TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 3>3 '^(^O Date: 

Address: 3>%9 N 17 6 h 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of propert y (DVD): Pre-Stabilizatio n & Post-Stabilization Video s 

u Executive Summar y 

IK Signed Access Agreemen t For m 

IfeK Advance Notice Form 

M Pre-Stabilization Video Agreement Form 

M Access Tracldng Form 

« Property Access Assessment Form 

^ Neighbor Access Agreement Form 

i?^ Paint Match Form 

^ Pre-Stabilization Property Safety Assessment Form 

H Worli-Site Hazards Analysis Checklist 

H Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

H Douglas County Assessor Property information 

Q^ Property Completion Agreement Form Signed by Property Owner 

D Property Close-Out Check List Signed By EPA 

Prudent technologies, Inc. Signature Date 

EPA Signature 4 ^ 

30055129 i 

Superfund 
TECHNOiLOGIBS, INC 

Property Summary 

Date: H/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov 

Property Address: 3909 N 17 St. SAID #: 33560 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 9/23/2009 

ii. Work Began: 10/08/2009 

iii. Close-Out Date: 10/15/2009 

B. Enclosures; 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Advance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracking Form 

7. Property Access Assessment Form 

8. Neighbor Access Agreement Form 

9. Property Paint Match Form 

10. Pre-Stabilization Property Safety Assessment Form 

11. Work-Site Hazards Analysis Checklist 

12. Pre- Stabilization Property Hazard Assessment Photographs 

13. Douglas County Assessor Property Information 

14. Signed Property Completion Agreement Form 

15. Property Close-Out Check List Signed By EPA 
PAGE 01/B5 

09/23/200 9 19:3 5 40259U.079 

Prudent Teclwologiea, Inc. CPrndent) is under contract (Contract ^ EP-R7-08-07) with fh« U. S. Environmental Protection 

Agenc> (EPA) to stabilize Lead Based Paint (LBP) at a number ofproperties located in Omaha, Nebraska, including the 

property located at_^<^<g> ^ j ^ f-f ^ '^ ^ 

The EPA requests your permission, ro allow Prudent to perlbrm LBP Stabilization at this property. By signing ttils fonn, the 

property owner grants permission to Prudent (o perform acHvittes related to LBP Stabilization including scraping paint and 

painting of the referenced property. Further, tiie owner/tenant verifies that they have received dw LBP pamphlet "Renovate 

Righl." 

By signing this doeuinent I agree to allow an EPA contractor to conduct a $oil cleanup at my property foilowing completion of 

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

cannot provide assurances of which contractor will be bound to the soil cleanup. I ftjither understand that the soil cleanup 

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

cleanup at my property, 

f^i^Yes. I have read and understand the paragraph above. 

A 

Date 

Ifyou have any questions about the LBP stabilization planned for your property, please contact Prudent's Customer 

Relatjons/Office Manaper for the Lead Based Paint Stabilization, Mrs . Sliannon Holt, at (402) 504-1004 or (401W12-0223. 

General questions about the Omaha Lead Site cleanup can be directed to the EPA Public Infbrmation Centers at (402) 73 T* 

3045 (South Omaha offlce) or (402) 991-9583 (Nonh Omaha ofTice). 

Property Access Granted By: 

g^m^,-^ TJn Lsort 

(Please Print Name) 

Property Owner Signature: V'^JT^?'^^"^'^'^^^''^^^'*'* ^ 

<:=^/^/^? 

(Date) 

tOSO W9ni Parkway. Suits 408 2905 N. 24"' Street, Suite 308 4242 Mtdlcal Ortva, Suitr 4258 

(ansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

>hon«: (816) iiMIt i 

:8x: ($19) 363-3707 

Phon*: (402)904-1004 

Fax: (402)804-100$ 

Phone: (210)822-9888 

Pax: (210) 579-8S77 
PAGE 02/05 09/23/2009 19:35 402591^7 i ^ l 9 

inswiNc. 

PROPERTY INFORMATION rwurer^ i T II 

^ ^ (To be eomfietSi by re<iidtnt and and/o' 

r property owner^^^jilaaaLCrint) 

RESIDENT NAIME: /owne r ^ Renter 

RESIDENT ADDRESS:^ <r. 

IF RENTAL. PROPERTV OWNED BY: 

OWNER'S MAIUNG ADDRESS: 

OWNER'S TELEPHONE NUMBER-HOME: {^/y2)^j^'7(0^^t / WORK: _J 1. 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: TL? NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHOM PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

U o 0<'^<f 

AUTIKJRITY FOR KNVIRONMENTAL RKSPONSE ACIIONS: The uciivitics to be implemenied by EPA under this Hgreem«nt wc 

pursuant to Scaion KM ofCERCJ-A. 42 U.S C. 960*. liPA'* nglu ofaccess to the propeny l.( pr(>vidcd for in Section 104(c) ot'CF.RCl.A. 

42 (J.S. C 9605(c). which provides entry for "detemiining the need for response, or choosing or taking any r0.^ponse action under this title, or 

oihcrwiK enforcing the provisions ofthe title." 

(060 Word Pirkway, Suite 408 2S0S N. 24" &tre«l. SuHe M8 4242 MMilcal Drtv0, Sutto 4280 

Kanaaa City. IMO 84114 Omaiia. Nebra«k« 08110 San Antonio. TX 78229 

PhonK (816) 363>3703 Phone: (402)804.1004 Ptione: (210)822-8888 

.Cflx: (818) 363-3707 Fax: (4021 504.10QS 
09/23/2009 19:35 40259M079 ^ P^GE 03/05 i9M0 

nCHNQLOGns, INC. 

Advanced notice needed. 

After signing the access you allow Prudent to begin Lead Based 

Paint StabiUzation. All Plants, weeds and any vehicles or items on 

open porch (enclosed porches will NOT be stabilized) must be 

removed prior to stabilization. All Pets must be out of yard during 

stabilization. How much notice do you need to have above 

mentioned tasks completed? Ifyou are a landlord you will need to 

contact the tenant as Prudent Technologies will only inform you. 

Do you have any pets that reside in yard? N O 

Notice needed: 3 P^/ ^ f^'<^^ ^ ^ 

Number to call to give notice: ^OZ PoP " oyv / 

Whom we are giving notice to: ^ C 'Sohnsa ^ C:>C^A^&\ 

Home Owner^s Signature 

8080 Ward Parkway. Suite 40S 2505 N. 24'" Slrast. Suite 308 4242 Medical Drive. Suite 42S0 

Kansas City. MO 64114 Omaha, Nebraska 68110 San Antonio. TX 7t220 

Plione: (816) 363*3703 Phone: (402) 804>1004 Phone: (210)B22'9U8 

Pax; (816)363-3707 Pax: (402)904-1009 Fax: (210) S79-6577 
^ PftGE 04/05 

09/23/2009 19:35 40259^7 9 

m 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABIUZATION VIDEO AT MY PROPERTY, 

THE VIDEO IS JUST A TOOL USED TO DOCUMENT THE CURRENT 

PROPERTY STATUS/CONDITION. A POST VIDEO WILL ALSO BE 

SHOT PRIOR TO COMPLETION OF STABILIZATION. 

OWNERS NAME: "^^rfxtS "I^Us^ " 

3^0 ^ K 17^ St^ 0^\^<^, ^ ^ PROPERTY ADDRESS:

BVID/SAID: 53 5 6^ 

HOMEOWNERS SIGNATURE: < 

PRUDENT REPRESENTATIV *JTATIVEE SI SIGNATURE G : Q |\ o ^ C<L S ^ C k « <" 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

Pn^­

8080 Waf«l Parkway, Suite 408 2505 N. 24*" Straai Suite 308 4242 Medical Drive, Suits 4260 

Kanaas City, MO 64114 Omaha, Nebraaka 68110 San Antonio. TX 78228 

Phona: (816) 363-3703 Phent; (402) 804-10O4 Phone: (210) 822-8588 

Fax; (816) 363-3707 Fax; (402)604*1008 Fax: (210) 67»-6877 
TECHNOLOGIBS^] 

;su. 

ACCESS INFORMATION TRACKING SHEET 

* ^ l 

BVID: 5>3>S)^ ^ PROPERTY ADDRESS: S^<^ ^ /O' ' 

Property Owned By: 

(If new property owner) 

Owners Phone No's: Home: - Work: 

Cell: -— Fax: — 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

IMh ^ 

iu^^. ^ ^1%^f-»--Tj ' ' f f J 

Comments: 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omalia, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax:(210)579-6577 
TECHNOLOGIES.] 

Access Assessment Form: (Must be completed for every property. 

Information must be obtained from a property walk thru, not given 

by owner) 

Is the property stucco or asbestos? 

If yes, is any of the stucco or asbestos damaged or cracked? 

If yes, stop as we can't stabilize this property. It requires special preparation 

techniques. It will be returned to EPA and they will assign at a later date. 

-\y O 

Does this property require lots of scrapping? 

Does this property require a lift or scaffolding to reach upper levels? 

Does this property have lots of plants or items in areas where painting is 

required? 

yes. 

Does this property have any significant structural damage? 

If yes, EXPLAIN? 

8080 Ward Parkway, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES, INC 

Does this property have a garage? 

VO 

If yes, describe location of garage. 

Does this property have aluminum siding? 

If yes, is it original factory finish or has it been painted over? 

A/ 0 

Does this property have any other type of structural components? (I.e. roof 

shingles as siding)? 

A / 0 

If yes, EXPLAIN? 

Is this property vacant or(occupied? 

Are there any pets at this property? 

rJ€) 

Are there any low hanging power lines? 

8080 Ward Parkway, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9688 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 679.8677 
OOLOGIES. INC. 

2. TO BE FILLED OUT ONLY IF CH.ANGINC; COLOR 

PROPERTY ADDRESS: ?.^0 ^ H 1 1 S^ " 

BVID: 33 5 ^ Q 

Paint Paint Location Paint Description 

Yes No 

Siding .'ser/ou/s &rgLy S IA/ - (^1,S^ S^k^ X 

SolTit SW - 6:^SC'- fVihV^ p;n'.<.Vi X 

Fascia 

•Si^- 6^5 ^ "-^ft n x

Comer Trim SW - 6^54- ^ ^G^ln X 

Window Trims S<i^' 

InVroro r?[g>r |g - <:.W g-L^ff, r^:n!<t X 

Door Trims S ^Y»^ e. ^ 

Front Porch Ceiling c^l 

C ^ c [OS f<^ X 

Front Porch Ceiling Beams SW G2S£ j - ^\ac t 

Front Porch Floor K J L 

Front Porch Railings ^\ac W SW-6^58-^^. ' 1£1 X 

Front Porch Steps SW6^5 ^ ^.:aKtn ^^/SifN A 

Siding Baseboards KA 

Foundation KU^(«- '^w/ -6>5a-5a^;n X 

RftPcK Lg.}k<:^ f^U/^i^ S^y - ^2-59 - g2i^{n >C 

O.fDlOfl fno(^^^n-Mf^po^hpr)?v-,- 2)\nP^,' f)\0 ' /(9A6 ^ 

r 

I AGREE TO THE COLORS INDICATED ABOVE. I UNDERSTANT THAT I 

CANNOT CHANGE THE SELECTED COLORS LATER ON AS PRUDENT 

WOULD HAVE PURCHASED THE PAINT SPECIFICALLY FOR THE 

REFERENCED PROPERTY. ALSO I UNDERSTAND THAT COLORS SELECTED 

.A N4AY NOT LOOK. EXACTLY AS IT IS SHOWN ON SWATCHES AFTER 4* PAINTING ON MY PROPERTY. .0 i > 

V 

Homeowner signature Date:CP^/2i^/^9 O 

8080 Ward Parkway. Suite 405 I N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio. TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-657" 
TBCHNOLOGIBS. INC 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

8080 Ward Parkway, Suite 405 2505 N. 24*" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
^^^ ^ 

TECHNOU>GIES> INC 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 'b^^ ^ ^ ) n S,T 

BVID/SAID: ^^&6 0 

PRUDENT ASSESSMENT REPERSENTATIVE: 

^_ J A^(^\ ^ 

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.) 

8080 Ward Parkway, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
• ^ 

TECHNOLOGIES.] 

Checklist for the Worksite Hazard Analysis 

Address: v3^o? A/, p" ^ ^ 

Crew: Date: 

Item Corrective Action 

Overhead Lines \c^aAM^'^^^J)i^t<A^ 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines lE^poS^ J J.)l^f^KQ^ U^i/Y-^ 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required 

High Traffic Area 

Garage 

Structures 

Driveway 

Sidewalk cjx^^- ^ 

Foundation 

Retainingff. wall Wallss 

i'cncei^ 

Trees S 

'JCU^ ;jiX^V^o^ 

General Condition of yard 

Damaged Areas: sink -i^^fepi^^^ . holes/rotted wood A^iv^rfri:.^g^(l^ 

Sprinkler System td- Pets 

Insects \)HLji^ ^e>i5e ^ .^jtJ^f ^ ^yc>Y4~ ^ 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhooi 

^"^S^l^u^ actor 

8080 V9ar9 Parkj^fTSulte 405 2505 N. 24'" Street, Suite 308 424e Medical Drive, Suite 4250 

Kansas CityJ|(J064114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816)^63-3703 Phone: (402)504-1004 Phojie: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 ax: (210) 579-6577 

^ 
Inc. (Prudent; if under coarrac. 

rfze t-cad Based P2 - '' 9P) at a 

permission ro allow Prudent tr pcrta 


PAGE 85/85 


09/23/2009 19:35 4025 9^79 


Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

y£ I have received a copy of the pamphlet, Renovate Right: important Lead Hazard 

Information for Families, Child Care Providers and Schools informing me of 

the potential risk of i:he lead hazard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the work began. 

TTOSQ^JS a . J<?.hr>'S S^O- <39'/^j/'^9 

Printed name of recipient Date 

Self-Certffioation Option (for tenant-occupied dwellings only) — 

If the lead pamphlet was delivered but a tenant signaiure was not obtainable, 

you may check the appropriate box below. 

Q Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet. Renovate Right: Imporiant Lead Hazard Information for Families. 

Child Care Providers and Schools, to the rental dwelling unit listed below at the 

date and tin^ indicated and that the occupant refused to sign the confirmation 

of receipt. I further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

'^|/^navailable for signature — l certify that l have made a good faith effort to 

deliver the pamphlet. Renovate Right: Important Lead Hazard Information for 

Families. ChUd Care providers and Schools, to the n&ntal dwelling unit listed 

below and that the occupant was unavailable to sign the confirmation of receipt. 

I further certify that I have left a copy of the pamphlet at the unit by sliding it 

under the doon 

dc^ocf­ i[AUl( f6Vs­ -^/^3/ '« T 

Printed name of person certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person certifying lead pamphlet delivery 

Unit Address 

Note Regarding Mailing Option — As an alternative to delivery in person, you 

may mail the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

at least. 7 days before renovation (Document with a certificate of mailing fnjm the 

post office). 
Douglas County Account Information Page 3 of3 

Year Built 

1910 

Detail Type 

Add On 

Appliance 

Basement 

Fixture 

Fixture 

Garage 

Porch 

Porch 

Year 

Remodeled 

0 

Percent 

Remodeled 

0% 

Detail Description 

Fence Chain Link 

Allowance 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

Detached 

End Screen 

End Screen 

Adjusted Year Physical Age Built 

1910 99 

Units 

1.0 

1.0 

958.0 

1.0 

1.0 

324.0 

147.0 

25.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R0701660000 9/16/2009 
Douglas County Account Information Page 2 of3 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1999-04-06 

Deed Type: Book: 2127 Page: 427 

Price: $10,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6400.0 1.0 160.0 40.0 No 

Improvemen t Informatio n 

Building 1 

3«Q»N1T$T second rloflf 

SKOMl t i i »!>•"» i» 

I2ff 

I I I 

FintFbar i r 

t57.S«q.t. l-U 

i r 

« 

11» 

llff 

1 1/2 STORY '» 

SinMModitll 

K7J5*«.a. 

CLICK CLICK TO ENLARGE IMAGE TO ENLARGE IMAGE 

Square Footage: 1474.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

Built As: 1 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 7.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Hip/Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

http://douglasne.mapping-onIine.com/DouglasCoNe/static/accountinfo.jsp?accountno=R0701660000 9/16/2009 
Douglas Coimty Accoimt Infomiation Page 1 of3 

Douglas County, Nebraska Property Record - R0701660000 

Print Reoort 

NEW Feature - Parcel Dimensions available ® scale 0-50 ft west of 52nd St - Vie w OO Ma p Infonnation is valid as of 2009-9-15 Treasurer's Tax Reoort 

New Feature «!4i 'r¥ ^ Auto Sales Search 

Owner 

JOHNSON JMAES C 

ETAL 

3909 N 17 ST 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number 0166 0000 07 

Account Type: Residential 

Parcel Number 0701660000 

Parcel Address: 3909 N 17 ST 

OIUIAHANE 68110-0000 

Legal Description: BOULEVARD PARK ADD LOT 12 BLOCK 9 N 40 FT 40 X 160 

Value Informatio n 

Land Improvement Total 

2009 

2008 

2007 

2006 

2005 

2004 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

$7,000.00 

$33,300.00 

$32,000.00 

$32,000.00 

$28,000.00 

$10,300.00 

$9,300.00 

$40,300.00 

$39,000.00 

$39,000.00 

$35,000.00 

$17,300.00 

$16,300.00 

Sales Informatio n 

Sales Date: 2007-01-12 

Deed Type: WD Book: 2007 Page: 006292 

Price: $39,000.00 

Grantor. HOUGHTON DEWEY E ETAL 

Grantee: JOHNSON JAMES C ETAL 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1999-09-24 

Deed Type: D Book: 2135 Page: 357 

Price: $12,000.00 

Grantor: 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R0701660000 9/16/2009 
Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: 335-^ 0 

Property Address: 3^0^ H f?'"' 5| ­

Owner's Name: sjouma^ woii«-6^<'>-> 

S.NO 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

Performance Standards/ciose-Out Criteria 

Was the entire 8tructure(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. 

Was all scraping and other preparation work completed 

satisfactorily? 

Were ail required areas of the structure(s) primed as needed and 

painted with two top coats? 

Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

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 debris? 

Is the grass area that surrounds the structure(s) in reasonably good 

condition? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

Are all items such as polyethylene sheeting, ladders, paint brushes, 

cones, barrier tape etc properiy removed? 

Is there any evidence of property damage that was done by the 

contractor? Any property damage needs to be completed prior to 

the EPA Close-Out 

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

contractor that need to be moved back? 

Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? 

Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Yes 

/ 

< . 

r^ 

y

/ 

/ 

/ 

t / 

/

1 / 

NO 

( / 

/ 

i 

1 

Prudent Representative Signature: 

Date: 

Property Owner Signature: 

Date: 

8080 Ward Parkway, Suite 405 2505 N. 24*" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9588 

Fax: (210) 579-6577