TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 69 4 Date: Oft( u A

Address: P.C;^ ^ eLl\SnN \ ^ V 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC.

 IJOO^ 

 Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

0 Video of property (DVD): Pre-Stabilizatlon & Post-Stabilization Videos 

IE Executive Summary 

()/ Signed Access Agreement Form 

1/ Advance Notice Form 

^ Pre-Stabilization Video Agreemen t For m 

M Access Trackin g For m 

S? Propert y Access Assessment For m 

D Neighbor Access Agreemen t For m 

i / Paint Match Form 

i / Pre-Stabilization Property Safety Assessment Form 

^ Work-Site Hazards Analysis Checklist 

0 Photographs: Pre-Stabilization Property Hazard Assessment Photographs 

i / Douglas County Assessor Property information 

0 Property Completion Agreement Form Signed by Property Owner 

n Property Close-Out Check List Signed By EPA 

PAident Technologies, Inc. Signature ' ' Date 

'Mo 

Date 

30054338 

IPDMH 

Superfund 
TBCHNOLOGIES. INC. 

Property Summary 

Date; 8fit^2009 \ LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of; Aug 

Property Address; 2598 Ellison Av. SAID #; 696 

A. Exftcutive Summary; 

Issues Encountered; NONE 

Issues Resolved; NONE 

9r Unique Findings; NONE 

d. Other Relevant Information; 

i. Access Date; 8/11/2009 

ii. Work Began; 8/13/2009 

iii. Close-Out Date; 8/14/2009 

B. Ej^cjpsures; 

1. I^re-Stabilization Video 

2. i^ost-Stabilization Video 

3. Signed Access Agreement Form 

4. Xdvance-Notice Form 

5. F|re-Stabilization Video Agreement Form 

6. .Recess Tracking Form 

7. Property Access Assessment Form 

8. lyeighbor 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. jiroperty Close-Out Check List Signed By EPA 
C>^Ct 

TBCHNOUXFIBS . INC T 

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 of properties located in Omaha, Nebraska, including the 

property located at ^S^ ^ £LL\<:o o Atvg^ 

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 the LBP pamphlet "Renovate 

Right." 

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 

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

contractor will make all reasonable efforts to address concerns that 1, as the property owner, may have regarding soil 

cleanup at my property. 

[ v^es , 1 have read and understand the paragraph above. 

^^X^-0-t>yvgc) (_J^ 

Signature of Property Owner 

Date 

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

Relations/Office Manager for the Lead Based Paint Stabilization, Mrs. Shannon Holt, at (402) 504-1004 or (402>8t2-0223. 

General questions about the Omaha Lead Site cleanup can be directed to the EPA Public Information Centers at (402) 731 ­

3045 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Propertyj^ccess Granted By: . i . 

(Please Print Name) 

Property Owner Signature: yXAr r t ^ J^ ^ ( y „ v^'^Zc<_v *>^X^<-g.'ff7tJ 

(Sign^e) 

$-i/-o' ) 

(Date) 

3080 Ward Parkway, Suite 40S 2S05 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

<ansasCJty, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

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

-ax: (816) 363-3707 Fax: (402)504-1005 Fax: (2104 .S7<>-fi.<;77 
TBCHNOLOCIBS. INCr~ 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner — please print) 

RESIDENT NAME: Owne n Renter 

RESIDENT ADDRESS: 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: i^^l ) MSl-3*?0 7 WORK: _( I. 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: O 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.) 

CO f<^-f ^ 

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

pursuant to Section 104 of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property is provided for in Section 104(e) of CERCLA. 

42 U.S. C 9605(e), which provides entry for "determining the need for response, or choosing or taking any response action under this title, or 

otherwise enforcing the provisions ofthe title." 

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

.ansasCity, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

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

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

Advanced notice needed. 

After signing the access you allow Prudent to begin Lead Based 

Paint Stabilization. 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? If you 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? 

Notice needed: An ^ ^irrje. 

Number to call to give notice: U 5 \ - =>^^lWhom we are giving notice to: 

^ Home Owner's Signature 

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 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABILIJ^ATION 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. 

OWNER f \otcT^ce VAict:€tso^ S NAME; 

PROPERTY ADDRESS: 2.S^S tLL>sor> Ave. 

BVID/SAID: ^ ^ C 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVE SIGNATURE: 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTINGVIDEO: (LE. PETS, NOTICE NEEDED): 

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 

7 
TECHNOLOGIES, INC 

ACCESS INFORMATION TRACKING SHEET 

BVID: ^<^ C PROPERTY ADDRESS : a6^ S t K^«'' rV^ 

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 

^fnlo ^ A-9 ^ K>v-| t^-cyy- ^r^.A'^^-J' t^ eiC)i'-tV^ 

i . y \ 

' / 

Comments: 

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.] 

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 ofthe 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. 

Does this property require lots of scrapping? 

r*>a J C\A'J\ _ H, 

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? 

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? 

If yes, describe location of garage. 

h^c^ w^5;^«. . i h ^ -c^ ^ 

Does this property have aluminum siding? 

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

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

shingles as siding)? 

If yes, EXPLAIN? 

Cr\e>r<L Is this property vacant or occupied? 

<,Ar^e ^ 

^^^^M , 

Are there any pets at this property? 

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)822-9588 

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

TECHNOLOGIES.] 

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 
fOLOGIBSi. IN C 

2. TO BE FILLED OUT ONLY IF CHANGING COLOR 

PROPERTY ADDRESS: rVo^e.r>ce. V^•^ r•\ireUor^ 

BVID: ^ 3 G 

Paint Paint Location Paint Description Yes No ^ SCO <i&Z5 Siding w ­ '^'^B ^ c€:x^o:\r* ffeacV» 

SCO CSi- ^ Soffit \ ^ 

Fascia 

Comer Trim 

Window Trims 

|2.0buJ£.-V C\<OiYsi\<^ V ^ 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams -^ 

Front Porch Floor 1 ^ 

Front Porch Railings — -

Front Porch Steps .—^ 

Siding Baseboards 

Foundation i — 

<5«,K-^< ^ictJ ^ L - ^ 

^okjMie. 'Wi ^ 

. ^ 

^icaJU^ tMs^ejJCl 

^ 

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 

MAY NOT LOOK EXACTLY AS IT IS SHOWN ON SWATCHES AFTER 

PAINTING ON MY PROPERTY. 

Homeowner signature: l^^^^^'^^^^-^g^ /?S% ^ \i^X^/ ^ ^^"^Z/-^P 9 

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 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 2 S ^ ^ ^ l>^^ ^ ° ^ *V>A^ 

BVID/SAID: G ^ ^ 

PRUDENT ASSESSMENT REPERSENTATIVE: 

^£^'^Y~^ i^Uy^ ^ 

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 
% 

TEQINOLOGIBS, INC 

Checklist for the Worksite Hazard Analysis 

Address: 

^.^VrvJ^vfi/jW^ 7^ t>x<J/ o.-^^ ^ 

CrewTpreman/SiU)-Contractor 

8080 Ward Parla(ay, Suite 405 2505 N 24"" Street, Suite 308 Medical Drive, Suite 4250 

Kansas City, hn) 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 1210)579-6577 


imT ^ 

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1 a4f»i*^ * .1 • '^di,>'^****** ' 

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Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

Q^l 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 the lead hazard exposure from renovation activity to be 

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

Printed name of recipient Date 

Signature of recipient 

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

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

you may check the appropriate box below. 

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

pamphlet, Renovate Right: Important Lead Hazard Information for Families, 

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

date and time 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. 

li^^navailable for signature — I certify that I have made a good faith effort to 

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

Families, Child Care providers and Schools, to the rental dwelling unit listed 

beiow 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 door. 

Printed name of person certifying Attempted delivery 

date and time 

lead pamphlet delivery r)/^ ^ 

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 from the 

post office). 
Douglas County Account loiMmatio Tjittms n Page 1 of2 i^^G 

Douglas County, Nebraska Property Record - R l 134720000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VleW_„On_Map Information is valid as of 2009-8-3 Treasurer's Tax Report 

New Feature r^ r^ ,t4> Auto Sales Search 

Owner 

HICKERSON FLORENCE 

ETAL 

2598 ELLISON AVE 

OMAHA NE 68111-0000 

Property Informatio n 

Key Number: 3472 0000 11 

Account Type: Residential 

Parcel Number: 1134720000 

Parcel Address: '2598 ELLISON AV ' 

OMAHA NE 68111-0000 

Legal Description: FORT VIEW ADD LOT 2 BLOCK 0 S 66.5 FT LT 1 & S 66.5 W 10 FT 66.5 X 60 

Value Infor matio n

2009 

2008 

2007 

2006 

2005 

2004 

Land I

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

mprovement 

$36,000.00 

$36,000.00 

$30,400.00 

$30,400.00 

$30,400.00 

$13,600.00 

Total 

$38,400.00 

$38,400.00 

$32,800.00 

$32,800.00 

$32,800.00 

$16,000.00 

Land Infor m a tio n

Acres 

0.1 

SF Units 

4620.0 1.0 

Depth Width 

66.0 

Vacant 

70.0 No 

Improvemen t Info rmatio n

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rl 1... 8/10/2009 
Douglas County Account In^Mmatio TjStrtm n Page 2 of 2 

2898 aLISON AV 

Mir 

FnlHoor Mir 

MO 

OlKM 1" " Mff 

RANCH 

CLICK TO ENLARGE IMAGE 

CLICK TO ENLARGE IMAGE 

Square Footage: 964.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

Built As: Ranch Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1949 0% 1949 59 

Detail Type Detail Description Units 

Add On Canopy 44.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 964.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno==Rl 1... 8/10/2009 
TECHNOLOGIES, INC 

Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: U^O 

Property Address: '^f ? A/;/.>/xy (^ ^ 

Owner's Name: N t /Jf/^L^ f// ^ j^f^^/T^J 

S.NO Performance Standards/close-Out Criteria j Yes NO 

1 Was the entire structure(s) painted with the exception of the stated, 

excluded areas? This would include painting of other associated j yC 

features including fascia, eaves, siding, all trim, porches, box ; | 

beams, columns, rails, and exterior surfaces of garages. 1 

2 1 Was all scraping and other preparation work completed / 

! satisfactorily? "^ 

, 3 

1 

1 

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

painted with two top coats?

 j / 

^ 

4 Are ail of the areas where contaminated materials have been spilled / | 

thoroughly vacuumed/ cleaned? ^ | 

5 Did the contractor collect/vacuum all falling and scraped paint chips , { 

on the entire property, roadways, alleyways, public access areas j J ! 

and also remove any other generated debris? i 

!6 Is the grass area that surrounds the structure(s) in reasonably good i / 

condition? \ v ; 

; 7 { Was the paint products utilized equivalent to a 30 year i > T 

j product/quality? | v 

: 8 Are all items such as polyethylene sheeting, ladders, paint brushes, Y 

: cones, barrier tape etc properly removed? ' 

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

contractor? Any property damage needs to be completed prior to i \ / 

the EPA Close-Out. \ 

• 1 0 Are there any property items that were temporarily re-located by the j ' \ / 

contractor that need to be moved back? \ \ 

11 Are there any (known) lingering issues with the property owner(s) 1 ) 

that have been left unresolved? ^ 

! 12 Other Considerations? Property Owner Discussions? Additional { ! ; 

Wortc that is Required 1 v 

Prudent Representative Signature: IQ^ l \ 

Da.e:HV^^f J -

Property Owner Signature: ^"^^^^^^^-- ^ ^ ' /'^^^^f^j,,...^^ ^ 

Date: -J^-^/^^^f 

3080 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