TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 315^ 4 Date: ^^ l l^^TjOlJ^ 

Address: ^^\ ^ N1 . \/O ^ ^ ^ 

Stabilization Contractor: Professional Environmental Engineers Year: 2010_ 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

B"^ Video of property (DVD) 

B Executive Summary 

E^'^^ Signed Access Agreement for subject property 

D Pre-Renovation Form signed by Property Owner 

B^*^^ Pre-Renovation Form for Occupant/Tenant, if applicable 

D ^ Painting Agreement 

D Settlement documents (i.e., for damage or to replace plants, etc.) 

\Er Renovation Recordkeeping Checklist signed by Certified Renovator 

B ^ Photographs A^/v ^ OA A ^pjf ^ 

[fe^ Satisfactory close-out check list signed by Property Owner 

D Property close-out check list signed by EPA 

^ r Property information firom Douglas County Assessor's Office 

D Hazard analysis, if prepared 

0 r::i.^ m S 

Professional Environmental Engineers Signature 

(after file folder review) 
^ PROFESSIONAL 

SCO S.Ewlng, Suite E ENVIRONMENTAL ENGINEERS, INC. St. Louis, MO 63103 

(314)531-0060 • ^ "Providing cost-effective environmental solutions" Fax (314) 531-0068 

Consulting • Engineering Design • Remedialion • Abatement • Emergency Response 

2010 

Property Owner Close-Out Form 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-06) 

SAID: 0\ 0 0 ^ 

Property Address^^^\ ^ \ 0 \C 0 "^ ^ 

Owner's Name: ^\(^^3C\\C K AO . \C X ^O^ ^ 

Performance Standards/Close-Out Criteria YES NO 

1. Was the entire structure(s) painted with the exception of the stated, excluded areas? This 

would include painting of other associated features including fascia, eaves, siding, all trim, 

porches, box beams, columns, rails, and exterior surfaces of garages. X 

2.

3. Wer

 Was

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 al

 al

l scrapin

l require

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d

 an

 area

d othe

s of

r

 th

 preparatio

e structure(s

n wor

) prime

k complete

d as neede

d satisfactorily

d and painte

? 

d with two top 

X

coats? y. 

4. Was the paint products utilized equivalent to a 25 year product/quality? 

5. Are all of the areas where contaminated materials have been spilled thoroughly 

vacuumed/ cleaned? X 

6. Did the contractor collect/vacuum all falling and scraped paint chips on the entire 

property, roadways, alleyways, public access areas and also remove any other generated X 

debris? 

7. Is the grass area that surrounds the structure(s) in reasonably good condition? X 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, 

etc. properly removed? X 

9. Is there any evidence ofproperty damage that was done by the contractor? Any property 

damage needs to be completed prior to the EPA Close-Out. 

10. Are you satisfied with the work performed? 

11. Are there any property items that were temporarily re-located by the contractor that 

need to be moved back? 

12. Are there any (knovm) lingering issues with the property owner(s) that have been left 

imresolved? 

Other Considerations/Property Owner Discussions/Additional Work that is Required: 

^\^m\)

Propert ipertyy Owne Ownerr Signatur Si^iatur e Date 

Professional Environmenml-Engineers Signature Date 
2505 North 24'^, Suite 219 

Omaha, NE 68110 

(402) 504-4688 

Fax (402) 504-3281 

PROFESSIONAL 

ENVIRONMENTAL ENGINEERS, INC. 

"Providing cost-effective environmental solutions" 

Consulting • Engineering Design • Remediation • Abatement • Emergency ResfTonse 

Lead Base Stabilization Omaha, Ne 

Close Out Report 

2010 

SAID# 31354 

3315 N. 16 St 

• Dates worked: 04/14/10 to 04/16/10 

• Pre property condition: House has wood siding with paint in very poor condition. Paint 

was flaking off all over. House has broken window in the back. 

• Problems encountered: None 

• Owner request/concerns: Color changes. 

• Inspection/closeout dates. Owner signed 04/20/10, inspected by PE project manager. 
EPA Paint Stabilization 2010 

SAID# S1SS4 

Property Address 3315 K1. II# ^ c5{red" 

Stories 2-

Garage? KS 

Access signed 4-\^-^0\6 

Pre-video 4-/5'ZO/0 

Post video 4-2i-2oto 

Contractor Assigned y\ L j l&CV/ ^CQSi 

Date started m^iio 

Weather/temp I D ^ 

Date ended 

Paint used XQ(y\ rn^ffi ?)(y\ OiA(^ 

Prime used 

Poiy used itoL 

Problems/Issues 
CONS]J^r FOR ACCESS TO PROWRT m] Y 

OMAHA LEAD SITE REMEDIAL ACTION - LEAD-BASED PAINT STABILIZATION 

PROPERTY ID 3fi^j \ PROPERTY ADDRESS; "btSx P W \ 0 trS\' 

OWNERNAME E : i , ^rp DAYTIME PHONE;>b\'Z'' 0\?) 0 

CELL PHONE: E-MAIL: 

OWNER'S ADDRESS IF DIFFERENT: 

TENANT'S NAME IF APPUCABLE: 

DAYTIME PHONE: 

CELLPHONE: E-MAIL: 

Professional Environmental Engineers, Inc. (PE) is under contract (#EP-R7-08-06) with the U.S. Environmental Protection 

Agency (EPA) to stabilize lead based paint (LBP) on residential structures at a number of properties located in Omaha, 

Nebraska. The paint stabilization work is being done to protect the soil cleanups that are being performed by EPA contractors. 

Paint stabilization activities will include: scraping of cracked or flaldng LBP from structures, application of a prime coat and two 

(2) coats of paint. Moving parts of windows and doors are not included and will not be addressed. 

Your cooperation is requested in giving permission to this EPA contractor (PE) to enter and havie access to this property for the 

purpose of stabilizing lead -based paint as outlined on the property identified above. 

By signing this document I agree to allow an EPA contractor to conduct a soil cleanup at my property following completion of 

lead-based paint stabilization, if the soil cleanup has not already been performed. I understand that the stabilization contractor 

can not provide assurances that the soil cleanup contractor will be bound to. I further understand that the soil cleanup 

contractor will make all reasonable efforts to address concerns that I, as the property owner, may have regarding soil cleanup at 

my property. 

HYes, I have read and understand the paragraph above. 

• g?acy - Signature of Property Ovmer Date 

I fully understand that by signing this Consent for Access, (1) this access will remain in effect until the work has been 

satisfactorily completed, (2) that the Property Owner or Tenant, if applicable, will be given the Housing and Urban Development 

(HUD) and EPA pamphlet, "Renovate Right, Important Lead Hazard information for Families, Day Care Providers, and 

Schools", (3) the Property Owner or tenant will remove all obstructions from surfaces to be painted, (4) will abide by health and 

safety guidance provided by EPA, (5) will allow photography of property before and after the paint stabilization work, (6) will be 

contacted by a PE representative approximately 48 hours in advance of starting work, (7) agree not to obstruct or tamper with 

any of the LBP stabilization actions, and (8) will participate in final property inspection and sign the Completion Agreement and 

Property Owner Satisfaction Survey. 

Should you have any questions about the planed Lead Based-Paint stabilization activities for your property, please contact 

Professional Environmental Engineers, Inc. Project Manager, Willie Clay At 402-504-4688. General questions about the Omaha 

Lead Site cleanup can be directed to Pauletta France-lsetts, EPA Remedial Project Manager 402-731-2454, or the EPA Public 

Information Centers at 402-991-9583 (North Omaha office) or 402-731-3045 (South Omaha office). 

'^Yes , I grant access to my propeily and was given the pamphlet D No, I do not grant access to my property and I was 

"Renovate Right, Important Lead Information for Families, Child given the pamphlet "Renovate Right, Important Lead 

Care Providers, and Schools." Information for Families, Childe Care Providers, and Schools." 

signature Date Signature Date 

SPECIAL INSTRUCTIONS AND CONSIDERATIONS 
PAINT STABILIZATION PRE-PROPERTY 

PAINT MATCH ASSESSMENT 

PROPERTY ADDRESS :^8\P)V \ln ^-V 

BVID: 

AREA(S) TO BE PAINTED: 

- R. HOUSE PROPER : \\tS , ^ COLOR: .^A. ^oVcr^-u:>W^..?g 

HOUSE TRIM: y f ^ ^9 ^ COLOR: VJ\^1W^ i' S ^ 

GARAGE: Ve^(-^A- .COLOR: (n?^ % ^ H

GARAGE TRIIW: \K^ \ ^ / ^ COLOR: U3h\U>,g^^ 

PORCH: ^J-eV^ 5 /^ COLOR: 


PORCH TRIM: N^^ 5 ^ COLOR: 

(COMPLETE ALL SECTION, YES, NO, OR NON-APPLICABLE) 

I AGREE TO THE COLORS LISTED ABOVE. ONCE THE PAINTING 

BEGINS, I UNDERSTAND I CAN NOT CHANGE THE ABOVE SELECTED COLORS: 

PROPERTY OWNER SIGNATURE: PE ACCESOR SIGNATURE: 

Qj-rrk^ JJP M-­
PRE-^koVATION FORM - OCCU Av T 

This form is to be used by the firms contracted by the Environmental Protection Agency-Region 7 to perform Lead-Based 

Paint stabilization activities at the Omaha Lead Site, Omaha, Nebrasica. 

Occupant Confirmation 

Pamphlet Receipt 

D I have received a copy of the lead hazard information pamphlet, Renovate Right: Importand Lead Hazard Information for 

Families, Child Care Providers and Schools, informing me of the potential risk of the lead hazard exposure fixjm renovation 

activity to be performed in/on my dwelling unit. I received this pamphlet before the work began. 

Occupant Opt-out Acknowledgment 

n(A) I confirm that I own and live in this property, that no child under the age of 6 resides here, that no pregnant woman 

resides here, and that this property is not a child-occupied facility. 

Note: A child resides in the primary residence of his/her custodial parents, legal guardians, foster parents, or 

informal caretaker if the child lives and sleeps most of time at the caretaker's residence. 

Note: A child-occupied facility is a pre-1978 building visited regularly by the same child, under 6 years of age, on at 

least two different days within any week, for at least 3 hours each day, provided that the visits total at least 60 hours 

annually. 

H^B) I understand that the renovation firm, contracted by the Environmental Protection Agency (EPA), will be using leadsafe work practices required by EPA's Renovation, Repair and Painting Rule. 

Printed Name of Occupant 

ignature of Occupant Date 

tenovator's Self-Certification Option (for tenant-occupied dwellings only) 

struction to Renovator: If the lead hazard information pamphlet was delivered to the owner but a tenant signature was not 

sbtainable, you may check the appropriate box below. 

D Declined - 1 certify that I have made a good faith offer to deliver the lead hazard information pamphlet to the rental 

Iwelling unit listed below at the date and time indicated and that the occupant declined to sign the confirmation of receipt. I 

•urther certify that 1 have left a copy of the pamphlet at the unit with the occupant. 

E Unavailable for signature - 1 certify that I have made a good faith effort to deliver the lead hazard information pamphlet 

to the rental dwelling unit listed below and that the occupant was unavailable to sign the confirmation receipt. I further 

certify that 1 have left a copy of the pamphlet at the unit by sliding it under the door or by (fill in how pamphlet was left) 

Printed Name of Person Certifying Delivery Attempted Delivery Time 

Signature of Person Certifying Lead Pamphlet Delivery Date 

Unit Address 
-Douglas County Account Infomiation Page 1 of3 ' ' m [

V 5ibsq 'i 

Douglas County, Nebraska Property Record - R2249090000 

Print ReDort 

NEW Feature - Parcel Dimensions available m scale 0-50 ft west of 52nd St • ViOW OH Ma O Information is valid as of 2010-3-16 Treasurer's Tax Report 

New Feature -•-•- • Auto Sales Search 

Owner 

DE LA ROSA SIDONIA 

1317 S 28 ST 

OMAHA NE 68105-0000 

Property Informatio n 

Key Number 4909 0000 22 • - ~ 

Account Type: Residential 

Parcel Number: 2249090000 

Parcel Address: 3315 N 16 ST 

OMAHA NE 68110-0000 

Legal Description: SULPHUR SPRING LOT 10 BLOCK 2 52.8 X 124 ' 

Value Informatio n 

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

Improvement 

$43,000.00 

$43,000.00 

$46,700.00 

$30,300.00 

$30,300.00 

$4,200.00 

Total 

$45,600.00 

$45,600.00 

$49,300.00 

$32,900.00 

$32,900.00 

$6,800.00 

Sales Informatio n 

Sales Date: 2006-06-06 

Deed Type: 

Price: 

Grantor 

Grantee: 

QC 

$33,000.00 

Peter T Grayson 

Sidonia de la Rosa 

Book: 2006 Page: 063553 

Valid/Invalid: Invalid 

Exclusion Reason: Non Bono with Doc Stamps 

Sales Date: 2004-09-04 

Deed Type: 

Price: 

Grantor: 

CO 

$6,800.00 

Peter T Grayson 

Book: 2004 Page: 118879 

'•'• • 

http://douglasne.mapping-onIine.eom/DouglasCoNe/static/accountinfo.jsp?accountno=R22... 3/29/2010 
Douglas County Account Information Page 3 of 3 

3315 N 16 St 

TWO STORY 

itais 

2Stoiy 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: i 2014.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: ; Fair 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 8.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 2.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1910 2005 0% 1929 81 

Detail Type DefaiV Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 1058.0 

Basement Finished 1058.0 

Basement Outside Entrance 1.0 

Fixture Additional Fixtures 1.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 2.0 

Garage Detached 360.0 

Porch Slab Roof Ceiling 96.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R22... 3/30/2010 
(effective April 2010) 

Name of Firm: MO . ^W\Cg % 

Date and Location of Renovation: ^ 1 l*^ | \ v J 

Brief Description Of Renovation: T) Q \(Wp c4:0i^ ^ i 0!7 . CXA->(Q VA 

Name of Assigned Renovator: ( V^\S>rV-\OvY~\ 

Name(s) of Trained Workers: 

Name of Dust Sampling Technician, Inspector, and/or Risk Assessor, if used: f> \ Q y 

U Copies of renovator and dust sampling technician qualifications (training certificates, certifications) on file. 

' 3-Certified renovator provided training to workers on (check all that apply): 

l>Posting warning signs XlSetting up plastic containment barriers 

Qltlaintaining containment Ds^voidiiig spread of dust to adjacent areas 

^b^aste handling X f ost-renovation cleaning 

H Test kits used by certified renovator to determine whether lead was present on components affected by 

renovation (identify kits used and describe sampling locations and results: Y" ) ^ 

J Warning signs posted at entrance to work area. 

3^Work area contained to prevent spread of dust and debris. 

^ Windows in and within 20 feet of the work area are closed 

^Doors in and within 20 feet of the work areas are closed and sealed 

IDiDoors that must be used in the work area are covered to allow passage but prevent spread ofdust. 

"Rpround covered by plastic sheeting extending 10 feetfirom work area - plastic anchored to the 

building and weighted down by heavy objects. 

^ If necessary, vertical containment installed to prevent migration ofdust and debris to adjacent 

property. 

H Waste contained on-site and while being transported off-site. 

Renovation Recordkeeping Checklist Omatia Lead Site 
(effective April 2010) 

^ ' ork site properly cleaned after renovation. 

D All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for 

removal. 

D Work area HEPA vacuumed to get paint chipsfirom ground surface, if necessary. 

^H Certified renovator performed post-renovation cleaning verification (describe results): 

U I certi& under penalty of law that the above information is true and complete. 

^feoiio 

Name and Title Date 

Renovation Recordkeeping Checklist Omaha Lead Site