# TRANSMITTA Lo f OMAH ALEA D SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAI D # : 31 1 Date : Novembe r 2 0 Address : 181 8 Pinkne y St . Remediatio nContractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S B Vide o o f

propert y (DVD ) ETExecutiv e Summar y ^ Signe dAcces s Agreemen t fo r subjec t propert y y Paintin g Agreemen t D Settlemen t

document s (i.e. , fo r

damag e o r

t o replac e plants , eic. ) D Photograph s B ' Satisfactor y restoratio nsigne db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A y Propert y informatio nfro mDougla s Count y Assessor' s Offic e D D D f)^A ^

^le/o ^ 

## Signature dDate

4031064 5 

# ililH i Superfun d

### Date : PROPERT Y SlIMMAR Y LB PSTABILIZATIO NEP A CONTRA T EP-R7-08-0 7 Mont hof : Novembe r Propert y Address : 181 8 Pinkne y St . SAID : 31 1 A . EXECUTIV ESUMMAR Y A. l Issue s Encountered : Non e A. 2 Issue s Resolved : Non e

A.. 3 Uniqu e Findings : Non e 122A. 4 Othe r

Relevan t

Information : Non e Acces s Date : 09/29/0 8 Wor k Bega nDate : 10/18/0 8 Cioseou t Date : 11/05/0 8 Eniciosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio nFor m 6 . Pain t Matc hFor m 7 . Trackin g For m 8 . Dougla s Count> ' Assesso r Property ' Informatio nPag e 9 . EP A Propert y Cioseou t form 10 . Property'Completio nAgreemen t

TECHNOLOGIES , INC .

## TECHNOLOGIES , INC . ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Propert y Statu s For m Address : Kl ^ P,Vil^m.C r ^ Date : ^-^f-0" ? Phone; , 4^'<r5'- /

7 7 f BVID : 3/ ^ 

# "^W/l %§f'MJ^yA

l Item# O nMa p Plan

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dLocation



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## f / I f / f j f Propert y Owne r Signature: ^ ^i&yf . J<^ ' Pruden t Employee Signature : 808 0 War d Parkway , Suit e 40 5 Kansa s City , M O 641 U Phone:(816)363-370 3 Fax : (816 ) 363-370 7 250 5 N . 24"^ Street , Suit e 30 8 Omaha , Nebrask a 6811 0 Phone : (402)504-100 4 Fax : <402\

SOd-inn R 424 2 NIedica l Drive , Suit e 425 0 Sa n Antonio , T X 7822 9 Ptione : (210)822-958 8

## Pruden t

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

#EP-R7-08-07 ) withth e U . S . Environmenta l Protectio nAgenc y (EPA ) t o stabiliz e Lea dBase dPain t (LE|P) at anumbe r ofpropertie s locate di nOmaha , Nebraska , includin g th e property locate dat |^[ ^ Pinl/ni? U \ i Th e EP A request s you r

permissio nt o allo w Pmden t t o performLB PStabilizatio nat thi s property . B y signin g thi s form , th e property owne r grant s permissio nt o Pruden t t o performactivitie s relate dt o LB P Stabilizatio nincludin g scrapin g pain t an dpaintin g o f

th e reference dproperty . Further , th e owner./tenant verifie s that

the y hav e receive dlli e LB Ppamphle t "Renovat e Right. " If yo u hav e an y question s abou t th e LB Pstabilizatio nplanne dfor you r property , pleas e contac t

Prudent' s Administrativ e Clerk

for th e Lea dBase dPain t

Stabilization , Mrs . Debora hAkerele-Johnson . at (402 ) 504-1004 . Genera l question s abou t th e Omah aLea dSit e cleanu p canb e directe dt o th e EP A Publi c Informatio nCenter s at (402 ) 731-304 5 (SouthOmah aoffice ) o r (402 ) 991-958 3 (NorthOmah a oifice) .



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### RESIDENT NAM E RESIDENT ADDRES S PROPERTY INFORMATIO N V (T o be completedbv resident and/o r propert> ' owgp:-..^ e

leas e print ) Rente r 

# /f/^/y : f\..K

^ - y 5/ . 

# i ^ I F RENTAL , PROPERT YOWNED BY : OWNER' S MAILIN G ADDRESS : 

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S^y)2£ ^ OWftJER' S TELEPHON E NUMBE R - HOME : (^^^ ) ^X^y V ^.^fwORK : i^CZ ^ ^ ^ D " ^

^ 0/J! S NUMBE R O F OCCUPANT S UNDE R 7 YEAR S O\Si\0O - NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : / NUMBER O F CHILDRE 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 YGATES . ETC. ) /-^ ^

.'VUTHORrr

V FO RENVIRONMENTA

LRESPONSEACTIONS ; Th e activitie s to be implemente db y EP. ^ unde

r thi s agreemen

t :ir e puisuan t to Sectio n10 4 of CERCLA, 42 U.S.C . 9604 . EPA' s righ t of acces s t o th e propert y i s providedfor

i nSectio n104(e ) of CERCLA , 42 U.S . C 9605(e) , whic

hprovide s entr

y fo r "determining th

e nee dfo r response , o

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y respons e actio

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08 0 WerdParkway , Suit e 40 5 .ansa s City , M

O 6411 4 •hons : (816 ) 363-370 3 sx : (815 ) 363-370 7 250 5 N . 24' " Street , Suit e 30 8 Omaha , Nebrask a 6811 0 Phone : (402)504-100 4 Fax : (402)504-100 5 424 2 Medica l Drive , Suit e 425 0 Sa n Antonio , TX 7822 9 Phone : (210)322-953 8 Fax : (2 1 O J579-657 7

# v^ciiip<c;ii i ociiii|jit ; rre-nenovatio n hor m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t M 1 hav e receive d a cop yo f tli e pamphlet , Renovat e Right : Importan t Lea d Hazard . ^ l Informatio n fo rFamilies . Chil d Car e Provider s an d School s informin g m e of th e potentia l ris k

of th e lea d hazar d exposur e fro m renovatio n activit yt o b e peri'orme d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . Printe d nam e of recipien t \IL ^ ^^' ^ Signatiir e of recipien t Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — i f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , 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 fait h effor t t o delive rth e psfTiphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n fo rFamine , Chil d Care Provid& 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 occupan t refuse d t o sig n th e confirmatio n o f iBceipt . I furthe rcertifytha t I hav e left a cop yo fth e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e —i certifytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n fo r Fanilies , Chil d Car e provider s an d Schools , t o th e rental dwellin g uni t liste d below^ d tina

t th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I fijFfna rcertifytha t I hav e left a cop yo fth e pamphle t a t th e uni t b yslidin g i t UF(de/th e door , j i \ PnntEx J nam e of persoii'Certrlyin g J Attempte d deliver y dat e an d tim e lea d pamphle t deliver

y Signiitur e of perso n cert|f^n g lea d pamphle t deliver y 

# f^i yP'^^i^. , Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n alternativ e t o deliver yi n person , yo u ma ymai l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d a t leas t 7 day s before renovatio n (Documen t wit h a certificat e o f mailin g fro m th e pos l office) .• . . 1 r « - • /'•' Alife / ^ - f^-f" ^

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# pain t matc h far m /yfr t "(' ^ x F'ain t matchin g form : ' — ^ FTopert yaddress : /f/ / ^/j^^-^ ' I5VID : 5/ /

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## fag e 1 or .. i Dougla s County , Nebrask a Propert yRecor c Informatio n i s vali d a s o f2008-9- 4 "^^''"'"" ' • Owne r WATSO N MARSHALL E A 181 8 PINKNE YS T ^ ' OMAH AN E 68110-000 0 Propert yInformatio n

Ke yNumber : Accoun t Type : Parce l Number : Parce l Address : Lega l Description : Valu e Informatio n

Lan d 200 8 200 7 ' 200 6 ' 200 5 ! 

### 200 4 1 200 3 298 2 000 0 1 5 Residentia l 152982000 0 181 8 PINKNE YS T OMAH AN E 68110-000 0 1 - R152982000 0 Parce l Dimension s availabl e @ sea l

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. Improvemen t S4.80 0 G

O $4,800.0 0 $4,800.0 0 $4,800.0 0 $4,800.0 0 $4,800.0 0 $38,50 0 0 0 $34,50 0 0 0 $34,500.0 0 $34,500.0 0 $14,000.0 0 $14,000.0 0 Prin t Repor t e 0-5 0 f t wes t o f Got h S t - VIe wo n Ma p Treasurer' s Tax.Repor t ->->- > Aut o Sale s Searc h

Tota l $43,300.0 0 $39,300.0 0 $39,300.0 0 $39,300.0 0 $18,800.0 0 $18,80 0 0 0 Sale s Informatio n

Sale s Date : Dee d Type : Price : Grantor : Grantee : Valid/Invalid : Exclusio n Reason : Lan d Informatio n Acre s S F 0.1 4 2002-03-0 8

Q C Soolf ; 220 4 $ 1 0 0

Invali d No n Bon o wit h Do cStamp s

; Unit s 625 0 0 1. 0 Dept h Widt h 125. 0 50. 0 Page : 72 9

\^acan t N o

' Improvemen t Informatio n 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno==Rl5.. . 9/24/200 8

## uougia s count y Accoun t inrorrnatio n Tiaii c 

### rag e z u i . i Buildin g 1 131 8 Finknc y

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CLIC KT O ENLARGEJMAG E 1.-2SloryUnfi n
CUCKJO_EJiLA.RGEJMAG. E Squar e Footage : Perimete r Uni t Type : Buil t As : HVAC : Exterior : Interior : Roo f Cover : Roo fType : 1374. 0

0. 0 2 1/ 2 Stor yUnfi n Force d Ai r Fram e Sidin g Drywal l Compositio n Shingl e Hi p Floorcover : Allowanc e Percen t Complete : 100.0 % Qualit y• Averag e Condition : Averag e Cond o Squar e Footage : 0. 0

Rooms : 7. 0 Units, : 1 0 Baths. : 2. 0 Bedrooms : 3. 0 Stories : 2. 5 Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea rBuil t 191 0 Yea r

Remodele d 0 Percen t

Remodele d 0 % Adjuste d Yea r Buil t 

### 191 0 Physica l Ag e 9 8 Detai l Typ e Applianc e Basemen t Basemen t Fixtur e Fixtur e Garag e Porc h Porc h Porc h Porc h Detai l Descriptio n Allowanc e Bsmn t Bloc k

8 f t Finishe d Bas e Fixture s Bat h Ful l Detache d En d Soli d Wal l En d Soli d Wal l Ope n Sla b Sla b Roo f Cei l Unit s 1. 0 696. 0 300. 0 1. 0 2. 0 440. 0 13 6 0 136. 0 200. 0 192. 0



## http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=Rl5.. . 9/24/200 8

# Prudien t Propert yCiose>Ou t For m (Lead-Base d Pain t Stabilization ) SAID; ' 8i C 

# iM . ^ Propert yAddress : 

### Owner' s Name : lAaY^sir^Ajlf . A^CUd^d"> t 

# Performanc e Standards/close-Ou t Criteri a YE S N O 1 . Wa s th e entir e structure{s ) painte d wit h th e exceptio n o fth e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , el l trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 

# y 1 . Waj s al l scrapin g an d othe rpreparattio n worl < complete d satisfactorily ? 3 . Wer e al l require d areas o f tii e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 . Waj s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 5 . Ar e al l o f th e area

s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed /

cleaned ? 

# < y 5 . Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chips o n th e entir e property , roadways , alleyways , publi cacces s areas an d also remov

e an yothe rgenerate d debris ? ^ 

# 7 ' 7 . I s th e gras

s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? ^ 8 . Ar e al l item s suc h a

s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? _ ^ 

# c ^ 

# y 9 . I s ther e anyevidence o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o be complete d prio rt o th e EP AClose-Out . 

# • 10 . Ar e ther e anypropert yitem s tha t wer e te.mporatil yre-locate d b yth e contracto r tha t need t o b e move d back? 

# c/ i 11 . Ar e ther e any(known ) lingerin g issues wit h th e propertyowner(s l tha t hav e bee n lef t unresolved ? Otlie rConsiderations?propert yOwne rDiscussions?Addltions l Wor k tha t i s Require d 

# y

Pruoen t Rei^esentatl v 

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