## TRANSMITTA L o f

OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID# : ZCQ ^ Date : .S^/ ^ -ZO/ Q Address : 4^=g 4 ,^ . /8 ^ .<<{ 7 Stabilizatioi i Contnctor : Professiona l Environmenta l Engineer s Year : 2010 _ PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S Vide o ofpropert y (DVD ) Executiv e Summar y Signe dAcces s Agreemen t fo r

subject propert y 

# X Pre-Renovatio n For msigne dby Propert y Owne r D 

## Pre-Renovatio n For mfo r

Occupant/Tenant , i f applicabl e Paintin g Agreemen t 

# J " Settlemen t docimient s (i.e. , fo r

damag e or to replac e plants , etc. ) 

# X

D 

## Renovation Recordkeeping Checklis t signedb y CertifiedRenovator 

# Photographs pp ^ an da\ ^ 

# X Satis&ctor y close-ou t check lis t signedby Propert y Owne r 

# X Propert y close-out check lis t signedb y EP A Propert y information fromDougla s Count y Assessor' s OfBc e ; < 

## Hazar danalysis , i f prepare d D 

## Safet y Audit D 

## Othe r

(describe) : D



## ^^biment u cngmfMBT s S i Engmiier aSignatur e (afte r file folde r review ) 3020409 5 

# IHlHi l Superfun d

## 201 0 

# PROFESSIONAL ' 250 5 Nort h 24« \ Suit e 21 9 

# ENVIRONMENTA L ENGINEERS , INC
. Oinaha.N E 6811 0 (402 ) 504-468 8 

## "Providin g cost-effectiv e environmenta l solutions' ' Fa x (402 ) 504-328 1 Consultin g • Engineerin g Desig n • Remediatio n • At>atenien i • Emeigenc y Respons e 

## EP A Close-Ou t For m (Lead-BasedPain t Stabilizatio n EP A Contract EP-R7-08-06 ) SAID : 

# 2£Ff ) Propert y Address : 4S 3 •4

- S . / 8 S i Owner' s Name : \\/\dvC/\ ^ \JtJ(\ciO{t^ ^ Performanc e Standards/Close-Ou t Criteri a YE S N O 1 . Was th e entir e structure(s ) painte dwit h th e exceptio n o f the stated , excludedareas ? Thi s woul dinclud e paintin g o f othe r

associate dfeature s including fascia , eaves , siding , all trim , ly ^ 

## porches , box beams , columns , rails , an dexterior surface s o f garages . y 

## 2 . Wa s al l scraping an dothe r

preparatio n wor k

completedsatisfactorily ? 3 . Wer e all required area s o f th e structure(s ) primeda s neededan dpaintedwit h tw o to p coats ? y 

## 4 . Was the pain t product s utilize dequivalen t to a2 5 yea r

product/quality ? y ' 

## 5 . Ar e all o f th e area s wher e contaminate dmaterial s hav e bee n spille dthoroughl y vacuumed / y ^ 

## cleaned ? 6 .Didthe contractor collect/vacuumall falling an dscrapedpain t chip s on th e entir e property , - 

## 1 roadways, alleyvrays , publi c acces s area s an dals o remove an y othe r

generateddebris ? 7 . I s tfa e gras s are atfaa t surround s th e structure(s ) i n reasonably goodcondition ? y 

## 8 . Ar e all item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r

tape , etc . properl y removed? y 

## 9 . I s ther e an y evidenc e ofpropert y damag e tha t wa s don e b y th e contractor ? An y propert y damag e need s to b e complete dprior to th e EP A Close-Out . y ^ 

## 10 . Ha s the propert y owne r

signe dthe completio n form ? - ^ 

## 11 . Ar e ther e an y propert y item s tha t wer e temporarily re-located b y the contractor tha t needt o
- 

## b e move dback ? 12 . Ar e ther e an y (known ) lingerin g issue s wit h th e propert y owner(s ) tha t hav e bee n lef t t y ^ 

## unresolved ? Othe r

Considerations/Propert y Owne r

Discussions/Additiona l Wor k

tha t i s Required :

•



## EP A CO RSignatur e Dat e

# PROFESSIONA L 250 5 Nort h 24" , Suit e 21 9 

# ENVIRONMENTA L ENGINEERS , INC
. Omaha
. NE 6811 0 (402 ) 504-468 8 

### "Providin g cost-effectiv e environmenta l solutions " Fa x (402 ) 504-328 1 Consultin g • Engineerin g Desig n • Remedialio n • Ab^ileroen l • Eiii(V'9eni; vRespons e 

## Propert y Owne r Close-Ou t For m (Lead-BasedPain t Stabilizatio n EP A Contrac t EP-R7-08-06 ) SAID : 

# ?QP A Propert y Address : ii£Qd_2i_i2L ^ Owner' s Name : 

# -mm\!(U^ y - Performanc e Standards/Close-Ou t Criteri a YE S NO 1. Was th e entir e structure(s ) paintedwit h th e exceptio n of th e stated , excluded areas ? Thi s wouldinclud e paintin g of othe r

associate dfeature s including fascia , eaves , siding , al l trim , porches , box beams , columns , rails, an dexterior surface sof garages . 2. Was all scrapin g an dothe r

preparatio n wor k

completedsatisfactorily ? 3. Wer e all required area s of the structure(s ) primed as neededan dpainte dwit h tw o to p coats ? 4. Was th e pain t product s utilize dequivalen t to a 30 yea r

product/quality ? 5. Ar e al l of th e area s wher e contaminate dmaterial s have bee n spille dthoroughly vacuumed / cleaned ? 6. Di dth e contractor collect/vacuu mal l falling an dscrapedpain t chip s on the entir e property , roadways, alleyways , publi c acces s area s an dals o remove an y othe r

generate d 3 debris

debris ? ? 7. Is th e gras s are atha t surround s the structure(s ) in reasonabl y goodcondition ? 8. Ar e all item s IS suc h

as polyethylene sheeting , ladders , pain t brushes , cones , barrie r

tape , etc . properl y removed? 9. Istherean y evidenc e ofpropert y damag e tha t was don e

by the contractor ? An y propert y damag e need s to be completedprior to th e EP A Close-Out . 10 . Ar e ther e an y propert y item s tha t wer e temporarily re-located by the contractor tha t need to be movedback ? 11 . Ar e ther e an y (known) lingering issue s wit h th e propert y owner(s ) tha t hav e bee n lef t unresolved ? Comments : 

# 0-/7~i ^ Dat e 

# A •^-/7-yr
. ^ 

## Professiona l Gnvtronmenta l Engineer s Representativ e Dat e

# PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC
. "Providin g cost-effectiv e environmenta l solutions " 

# ''° ' Trtlah t N E 68 m ^^ ^

jj^g j ^!j^ i Consultin g • Engineerin g Desig n • Remedialio n • Abalemen t • Emergenc y Respons e



## LeadBas e Stabilizatio n Omaha , N e Clos e Ou t Repor t 201 0 SAID#205 9 453 4 S . 1 8 S t

•Date s worked : 05/17/1 0 to 05/17/1 0 •Pr e propert y condition : Hous e ha s viny l sidin g wit h painte dwoo dtrim s tha t ha d flaking pain t of f

o n t o th e ground , fron t porc h als o poor . •Problem s encountered : None . •Owne r request/concerns : N/ A •Inspection/closeou t dates . Owne r 05/25/10 , inspecte db y P E projec t manager .

### SAID # Propert y Addres s Storie s Garage ? Acces s signe d Pre-vide o Pos t vide o Contracto rAssigned ^ Dat e starte d Weather/tem p Oate ende d Pain t use d Prim e use d 

### Poly use d 

# Tf'»w \(m V EP A Pain t Stabilizatio n 201 0 

# L 5 

# J ^ 5--Q5 - 2b\ 0 S>\4-^^l ^ 5-18-ZPl Q 

# M C ^vvipe ^ f>M7li O 

# n ^ e. f m o ,

Problems/issue s05/14/2tt 0 08:3 6 #57 7 P.001/00 3 From : 

# CONSEN T FOR ACCES S T O PROPERT Y OMAH A LEA D SIT E REMEDIAL ACTIO N - LEAD-BASE D PAIN T STABILIZATIO N PROPERT Y ID : ^^Qo* ^ PROPERTY ADDRESS : 

# ^^f^- f ! S ­. I& ^ S ^ OWNERNAME : , , . . ^ 

# y\/|^r. ^ \lrx\aM'^ . DAYTIM E PHONE : E-MAIL : CELLPHONE : ~lCf\JfOr^rl-l ' OWNER' S ADDRES S I F DIFFERENT : . TENANT' S NAM E ff APPLICABLE : DAYTIM E PHONE : 

# nnr--lii n If/mih^z - CELLPHON E 

# .ic^-\o%^ . E-MAIL : Profenlona l Environmental Engineen , Inc . (PE ) i t unde r contrac t (#EP-R7-08.4)6 ) wit h th e U.S . Envlronnentt I Protectio n Agency (EPA ) t o ttabiliz e lendbate dpain t (LBP ) o n residentia l itructure i a t aaunbe r o f propertie s locate di n Omaha , Nebnuka . Th e pain t stabllliatio n worl ( i t bein g don e t o protec t th e sol i cleanup s tha t ar e bein g performe db y EP A contractors . Paia t stabiltatatio n activitie s will include : tcrapin g of cracke do r flakin g LB P fro mttnictures . applicatio n of aprim e coa t an dtw o (2 ) coat s of pain t Movin g part s of window s an ddoor s arcny t include dan dwil l no t b e addressed . Your cooperatio n i s requeste din givin g permiuio n t o th b EP A contracto r (PE ) t o ente r an dhav e t o th b propert y fb r th e purpos e ofstabilldn g lea d-base dpain t a s outline do n th e propert y identlfle dabove . B y signin g th b document I agre e t o allo w an EP A contracto r t o conduc t asoi l cleanu p a t m y propert y following completio n o f lead-base dpain t stabllteation , if th e soi l cleanu p ha s no t alread y bee n performed . I understan dtha t th e stabilizatio n contracto r can no t provU e auuranee s tha t th e soi l cleanu p contracto r wil l b e boun dto . I furthe r understan dtha t th e soi l cleaau p contracto r will mak e al l reasonabl e effort s t o addre u concern s tha t I , a s th e propert y owner , ma y hav e regardin g soi l cleanu p a t m

y property . DYSS, ! i d thsjpnMiap h aliovs
. 

# 5hL I O SI|a«ino(Piap«« ( M s 1 full y understan dtha t b y signin g th b Consen t for Access , (i ) th b acces s will remain i n effect unti l th e wor k

ha t been satbfactoril y completed , 9 ) tha t th e Propert y Owne r o r Tenant , if applicable , wU I b e give n th e Housin g an dUrba n Development (HUD ) an dEP A pamphbt , "Renovat e Right . Importan t Lea dHaxar dinformatio n far Fknllba , Da y Car e ProvUers , an d Schoob" , (3 ) tb e Propert y Owne r o r tenan t will remov e al l obstruction s fromsurhcc s t o b e palntml , (4 ) wi U abid e by health an d nfet y guUanc e provide d fay EPA , (5 ) wi U ilto w photograph y o f propert y before aa dafte r th e pala t stabUtaMlon work , (6 ) wU I b e contacte db y aP B repnaentativ c approiimatel y 4 S hou n i n advanc e o f startin g worit , (7 ) agre e no t t o obstrac t o r tampe r wit h an y o f th e LB P ttabllliatlo n actions , an d (8 ) wil l participat e b i fhia l propert y inspectio n an dsig n tfa e Cempletto n Agreemen t an d Propert y Owne r SatbfiutkmSurvey . Shon M yo n hav e aa y qneitloa t abou t tfa e plane dLeadBased-Pain t itabilbatio n activitie s fo r you r property , pleas e contac t Profenlona l Environmental Engineers , In c Projec t Manager , WiUi e Clay A t 4(0404-4688 . Genera l question s abou t th e Omah a LeadSh e cleanu p ca n b e directe dt o Paulett aFrance-lsetts , EP A Remedial Projec t Manage r 402r73l-24S4 , o r th e EP A Publi c Infonnatio n Center s a t 402-991-9S8 3 (North Omah aoffice) o r 402-731-304 5 (Sout h Omah aofflce) . YeSilgnntaocsastoiivprapeitirandiMsgiMnthspsfflphta t D lto,ldonatarantieceietomypnparfysndlwa s • RBnont a RVi ^ fanpertnlLBad bibmHlo n fBrFaniite , Chil d gbMH w puiphM-RmamtaMght hnportntlM d wor e MUVNIMI , i m oUHIWi
. MDnMUo n torFamlltaa , ChlM e C mPrevUm , an dSchoob. " DM e Slonstur e Dat e SPECIA L INSTRUCTION S AN D CONSIDERATION S 005/14/2fii p 08:3 6 #57 7 P.002/00 3 1 2 ^ 

### From : 

## PAJNT STABILIZATIO N PRE-PROPERT Y PAIN T MATC H ASSESSMEN T PROPERT Y ADDRESS:
. 

# A-'r M JS > 

# i rs v _DAT E 

# : 5-5 - 

# 1 0 BVID:
_

AREA(S ) T O B E PAINTED : HOUS E PROPER : 

## COLOR : ^\Y:V \ 

# :_ m L 

# lo m T X HOUSETRIIW : ^\'^ ^

^ V(Vi\m Q C1f\nC\YCAbLOR:

_ 

# i^yyyyyyiyz ^ yyxnr) L
. GARAGE : .TjJ ^ '. COLOR :
GARAG E TRI M 

# m . COLOR :
PORCH : 

# £ ^ COLOR : 

# z . 

# JZ
. PORC H TRIM : 

# m . COLOR : (COMPLET E AL L SECTION
. YES
. NO
. O R NON-APPUCABLE )



## I AGRE E T O TH E COLOR S USTE D ABOVE . ONC E TH E PAINTIN G BEGINS , I UNDERSTAN D I CA NNO T CHANG E TH E ABOV E SELECTE D COLORS :

### From : .^ ^ 05/14/2fil 0 08:3 7 fbl l P.003/00 3 

# f PRE-RENOVATIO N FOR M - OCCUPAN T Thi s for mi s t o b e use db y th e firni s contracte db y th e Environmenta l Protectio n Agency-Regio n 7 t o perfon n Lead-Base d Pain t stabilizatio n activitie s a t tii e Omah aLeadSite , Omaha , Nebraska . Occupan t Confirmatio n Pamphle t Receip t D I hav e receive dacop y o f th e lea dhazar dinfonnatio n pamphlet . Renovat e Right : Importan t Lea dHazar dInformatio n fo r Families , Chil dCar e Provider s an d Schools , infonnin g m e o f th e potential ris k o f th e leadhazar dexposur e fro mrenovatio n activit y t o b e perfonne din/o n m y dwellin g unit . I receive dthi s pamphle t before th e wor k

began . Occupan t Opt-ou t Acknowledgmen t D(A ) I confln n tha t I ow n an dliv e i n thi s property , tha t n o chil dunde r th e ag e o f 6 reside s here , tha t n o pregnan t woma n reside s here , an dtha t thi s propert y i s no t achild-occupie dfacility . Note : A chil dreside s i n th e primai y residenc e o f his/he r custodia l parents , legal guardians , foste r parents , o r informal caretake r i f

th e chil dlive s an dsleep s mos t o f tim e a t th e caretaker' s residence . Note : A child-occupie dfacility i s apre-197 8 buildin g visite dregularl y b y th e sam e child , unde r 6 year s o f age , o n a t leas t tw o differen t day s withi n an y week , for a t leas t 3 hour s eac h day , provide dtha t th e visit s tota l at leas t 6 0 hour s annually . 0 (B ) J understan dtha t th e renovatio n firm , contracte db y th e Environmenta l Protectio n Agenc y (EPA) , will b e usin g lead

saf e work practice s require db y EPA' s Renovation , Repai r an dPaintin g Rule . 

# KlacVixr . ^Q-^v.-^w- ? Printe dlilam e o f Occupan t 

# _tfiAj J y,mjA . 6 S^'C ^ Signatur e o f Occupan t Dat e Renovator' s Self-Certificatio n Optio n (fo r tenant-occupie ddwelling s only ) Instructio n t o Renovator : I f th e leadhazar dinformatio n pamphle t wa s delivere dt o th e owne r bu t atenan t signatur e wa s no t obtainable , yo u ma y chec k th e appropriat e bo x below . D Decline d- 1 certif y tha t I hav e mad e agoo dfait h offer t o delive r th e lea dhazar dinformatio n pamphle t t o di e renta l dwellin g uni t liste dbelo w a t th e dat e an dtim e indicate dan dtha t th e occupan t decline dt o sig n th e confirmatio n o f receip t I fiirther certif y tha t 1 hav e lef t acop y o f di e pamphle t a t di e uni t wid i th e occupant . O Unavailabl e fb r signatur e - 1 certif y tha t I hav e mad e agoo dfait h effort t o delive r th e lea dhazar dinfiumado apamphle t t o th e renta l dwellin g uni t liste dbelo w an dtha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n receipt . I fiuthe r certif y tha t I hav e lef t acop y o f di e pamphle t a t di e uni t b y slidin g i t unde r th e doo r o r b y (fd l in ho w pamphle t wa s left ) 

# A<:x<W'^ a Rar^-vlrt-^ ^

4-fZ-/ 6 Printe dNam e o f Perso n Certifyin g Delivei y Attempte dDelivery Tim e Signatur e o f Perso n Certifyin g Lea dPamphle t Delivei y Dat e
Uni t Addres s

## Dougla s Count y Accoun t Information Pag e 1 of 3 

# ^OS ^ Dougla s County , Nebrask a Propert y Recor d - R175561000 0 Prin t Repor t Vie w Interactiv e GI S Ma p Informatio n i s vali d a s o f 2010-4-1 6 Treasurer' s Ta x Repor t Ne w Featur e - • • • - > Subdivisio n Sale s Searc h Owne r VALADE Z MARI A 271 0 ALBERT A AV E BELLEVU E N E 68147-000 0 ^^ ^ 

# VGOP^^ S Propert y Informatio n Ke y Number : 556 1 000 0 1 7 \ r^(y ^ ^ ^ 0%>' ^ Accoun t Type : Residentia i Parce l Numbe r 175561000 0 ^ Parce l Address : [453 4 S 1 8 Sl l OMAHAN E 68107-000 0 Lega l Description : MISSOUR I AV E PAR KLO T 9 BLOC K1 4 0 X 13 0 Valu e Informatio n Lan d Improvemen t Tota l 200 9 $5,800.0 0 $58,800.0 0 $64,600.0 0 200 8 $5,800.0 0 $58,800.0 0 $64,600.0 0 200 7 $5,800.0 0 $58,800.0 0 $64,600.0 0 200 6 $5,800.0 0 $50,500.0 0 $56,300.0 0 200 5 $5,800.0 0 $50,500.0 0 $56,300.0 0 200 4 $5,800.0 0 $50,500.0 0 $56,300.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 1 5200. 0 1. 0 130. 0 40. 0 N o Improvemen t Info r matio n Buildin g 1



## http://douglasne.mapping-onIine.com/DouglasCoNe/static/accountinfo.jsp?accountno=R17.. . 4/30/201 0

### Dougla s Count y Accoun t Informatio n

Squar e Footage : 1412. 0 Perimete r 0. 0 Uni t Type :

Buil t As : "Tl7 2 Stor y Fi n HVAC : Force d Ai r Exterior : Fram e Viny l Interior : Drywal l Roo f Cover : Compositio n Shingl e

Roo f Type : Gambre i Floorcover : Allowanc e Yea r Percen t Yea rBuil t Remodele d Remodele d 

### 189 0 0 % Detai l Typ e Detai l Descriptio n Ad d O n Fenc e Chai n Lin k Allowanc e Bsmn t Bloc k 8 f t Bas e Fixture s FixtL ' Bat h Ful l 

# t ) Porc F Sla b Roo f Ceilin g » HS t HS I Unity Par k 

# 1 IS t 

### Pag e 2 of 3

*SS<S1SS T 4«US4R ^ lat f i d i t • a s ! M*.D3«n . le r 1 1/ 2 Stor y BwMltockSI t I * o r CLIC KT O ENLARG E IMAG E Percen t Complete : 100.0 % Quality : Averag e Condition : Averag e Cond o Squar e Footage : 0. 0 Rooms : 

### 6. 0

Units : 1. 0 Baths : 1. 0 Bedrooms : 2. 0 Stories : 1. 5 Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Adjuste d Yea r Physica l Ag e Buil t 189 0 

### 12 0 Unit s 1. 0 1. 0 

### 616. 0 1. 0 1. 0 108. 0 f " Ma p Satellit e | Hybri d | Ten-ai n |

9 V ) S lurch ' ! ' a t 

### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R17. . . 4/30/201 0 

# V(efTectiv e Apri l 2010 )


## RENOVATIO N RECORDKEEPIN G CHECKLIS T
Nam e o f Firm : \j[ C <^^\(l' ^ Dat e an dLocation o f Renovation : jDf l / / j U Brief Descriptio n o f Renovation : JWf ^ 9^Y)\\]tO;\\{^r ) Nam e of AssignedRenovator : CLY " \^\ i Q\l \M Q Vli ^ Name(s ) o f Traine dWorkers : )^\'^y£SIj ^ Nam e o f Dus t Samplin g Technician , Inspector , and/o r Ris k Assessor , i f used : Y\{ Q

^ Copie s o f renovato r an ddus t samplin g technicia n qualification s (trainin g certificates , certifications ) o n file . CS ^ Certifie drenovato r provide dtrainin g t o worker s o n (chec k al l that apply) : 1 ^ Postin g wamin g sign s RSettin g u p plasti c containmen t barrier s ^ Maintainin g contaiimien t b^voidin g sprea dofdus t t o adjacen t area s IS

^ Wast e handlin g QyPost-renovatio n cleanin g D Tes t kit s use db y certifie drenovato r t o determin e whethe r lea dwa s presen t o n component s affecte db y renovatio n (identif y kit s use dan ddescrib e samplin g location s an dresults : Yil^ K

G

^ Wamin g sign s poste da t entranc e t o wor k

area . IJ ] Wor k

are acontaine dt o preven t sprea dofdus t an ddebris . \ D Window s i n an dwithi n 2 0 feet o f th e wor k are aar e close d -{ ^ Door s i n an dwithi n 2 0 feet o f th e wor k area s ar e close dan dseale d Q Door s tha t mus t b e use di n th e wor k

are aar e covere dt o allo w passag e bu t preven t sprea dofdust . aGroun dcovere db y plasti c sheetin g extendin g 1 0 feet fromwork are a- plasti c anchore dt o th e buildin g an dweighte ddow n b y heav y objects . p I f necessary , vertica l containmen t installe dt o preven t migratio n ofdus t an ddebri s t o adjacen t property . n i Wast e contmne don-sit e an dwhil e bein g transporte dofF-site .

Renovatio n Recordkeepin g Checldis t Omah a Lea d Sit e(effectiv e Apri l 2010 )



### S ^ Wor k

site properl y cleane dafter renovation . KAI I 

### chip s an ddebri s picke dup , protectiv e sheetin g misted , folde ddirt y sid e inward , an dtape d fo r removal . ( \Wor k are aHEP A vacuume dt o ge t pain t chip s fromgroun dsurface , i f necessary . [ ^ Certifie drenovator performe dpost-renovatio n cleanin g verificatio n (describ e results):

1 3 (/:ertii y unde r penalt y o f la w tha t the above infonnation i s tme an dcomplete .

Nam e an dTitl e Dat e

Renovatio n Recordkeepin g Checklis t Omah a Lea d Sit e