### TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID : 3877 5 Date : 12/26/200 8 Address : 244 0 CROW N POIN T Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S [i

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### Vide o o f propert y (DVD ) Executiv e Summary Signe dAcces s Agreemen t fo r subjec t propert y Paintin g Agreemen t Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) Photograph s

Satisfactory restoratio n signe db y Property Owne r Property close-ou t chec k lis t signe db y EP A Property informatio n fromDougla s County Assessor' s Offic e



### Signatur e / • Dat e

4030985 2 

# IlilUii l Superfun dPROPERT Y SUMMAR Y 1 Date : 12/23/0 8 LB P STABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r | 1 Propert y Address : 244 0 CROW N POIN T SAID : 3877 5 

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

A. 3 Uniqu e Findings : None A. 4 Othe r Relevan t Information : None Acces s Date : 11/12/0 8 Wor k Began : 11/13/0 8 Closeou t Date : 11/14/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio n Form 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeout for m 10 . Propert y Completio n Agreemen t

TECHNOLOGIES . INC .ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , mc . SiXnCE S 

# Property Statu s Form Phone : ^ j - ;?^^ ^ BVID : 5g)77 5 Plan t & Permanen t Landscapin g T nRemai nI nPlac e Itesn # Descriptio nan dLocatio n OnM ^

Pre-Existin g Conditio no f Structure s Doe s you r Basemesi t hav e ahistor y o f leaking ? Ye s —N o Item # Descriptio n& Locatio n O nMa p

Propert y Owne r Pruden t Emplo ; Signature : Signature : 

# <inM ^ 260 5 N . 24*^ Street , Suit e S0 8 424 2 Medica l Drive , SuK a426 0 808 0 War dPariamy . i»iit » 40 B Omaha , Nebrask a6811 0 Sa nAntonio , T X 7822 9 KansMCny , M O 8411 4 Phnn« > /MmBMjWB D

# 3fe77 ^

Pruden t Technologies , Inc . (Prudent ) i s und w contrac t (Contrac t #EP-R7-08-07 ) wit hth e U . S . Environmental Protectio n Agenc y (EPA ) t o stabiliz e Lea dBase dPain t (LBP ) a t anumbe r o f prop^e s locate di n Omaha , Nebraska , includin g th e property locate da t o?M^ 0 0 rfN\bT\p>r>Yr\ V Ai/ f Th e EP A request s you r permissio n t o allo w Pruden t t o performLB PStabilizatio n at thraprc^erty . B y signm g tiiis form , tiie propert y owne r grant s permissio n t o Pruden t t o perfor mactivitie s relate dt o LB P Stabilizatio n mcludin g scnq>in g pain t an dpaintin g ofth e reference dproperty . Further , th e owner/tenan t verifie s tha t the y hav e receive dtiie LB P pamphle t "Renovat e Right. " I f

yo u hav e an y question s abou t th e LB P stabilizatio n planne dfo r you r property , pleas e contac t Prudent' s Administrativ e Clerk fo r th e Lea dBase dPain t Stabilization , Mrs . Debora hAkerele^ohnson . at

(402 ) S04-1004 . 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 (Souti i Omah aoffice ) o r (402 ) 991-958 3 (Norti i Omah a office) . (Pleas e Prin t Name ) Propeity Owner Signature ; (Signature ) (Date ) PROPERT Y INFORMATIO N

. (T o b e con^ett db y raldcat aad/orpropcrt y owne r - pleai e print ) RESOENTNAME : W^dty J i f ^ /l/l^^^^ ^ RESIDENT ADDRESS : I F RENTAL . PROPERT Y OWNE D BY : OWNERf S MAIUN G ADDRESS ; OWNERT S TELEPHON E NUMBER-HOME : / >^^ > TS/ ' "^^^"^^yNanK i l \ 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 OLDER : / NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D \WHO PLA Y I N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : ( ^ COMMENT S O R SPECIA L INSTRUCTIONS : (LE . DOGS , ENTR YGATES , ETC. )

AiniroiOT Y FORENVntONMBOTA LRESPONS EACTlOWSiTteactiviCe i t o b e implemente db y EP AnndertMaagreei ^ ofCERCLA.42U.S.C.9604 . EPA' s righ t ofacces s t o th e property Upiovide d for inSectio n104(e ) ofCERCLA . 4 2 U^.C960S(e) , whic hprovide s entr y fiv "determinin g th e nee dfb r response , o r cboosin g ortakin g any lespoo K actio nunde r tin s title , o r otfwiwis e enibiciii g te

«80«tai 4 Parkway . Sidt a40 8 250 6 N . 24" * Straet , Suit e 30 8 424 2 Medica l Drive , Sult a425 0 '.ansa s CHy . M O 6411 4 Omaha , Nebraak a6811 0 Sa nAntonio , TX7822 9 • hone : WIS ) 383470 3 »* • ""• "

# Curren t Sampl e Pre-f^novatio n For m Effectiv e unti l Apri l 2010 . Confirmatk m of Receip t of Lea d Pamphle t Q \}:metecei!^e6 a ccp^cAii\ep3rn(i\\et . Renovat e Rl^t : Importan t Lea d Haza ^ InfmmSo n fo rFamilies , CNI d Car e Provider s an d Schools informin g me of th e potential ris k of th e lea d hazar d exposur e fro m renovation activit y

to be performe d

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mydwrailin g unit . I received thi s pamphle t befor e tt)e wor ^

laegan . int d nam e

of rBci|!>ienl Printe Dat e Signatut B

of recipient Seif-CertiflcatiQ n Optio n (fo rtanant'Occupie d dwelling s only ) — If th e lea d pamphle t wa s delivere d but a tenant signatur e wa s no t obtainable , yo u ma ychec k

th e appropriat e bo xbelow . Q Refusa l to sig n —I certif ytha t I hav e made a goo d Mh effor t to delive rth e pamphlet, flSnovate FVgjhit : Important Lea d Hazar d Infonnatio n fo rFamSes , Cihik yCar e fVoMcfar s an d Sc/xx>l^ , to ttie renta l dvve l dat e and time indicate d an d tha t th e occupan t refuse d to sig n th e confirmation of tec^ . Ifurthe rcertif ytha t I hav e lef t a cop y

of th e pamjrfile t at th e unit vflt h tti e occuisant. Q Unavailabl e fb rsigrtatur a —I certif ythat ! hav e mad e a goo d Mh effor t to deRve rth e pamphlet, flienovaf© FVght - Important Lea d Hazar d infonnatio n fo r FamSes , (M i Car e prcwder s mi d Schools , to th e rental dwellin g unit liste d belo wand tha t th e occupan t wa s unavailabl eto sig n th e confirmation of receipt . I furthe rcertif ytha t I ha^r e teft a cop yer f th e paiTvphte t at th e unit tvslkSn g it underthedoor^ ^ ^^^^ ^

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of perso n certifyin g Attempte d deliver y dateandtim e lea d pamphle t delivef y Signatur e

of perso n certilyin g lea d ranphiet deRver ^

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# i^/ndha . /U>£ - Uni t Addres s Not a Regaidin g Mailin g Optio n —A s an altemativ eto delivet y

in person , yo u ma ymal l th e lea d pamphle t to th e owne rand/o rtenant . Panphle t mus t be maile d at leas t 7 day s befor e renovation (Documen t wit h a certificat e

of mailing fiDm th e pos t office) .

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U/6/200 8 11:24AIV I 2 o f 3111^^ 1 nttp://aouglasne.mappii^^nline.coin/DouglasCoNe/static/accountinfo. . Squar e Footage : Perimete r UnitType :

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HVAC : Exterior : Interior : Roo f Cover :

Roo f Type : Floorcover : YearBuil t 192 3 Detai l Typ e Applianc e Applianc e Basemen t Fixtur e Fixtur e Fixtur e Garag e Porc h 1350. 0 0. 0 1 1/ 2 Stor yFi n Centra l Ai rt o Ai r f>flasonr yCommo n Bricl < Drywal l Compositio n Shingl e Gabl e Allowanc e

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Units : Baths : Bedrooms : Stories : Foundation : Sprinkle rSquar e Footage : Adjuste d Yea r 100.0 % Averag e Fai r 0. 0 7. 0 1. 0 1. 5 5. 0 1. 5 Blocl < 0. 0 Physica l Ag e Buil t 192 3 8 6 Unit a 1. 0 1. 0 840. 0 1. 0 1. 0 1. 0 240. 0 261. 0

11/6/200 8 11:24 AM 5 o f 31 

### Pruder^ t Propert yCiose-Ou t For m (lead-Base d Pain t Stabilization ) SAID : S-?nl ^ PropertyAdd».« . :^446(MJ^ ) ^t.f t M ­ Owner' s Name : /.d6 $ fa/ flM £ 

### Performanc e Standards/close-Ou t Criteri a N O

Wa s th e entir e structure{s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woui d indud e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al ! trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 2 .

Wa s al t scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 .Wer e al l require d areas o f th e 5tructure(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 equivaien t t o a 3 0 yea rproduct/quality ? Are al i ofth e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? _______ ^ Di d th e contracto rcollect/vacuu m al l failin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s areas an d also remove an yothe rgenerate d debris ? I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# a 8 .Ar e ai l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? 9 . I s ther e an yevidence o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e 

# t needs t o b e complete d prio rt o th e EP AClose-Out . 10 . Ar e ther e anypropert yitem s tha t vrere temporatil yre-locate d b yth e contracto r tha t nee d t o b e move d back? 11 . Ar e ther e any(Icnown ) lingerin g issues wit h th e propertyowner(s ) tha t hav e bee n lef t unresolved ? 3the rtonsiderations?property Owne rDiscussions?Addttiona l Wori ctha t i s Require d



## Ctutdi ^ ^ esentativ e Dat e 

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