o title , o r oAeiv ^

0 8 0 Win dParfomy . Silt s 40 6 260 6 N . 24 ^ StrMt , Suit e 30 8 424 2 Medica l Ditv* . SuK e 42S 0

# Curren t Sampl e iSe-Renovatio n For m Effectiv e unti l Apri l 2010 . Confinnatio n o f Receip t o f Lea d Pamphle t S I iBv e receive d a cop yo f ttie pamptiiet , fierKvat e FS^ : Imptxtan t Lea d Hazan i Inkmnatlcmftyr^n^lies , CNI d Ca m Pnyi^demwT d School s trtfanvAngrrjec X th e poterrtia i ris k of th e lea d hazan d eoqxisure fro m renovatio n activityt o b e perfomie d i n m ydwellin g unit , i receive d thi s pamphle t bdloi e th e wor k t)egan . ^rjcJo. ^ < k s nVo-»r \ f> ^

ll-\^~07 ^

Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — if th e lea d pamphlet wa s delivere d bu t a tenan t signature wa s no t obtainable , yo u ma ychec k th e appropriat e bo xbelow . • Refusa l t o sig n — I ceitif ytha t I hav e mad e a goo d fait h effor t t o defive rth e pamphlet , Renovate FVc^ : Importan t Lea d Hazar d Infonnatio n fo rFamSes , CI M Ca m Provider s an d Schods , t o th e ranta l dwelRn g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t th e occupan t refuse d t o sig n th e confinnatio n o f receipt , i lurthe rcertifytha t i hav e left a cop yo f th e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fb rsignatur s — I certifytha t I have mad e a goo d fait h effor t t o deOverth e pamphlet , Fienovate fVgh t Importan t Lea d Hazan i Infonnatto n fa r FiatnlBes , ChB d Ca m pmvider s an d Schools , t o th e ranta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I lifllhe rcertif ytha t I have left a cop yo f th e pamphle t a t th e uni t b yslidin g i t unde rth e door . Cg>tf>-gAi ? Qo>\i>N.Vc>/ N h'l^'di f /A33 Printe d nam e of perso n certifyin g Attempte d deliver y dat e an d tim e » „ lea d pamphle t defiver y 

# .A..J J n,. ^ Signatur e o f perso n certifyin g lea d pamphle t deliver y 

## ^Aio^o ^ x t C^/3 ) Uni t Addres s Not e Regardin g Mailin g Option—A s a n altemativ e t o deliver yi n person , yo u mayman th e lead pamphle t t o th e owne rand/o rtenant . Pamphlet mus t b e maile d a t leas t 7 day s before renovatio n (Documerr t vvit h a certificat e o f rnailin g fio m th e postoflloe) .

# pain t match form: Pain t matchin g form : Propertyaddress : 59a M YYiLrd- k h ^ Apea-^-^^-^-v-H^^'^ ^ color-^"^' " "^"^'^ ^

^"^' ^ Explanation : Arpa-^-"^-.^^'^-^^"^^'^' ' color-^'^^ ^

^^" ^ " Explanation : Area : Color : Explanation : Area : color : Explanation : Area : * color : Explanation :

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### TrOc-^e,^-V J0^_j^^^5f ^ 0ja-A'^C--<t . l\}t>^Ae=r innp://aouglasne.m|pping-online.coin/DouglasCoNe/static/accountinfo. . ;.n^ ] Dougla s County , Nebrask a Propeit yRecor d - R180285000 0 Prin t Repor t NE W Feature- F>arce l Dimension s availabl e @ scal e 0-5 0 f t vi«s t o f 90t h S t - Vle W O n Ma p Infonnatio n i s vali d a s o f 2008-11- 5 Treasurer' s Ta xRepor t Ne wFeatur e ->->- > Aut o Sale s Searc h Owne r IVIARIO N JAVAND S ETA L 322 4 MYRTL E AV E OI\/IAHAN E 68131-000 0 Propert yInformatio n Ke yNumber : Accoun t Type : Parce l Number : 028 5 000 0 1 8 Residentia l 180285000 0 Parce l Address : 322 4 MYRTL E A V OMAH AN E 68131-000 0 Lega l Description : MONTCLAI R AD D LO T 7 9 BLOC K0 47. 5 X 12 0 [ Valu e Informatio n 200 8 200 7 200 6 200 5 200 4 200 3 Lan d $2,500.0 0 $2,500.0 0 $2,500.0 0 $2,500.0 0 $2,500.0 0 $2,500.0 0 Improvemen t $72,200.0 0 $72,200.0 0 $72,200.0 0 $72,200.0 0 $33,100.0 0 $33,100.0 0 Tota l $74,700.0 0 $74,700.0 0 $74,700.0 0 $74,700.0 0 $35,600.0 0 $35,600.0 0 Lan d Informatio n Acre s 0.1 3 S F 5760. 0 Unit s 1. 0 Dept h 120. 0 Widti i 48. 0 Vacan t N o Improvemen t Informatio n Buildin g 1

11/13/200 8 11:4 5 AlV I lo f 3,..» - _.—... , . 1 A.WWWM11I . J.11AV/1111U.L1U1 I nttp://ciouglasne.nj|Dping-online.coni/DouglasCoNe/static/accountinfo. , ;.n^ l 2 1/ 2 Stor yUnfi n 322 4 Myrtl e A v i ' i M. I i L . -?s \ • ^
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Buil t Aa :

HVAC : Exterior : Interior : Roo f Cover :

Roo f Type : Floorcover : Yea rBuil t 191 5 Detai l Typ e Ad d O n Applianc e Basemen t Fixtur e Fixtur e Garag e Porc h Porc h 1780. 0 0. 0 2 1/ 2 Stor yUnf m Centra l Ai rt o Ai r Fram e Sidin g Drywal l Compositio n Shingl e Hi p Allowanc e Yea r Percen t Remodele d Remodele d 0 0 % Detai l Descriptio n Unfinishe d Atti cW/floo r Allowanc e Bsmn t Bloc k 8 f t Bas e Fixture s Bat h Ful l Detache d Sla b Roo f Cei l Woo d Dec k Percen t Complete : Quality : Condition : Cond o Squar e Footage : Rooms :

Units : Baths : Bedrooms : Stories : Foundation : Sprinkle rSquar e Footage : Adjuste d Yea r 100.0 % Averag e Averag e 0. 0 8. 0 1. 0 2. 0 4. 0 2. 5 Bloc k 0. 0 Physica l Ag e Buil t 191 5 9 3 Unit s 817. 0 1. 0 812. 0 1. 0 2. 0 240. 0 178. 0

84. 0

11/13/200 8 11.4 5 AM 3 of :

# RUD E

Pruden t PropertyClose-Ou t For m (Lead-Base d Pain t Stabilization ) SAID : S^Sli'- t j j Propert yAddress : ^.^< 7 /Acjji.fi^ , fHl h Owner' s Name : ^'\}^kA < l/Zlfilldh) 

## Performance Standards/close-Ou t Criteri a YES 

### N O Wa s th e entir e structure(s ) painte d wit h th e exceptio n ofth e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 

# i X 3 7 2 .Wa s al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 .Wer e al l require d area s ofth e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 .Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? ^ 5 .

Ar e al i o f th e area s where contaminate d material s hav e bee n spiiie d ^ thoroughl yvacuumed/ cleaned ? 6 .

Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chips o n th e entir e property , roacways , alleyways , publi cacces s area s an d also remov e an yothe rgenerate d debris ? 7 .

I s th e gras s area tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# 1 7 8 .Ar e al l item s such a s poiyethyien e sheeting , iadders , pain t brushes , cones , barrie rtap e etc . 

### t / properl yremoved ? 9 .i s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropertydamag e 

## y needs t o b e complete d prio rt o th e EP AClose-Out . 10 .Ar e ther e anypropertyitem s tha t wer e temporatii yre-locate d b yth e contracto r !> ' tha t need t o be move d back ? 11 . Ar e ther e an y(known ) lingerin g issues wit h th e propertyowner(s ) tha t hav e bee n lef t unresolved ? 

## U ' Othe rConsiderations?propert yOwne rDiscussions?Additiona l Wor k tha t i s Require d 

## Pruden t Representative Signature :

• ,//<V-T— ^ 

# Dat e /P'/^'^J ' . / / ^

/],./ . PropertyOwne rSignature : /UJ^ir^^^yir^ ^

^ / Date : /^-/^-^^ ^