TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 17990 Date: 10/03/2008 

Address: 2205 Hanscom Blvd 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of property (DVD) 

0 Executive Summary 

M Signed Access Agreement for subject property 

[y Painting Agreement 

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

D Photographs 

0 Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

\ ^ Property information from Douglas County Assessor's Office 

D 

D 

D 

Signature 7 Date 

40309853 IWI 

Superfund 
PROPERTY SUMMARY 

1 Date: 10/30/08 | LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: October 

1 Property Address: 2205 Hanscom 

SAID: 17990 | 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: Did not paint east side upper/2'"' floor window franies,was painted before did 

not paint inside porcii floor-painted only painted west upper second floor window frame. 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Information: None 

Access Date: 10/03/08 

Work Began Date: 10/10/08 

Closeout Date: 10/30/08 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TEGHNOLOCIES, INC. 
PROPERTY SUMMARY O- Date; IQl^jf] ^ \ LBP STABILIZATION EPA CONTRAT EPJt7.08-07 | Month of. j^/t t 

PropertyAddrew; "^^Of^ /j£/n.<,Cam f^l\/J I 

A. EXECUTIVE SUMMARY 

Al bsMsEBcoimtered: bid t^f^cuyit Sa6:(' SUfJ Ufpir Id-M^oOT 0UiU<nO ^^Um^S 

iV^pM ^ b^r e - di^n ^ p ^ „„^ ^ r; ^ ^1^ ^ ^ p^^^^xU ^ 

-r^uf^^^^^e ^ 

A2 bsnei Resolved: 

A.3 UniqaeHlndfaigii: 

122A.4 Otiier Rdevant Information: 

FrHMfunrice i« ^ 
ENVIRONMENTAL A 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: ^^^o ^ HoM^Ca m Bb^^ ^ /^/d/Or ^ 

BVID: |^<^9 0 pho^: 3 a u -1'DUO 

Plant & Pennanent L>»nHHcapinp; To Remain Tn Place 

Itein# 

Desmption and Location < i t J^ 

On Map 

Pre-Existing Condition of Structures 

v ^ Does your Basement have a history of leaking? Yes — No ' ^ 

Item# Description & Location 

On Map 

I Ctach-^ in CoAcre ^ ^a^^^a { Gartxce 

Property Owner Prudent Employee 

Signature; Signature: 

8080 Ward Parkway. Siita 406 

Kansas City. MO 64114 

2S05 N. 24*^ StraM, Suita 308 

Omaha, Nebraska 68110 

4242 Madical DrIva, Suita 4260 

San Antonio, TX 78229 

Phone: (818) 363^703 Phone: (402)604-1004 Phona: /2101822.8888 
n^'^d 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. 

Environmental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a number ofproperties 

located in Omaha, Nebraska, including the property located at P-'^O.f^ ^lOsrtrzm ^\^c J . 

The EPA requests your permission to allow Prudent to perform LBP Stabilization at this property. By 

signing this form, the property owner grants permission to Prudent to perform activities related to LBP 

Stabilization including scraping paint and painting ofthe referenced property. Further, the owner/tenant 

verifies that they have received tiie LBP pamphlet "Renovate Right." 

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

Administrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (402) 504-1004. General questions about the Omaha Lead Site cleanup can be directed to the EPA 

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

office). 

Propeity Access Granted 

(Please Print Name) 

/a^y.^<?- ^ Property Owner Signature: ic ^fi-fT^^t-^ 

^ A 

(Signature) (Date) 

PROPERTY INFORMATION 

(To be completed by reiident and/or property owner - pleaae print) 

RESIDENT NAME: 7^fl<?mr^< ^ , /le^/^aAiti ^ ^ ' Renter 

RESIDENT ADDI^ESS: 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'SMAIUNOADDRESS; 790S Mtdsa^ ^JO^A I 

OWNER'S TEl£PHONE NUMBER-HOME: (V^ ^ \ S^Ce'^fSJd ^ WORK: J L 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD:. . NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER:. a 

NUMBER OFCHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

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

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement are punuant to Section 104 

of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property isprovided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entry 

for "determining the needfor response, or choosing ortaldng any response action under diis title, or otherwise enforcing 0te provisions ofthe title." 

i080 Ward Partovay, Suite 405 2505 N. 24** Street, Suite 308 4242 Medical Drive, Suits 4250 -.ansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 76229 

'hone: (816) 363.3703 Phone: (402)504-1004 
Current Sample Pre-Renovation Form 

Effecthre until April 2010. 

Confirmaftion of Receipt of Lead Pamphlet 

Q I have receivecl a copy of the pamphlet, Renovate Right: Important Lead Hazard 

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

the potentiai risk of the lead hazard exposure from renovation activity to be 

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

Printed rigmgp of recipient ' / Date 

}\ :7h.r>^'r^^ 4 - \Aef^ iM fi ^'^C , Signature of recipient 

Seif-Certlficatioji Ojstlon (for tenant-occupied dwellings onl ^ — 

If the lead pamphlet was delivered but a tenant signature was not otitainabie, 

you may check the appropriate box below. 

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

pamphlet, F^enoMats FVght: Important ijaed Hazard Information for FamSes, 

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

date and time indicated and that the occuf)ant 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. 

Q Unavailable for signature — I certify that I have made a good faith effort to 

delivBT the pamphlet, Fienovate FVght: Important Lead Hasird infonnation for 

families. Child Care providers and Schools, to the rental 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/^ _ --7 

Printed name of person certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of persOTi ceriif^ng lead pamphlet delivery • i 

Unit Address 

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

may maii the lead pamphlet to the ovmer and/or tenant. Pamphlet nuist be mailed 

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

post office). 
pai.t TM«h ^ ^^iJ: Z 

Paint matching form: . — ^i j Property address: ^^2^5^//^^^ ^ -^/'^ 

BVID: / 7 99 0 

Area: Color: ^^ ^ '^^'^^ 

Explanation: / 

Area: tSlor: ^^^^^^ ^,,^ w 

Expl anati on: 5? - 5 y- <- /'^^ ^ 

Area: /^^^^ ^- ^ Color: ^ ^ ^^^^ ^ 

Explanation: / ^ ^a.//^^ 

AJ^ea: ^^// ^ /^.^/.ce color: 

Explanation: 

Area: color: 

Explanation: 

; ^ ^ ^g^^'^-^. ^ 

Page 1 
ngTi i 

ACt^SS MFO (^HATioNTRA 0KM6 SHEET 

^ ^ g-ag>r/V^^.c^^ /-U pm /rm^ 

pRI|l^fOMWlQft 7^'ncc^, /v^ l/^/^anak. 

C* i t 

pT^^^V^^P ^^^H^HW^^^^ F 

DRie I tME I toeasor CoOncrOETML 

W^A/-^ 

/ /^^ f ^^y^f 2 ^ })A^ '/)c^i)i^ . 

: 

m 
Douglas County Account Ij^rmatio L^ n Page 1 of2 r 

Douglas County, Nebraska Property Record - R2403030000 

Print Report 

NEW Feature - Parcel Dimensions avaiiabie @ scale 0-50 ft west of 90th St - Vie.W..P,n....lVl3P. Information is valid as of 2008-9-4 Treasurer's Tax Report 

New Feature -*->- * Auto Sales Search 

Owner 

HERMANEK THOMAS A 

ETAL 

2205 HANSCOf\/l BLVD 

OMAHANE 68105-0000 

Property Informatio n 

Key Number: 0303 0000 24 

Account Type: Residential 

Parcel Number: 2403030000 

Parcel Address: 

Legal Description: 

2205 HANSCOM BD 

OMAHANE 68105-0000 

VIRGINIA PLACE LOT 15 BLOCK 1 50 X 120 

Value Informatio n 

2008 

2007 

2006 

2005 

2004 

2003 

Land 

$6,300.00 

$6,300.00 

$6,300.00 

$6,300.00 

$6,300.00 

$6,300.00 

improvement 

$107,000.00 

$107,000.00 

$82,000.00 

$82,000.00 

$82,000.00 

$60,500.00 

Total 

$113,300.00 

$113,300.00 

$88,300.00 

$88,300.00 

$88,300.00 

$66,800.00 

Land Informatio n 

Acres 

0.13 

SF 

6000.0 

Unita 

1.0 

Depth 

120.0 

Widtii 

50.0 

Vacant 

No 

Improvemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/Doiiffla<?rr>Mp/otQtiVA or*/^'^^'"' .+;_r_ 
Douglas County Accounti^ormation Page 2 of2 go 

784.0 F T 

i t a 

1,1 

• 19* . . . , .w 1 

i6» j^),;­

i t f 

'J »« Rrst HOOT I ^,f Setfldd Flaw 

U - ! TM.OFP .„ aeso^n tl ft ^" 

u iS(r 

10 (f 

v l f 

qUCK TO ENLARGE IMAGE 


CUCK TO ENLARGE IMAGE 


Square Footage: 1592.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality; Average 

Unit Type: Condition: Average 

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

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Frame Vinyl Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 2.0 

Floorcover: Allowance Foundation: 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year YearBuilt Physical Age Remodeled Remodeled Built 

1915 0% 1915 94 

Detail Type Detail Description Unita 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 784.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 304.0 

Porch Slab Roof Ceil 216.0 

Porch Slab Roof Ceil 96.0 

http ://douglasne.mapping-online.com/Dni i ol n CP^MO /C+O*; ^ u, 
b 

,*iit . - o-t. ••-rJ. J •; 

• • V • 

MPI^SI ^ 

ni^i^fciiail i Prtipierty ID Nvmb^r. 

B,.^4iSr\X._/l/i^.,>ja>.», i§>Y 

ferfcrmaii^^^^^^^^ J^j w 

1. Wtt1beeotiiestioBtfin(a)pdiitedwia 

..V<fefe4yj-'t-«-»-Ji-:.«- vw..'i--;1 1 WdlUitcnptiodtKSf^ '<«>e^c<^ia8ai^iiisfif^^ . .,i...^j.,.t,.u.. • ^.-^:^.».».j:.:.l-.^A. . 

1 Wii^ j ^ fepred'oe^of the strucbJoreCs) priced as needed tiid painted vHth^two-^top cbats? X 

4. Wdj^pdntpntductsuSlizedeiqi^ / 

6. Did1lietttiliwtiiJTC0nect^fMinmnaUfiU&^^ diip8"<atfaeaiUft;|>ret>e?^i v/^ 

7. is'^lie<|ii!0 iir^^flat sinroMds tbe 8tra\;tur^ in reasonably ioofd c<>nditi(m? / 

8, Aftjmi^^rodi'i&imiy^la^^ J, ciofliK^tpif :tai^;dfc. i^ ^ . ^ • ­

i.iilBciwid?, ih.*'a-£j^MA^^ - J..:...,. •j^ri^.».::. ..•^^• . .w.. > n:^ ;a^ >:.••,.- 4 .......w &..»:<«::. >^:, 

9. bWtoye<iidaiwqfpr^^ I oratraM^Ahy;^^ 

^ v ^uKcjfVj . .^.. ^ •i^-.v* .^;. . 

10.: AsrtolH^linS ^ Jtens *«* ***** tempcffarily it-iee^fey ttfecefitJSctbr that n«^ to be 

•fflSyedbwk ? _.._, _ . . . .^,, „ .......^ .:..••.;.,". .- :...^. 

iW&rkt^idR@^aii«d 

• .,...-;..>-?-1 - — ..^^—.*...* • ...'..> . • i,>.,-.. . ......tt.'.^^..,j....^-. ~ 

, ^ $'?--"--^-^--'-i -r 

:•: • -nai,..;.--.;^..^Ofe^v^.^....:..:,. 
^EPk 

Jun e 26,200 8 (latcrt r«vlfiOB) 

EPA Property Close^Ont Form (Lead-Based Paint StaMlizatioii) 

Bhckaad Vcatdi Ploparly ID Nutbe n /vvC / 

Performance Standards /Qoge-Oat Criteria 

yw BO 

1» Wiit e oattaDtliaotiira(s) painted wifliftftcncQplioa of 1fa( statedfCSBCi 

ifldpdppitliiwiiBofofl^tf MMcii*^cdfcMlBW8ti>clodfngflHdi,wv'eat all trim, pordMs, box 

beBBi»coluiiHM>ii8ib>aBdoxtcriflf BMnacwoiBBay^ < 

2. Waian$ci!apiiigiiidofliBf pwpawflOBWOikcopiptetedwtiifiKtoril}^ 

^ 

3. WwiBigqulwdawasofthe«lnictnreCi)primedas —i-j |noeaca and painted wifli two top ooais? K 

Al W»tt«pabitpndiietSQtfli2BdeqiiivaleattD830yearprodict^qaaIity7 

3. Andlofdiearaas vAureooataodaatedmateiWslavebeei spilled fl^^ :2 

6. l)idtiiBCoattachircollect/vacuBm all Ming and awapcdiwto drips on tiwentfa 

wad«m»i.tBc!ywp8.wd>lte access awas and also wowve a lyoflw < _ 

7. bDw^nas areatfiat suffuuiids die 8liucuin(8) in leasonabli' good condftion? 

^ 

S. AnsIliteiMtiidi8spofy«%laesheetfng,Iadden,p8imb|rad)e^ i. 9i bteewywJdwiceflfpropcf^dwnBgswMtwssdonolyiliec^tracto Any property tou^ 

needttobe coeariBtad prior to die EPA ClosfrOut ^ 

10. itedi m any pnpof^ items d»t wen tenvKv«riIyie>Iocatc|d by tbecotoraetortto 

moved back? \ 

11. Aiediera any Oawin) lingering issoesviMi die property o«Det(s)diat have been left t^ ^ SC 

Oflier OoosldaatiQns/Ptoperty Owne r Diseusstoos/A^ dhional Work tiiatjs Required 

EPA COR/RflpneealBtive