## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAI D # : 17990 Date : 10/03/200 8 Address : 220 5 HanscomBlvd Remediation Contractor : Pruden t Technologie s Year : 200 8 PAINT STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S ^ Video of propert y (DVD ) 0 Executiv e Summar y M SignedAcces s Agreemen t fo r

subject propert y [ y Painting Agreemen t D Settlemen t documents (i.e. , fo r

damage or to replac e plants , etc. ) D Photograph s 0 Satisfactor y restoratio n signedby Propert y Owne r D Propert y close-out chec k

lis t signedby EP A \ ^ Propert y information fromDougla s Count y Assessor' s Office D D D 

## Signatur e 7 Dat e

4030985 3 

# IW I Superfun d

### PROPERT Y SUMMAR Y 1 Date : 10/30/0 8 | LB PSTABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Octobe r 1 Propert y Address : 220 5 Hansco m SAID : 1799 0 | 

### A . EXECUTIV ESUMMAR Y A. 1Issue s Encountered : Di dno t pain t eas t sid e upper/2'" ' floor windo w franies,wa s painte dbefor e di d no t pain t insid e porci i floor-paintedonly painte dwes t uppe r secondfloor windo w frame . A. 2 Issue s Resolved : None

A. 3Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 10/03/0 8 Wor k Bega n Date : 10/10/0 8 Closeout Date : 10/30/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . SignedAcces s Agreemen t 5 . Pre-Renovatio n Form 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s Count y Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TEGHNOLOCIES , INC .

### PROPERT Y SUMMAR Y 

# O- Date ; IQl^jf] ^ \LB PSTABILIZATIO N EPA CONTRAT EPJt7.08-0 7 | Monthof . j^/tt PropertyAddrew ; "^^Of^ /j£/n.<,Ca mf^l\/J I A . EXECUTIV ESUMMARY A lbsMsEBcoimtered : bi dt^f^cuyi t Sa6:( ' SUfJ Ufpi r Id-M^oO T 0UiU<nO ^^Um^ S iV^pM ^ b^r e - di^n ^ p ^ „„^ ^ r; ^ ^1^ ^ ^ p^^^^x U ^ -r^uf^^^^^e ^ 

### A 2 bsne i Resolved :

A. 3 UniqaeHlndfaigii :

122A. 4 Otiie r Rdevan t Information :

FrHMfunric e i« ^ENVIRONMENTA L A CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^^^o ^ HoM^Ca mBb^^ ^ /^/d/Or ^ BVID : |^<^9 0 pho^ : 3 au -1'DU O Plan t & Pennanen t L>»nHHcapinp; T o Remai n T n Plac e Itein # Desmptio n an dLocatio n < i t J ^ O n Map

Pre-Existin g Conditio n o f Structure s v ^ Doe s you r Basemen t hav e ahistor y o f leaking ? Ye s — N o ' ^ Item # Descriptio n & Locatio n O n Map 

## I Ctach- ^ i n CoAcre ^ ^a^^^a { Gartxc e

Propert y Owne r Pruden t Employe e Signature ; Signature : 808 0 Ward Parkway . Siit a 40 6 Kansa s City . M O 6411 4 2S0 5 N . 24* ^

StraM , Suit a 30 8 Omaha , Nebraska 6811 0 424 2 Madica l DrIva , Suit a 426 0 Sa n Antonio , T X 7822 9 Phone : (818 ) 363^70 3 Phone : (402)604-100 4 Phona : /2101822.888 8

# n^'^ d

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

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

ofpropertie s locate di n Omaha , Nebraska , includin g th e propert y locate da t P-'^O.f ^ ^lOsrtrz m^\^c J . The EP A request s you r

permissio n t o allo w Pruden t t o perfor mLB PStabilizatio n a t thi s property . B y signing thi s form, th e propert y owne r

grant s permissio n to Pruden t t o perfor mactivitie s relate dt o LB P Stabilizatio n including scrapin g paint an dpaintin g ofth e referencedproperty . Further , th e owner/tenan t verifie s tha t they hav e receive dtiie LB Ppamphlet "Renovat e Right. " If

you hav e an y question s about th e LB Pstabilizatio n plannedfo r

your property , pleas e contac t Prudent' s Administrativ e Cler k

fo r

th e LeadBase dPaint Stabilization , Mrs . Debora hAkerele-Johnson . a

t (402 ) 504-1004 . Genera l question s about th e Omah aLea dSit e cleanup can b e directe dt o th e EPA PubU c Information Center s a t (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nort hOmah a office) . Propeit y Acces s Grante d (Pleas e Prin t Name ) 

## /a^y.^<? - ^ Propert y Owne r Signature : 

# i c ^fi-fT^^t- ^ 

# ^ A (Signature) (Date ) PROPERTY INFORMATIO N (T o b e complete db y reiiden t and/o r property owner - pleaa e print ) RESIDEN TNAME : 7^fl<?mr^ < ^ , /le^/^aAiti ' ^ ^ Rente r RESIDEN TADDI^ESS : I F RENTAL , PROPERT YOWNE D BY : OWNER'SMAIUNOADDRESS ; 

# 790 S Mtdsa ^ ^JO^ A I OWNER' S TEl£PHON E NUMBER-HOME : (V^ ^ \

S^Ce'^fSJd ^ WORK : J 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: . a NUMBE R OFCHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS . ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s to be implemente dby EP A unde r thi s agreemen t ar

e punuant to Sectio n 10 4 o f

CERCLA, 4 2 U.S.C . 9604 . EPA' s right o f

acces s t o the propert y isprovide dfo r i

n Section 104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entr y fo

r "determining the need for response , o r choosing ortaldng an y respons e actio n unde r dii s title , or otherwis e enforcing 0t e provision s ofth e title. "

i08 0 War d Partovay , Suit e 40 5 250 5 N . 24* * Street , Suit e 30 8 424 2 Medica l Drive , Suit s 425 0 -.ansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7622 9 'hone : (816 ) 363.370 3 Phone : (402)504-100 4

# Curren t Sampl e Pre-Renovatio n For m Effecthr e unti l Apri l 2010 . Confirmaftio n o f Receip t o f Lea d Pamphle t Q I hav e receivec l a cop yo f th e pamphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d SCITOOI S informin g m e o f th e potentia i risk o f th e lea d hazar d exposur e fro m renovatio n activit yt o b e performe d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . Printe d rigmg p o f recipien t ' / Dat e 

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i M f i ^'^ C , Signatur e o f recipien t Seif-Certlficatioj i Ojstlo n (fo rtenant-occupie d dwelling s onl ^ — I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t otitainabie , yo u ma ychec k th e appropriat e bo xbelow . Q Refusa l t o sig n —I certifytha t I hav e mad e a goo d lait h effor t t o delive rth e pamphlet , F^enoMat s FVght : Importan t ijae d Hazar d Informatio n fo rFamSes , Chil d Car e Prowcter s an d Schools , t o th e renta l dwellin g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t th e occuf)an t refuse d t o sig n th e confirmatio n o f receipt . I furthe 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 fo rsignatur e —I certif ytha t I hav e mad e a goo d fait h effor t t o delivB T th e pamphlet , Fienovat e FVght : Importan t Lea d Hasir d infonnatio n fo r families . Chil d Car e provider s an d Schools , t o th e renta 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 furthe rcertifytha t I hav e left a cop yo f th e pamphle t a t th e uni t b yslidin g i t unde rth e doon/ ^ _ -- 7 Printe d nam e o f perso n certifyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver y Signatur e o f persOTi ceriif^n g lea d pamphle t deliver y• i

Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n altemativ e t o deliver yi n person , yo u ma ymai i th e lea d pamphle t t o th e ovme rand/o rtenant . Pamphle t nuis t b e maile d a t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e o f mailin g fro m th e pos t office) .

# pai. t TM« h ^ ^^iJ: Z Pain t matchin g form : . —^i j Propert yaddress : ^^2^5^//^^^ ^ -^/' ^ BVID : / 7 99 0 

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## Dougla s Count y Accoun t Ij^rmatio n Pag e 1 of 2 L^ r Dougla s County , Nebrask a Propert yRecor d - R240303000 0 Prin t Repor t NE W Featur e - Parce l Dimension s avaiiabi e @ scal e 0-5 0 ft wes t o f 90t h S t - Vie.W..P,n....lVl3P . Informatio n i s vali d a s o f 2008-9- 4 Treasurer' s Ta xRepor t Ne wFeatur e -*->- * Aut o Sale s Searc h Owne r HERMANE KTHOMA S A ETA L 220 5 HANSCOf\/l BLV D OMAHAN E 68105-000 0 Propert yInformatio n Ke yNumber : 030 3 000 0 2 4 Accoun t Type : Residentia l Parce l Number : 240303000 0 Parce l Address : Lega l Description : 220 5 HANSCO M B D OMAHAN E 68105-000 0 VIRGINI APLAC E LOT 1 5 BLOC K1 5 0 X 12 0 Valu e Informatio n 200 8 200 7 200 6 200 5 200 4 200 3 Lan d $6,300.0 0 $6,300.0 0 $6,300.0 0 $6,300.0 0 $6,300.0 0 $6,300.0 0 improvemen t $107,000.0 0 $107,000.0 0 $82,000.0 0 $82,000.0 0 $82,000.0 0 $60,500.0 0 Tota l $113,300.0 0 $113,300.0 0 $88,300.0 0 $88,300.0 0 $88,300.0 0 $66,800.0 0 Lan d Informatio n Acre s 0.1 3 S F 6000. 0 Unit a 1. 0 Dept h 120. 0 Widti i 50. 0 Vacan t 

### N o Improvemen t Informatio n Buildin g 1



## http://douglasne.mapping-online.com/Doiiffla<?rr>Mp/otQtiV A or*/^'^^'" ' .+;_r _

### Dougla s County Accounti^ormatio n Pag e 2 of 2 

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qUC K T O ENLARG E IMAG E CUC K T O ENLARG E IMAG E Squar e Footage : 1592. 0 Percen t Complete : 

### 100.0 % Perimete r 0. 0 Quality ; Averag e 

### Uni t Type : Condition : Averag e Buil t As : 2 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 7. 0 Exterior : Fram e Viny l Units : 1. 0 

### Interior : Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 3. 0

Roo f Type : Gabl e Stories : 2. 0 Floorcover : Allowanc e Foundation : Sprinkle rSquar e Footage : 0. 0 Yea r Percen t Adjuste d Yea r YearBuil t Physica l Ag e Remodele d Remodele d Buil t 191 5 0 % 

### 191 5 9 4 Detai l Typ e Detai l Descriptio n Unit a Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 f t 784. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 

### 1. 0 Garag e Detache d 304. 0 Porc h Sla b Roo f Cei l 

### 216. 0 Porc h Sla b Roo f Cei l 

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