TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: %f-\^?> ^ Date: 

Address: M'lrj N SM sY 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

y Executive Summary 

V Signed Access Agreement Form 

y Advance Notice Form 

t^ Pre-Stabilization Video Agreement Form 

y Access Tracking Form 

^ Property Access Assessment Form 

y Neighbor Access Agreement Form 

y Paint Match Form 

y Pre-Stabilization Property Safety Assessment Form 

y Work-Site Hazards Analysis Checklist 

B' Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

H Douglas County Assessor Property information 

y Property Completion Agreement Form Signed by Property Owner 

D Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature Date 

^Mk^ 

30056125 

iniiMi 

Superfund 
TECHNOLOGIES, INC 

Property Summary 

Date: ll/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov 

Property Address: 1727 N 54 St. SAID #: 84939 

A. Executive Summary: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 10/13/2009 

ii. Work Began: 10/26/2009 

iii. Close-Out Date: 10/27/2009 

B. Enclosures: 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Advance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracking Form 

7. Property Access Assessment Form 

8. Neighbor 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. Property Close-Out Check List Signed By EPA 
TBCaiNaLOCIBS,INC.~ 

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 

propertv located at -f ^ J ? ^ / J ^ ^ ^ ^ 7^^ C>yy/9/yyP ^ /V ^ 

The EPA requests your pennission 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 

caimot 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 concems that I, as the property owner, may have regarding soil 

cleanup at my property. 

{^ YeSjJJiave,/€a9)and understand the paragr^h above. 

Signature 

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)812-0223. 

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). 

Property Access Granted By: 

(Please Print Name) 

Property Owner Signature: 4-/%­

(Date) 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 AAedical 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 
TBCHNCNLOGIBS. UMC 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner — g^se print) 

RESIDENT NAME: K^ L ^O'V^ . \\VVCLy\ U "^ V-gAjtirv f Crnvxes) Renter 

RESIDEN DENTT ADDRESS: V- , IA \ ^-. I 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

cell 

OWNER'S TELEPHONE NUMBER - HOME: (^ClZ ) 5\^ ' ' ^^^^**^Q'^= (^^Z \ S^tM^S'S ' 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 3 > 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.) 

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

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

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." 

U A /d./S-O^ ^•HQW ^ P/^r^r 

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 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9588 

Fax: (210) 579-6577 
TECHNOLOGIES. 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? ^ Q 

Notice needg^^ \ \^^^ ^ \)^^ft . 5cnip\ ^ 

Number to call to give notice: Z W .Qo^ S j ^^Z''^ij^ ^ ^ 

Whom we are giving notice to: \\C:>me.OU>rier' ITUai^u^ d^d ^ 

Home Owner's Signature 

^Q^L^-Si^^. 

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-STABILIZATION 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. 

OWNERSNAME: fCfQOu^^--' 

PROPERTYADDRESS: :Z^:2 ^ Ay ^4 ^ S7^ ^ ^^y^^Ayy^^ 

BVID/SAID: ^^^^ ^c^ S 

. ,CX^..^A,(b^cy-^ HOMEOWNERS SIGNATURE 

PRUDENT REPRESENTATIVE SIGNATURE : CK^^^ S^^^ 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

l\)ooe^ 

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 

ACCESS INFORMATION TRACKING SHEET 

^ ,-,27 N S^S/ BVID : ^'^^Jl PROPERTY ADDRESS 

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 \ 

A / \ 1 1 O . _ ll 1 ^, • .. ,D y /^*^/t^J^-<e—6/ 

^ 0 f J7 C>1 0'\/i^' ^ -"-i UJA^] ty y 

' 1 ^ 

v.'U 111 111 CU1 5 . 

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 
TECHNOLOGIBS, INC 

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? 

Ifyes, is any ofthe stucco or asbestos damaged or cracked? 

Ifyes, 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. 

-^^yy 

Does this property require lots of scrapping? 

Does this property require a lift or scaffolding to reach upper levels? 

y O 

Does this property have lots of plants or items in areas where painting is 

required? 

Does this property have any significant structural damage? 

y 

Ifyes, 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? 

y ^ 

If yes, describe location of garage. 

Does this property have aluminum siding? 

hy) 

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

r-\) 

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

shingles as siding)? 

Ifyes, EXPLAIN? 

Is this property vacant or occupied? \ 

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 
40L0GIBS.INC 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTYADDRESS: JT^^^J?.: ? A,/ 4"<g y y ^^/V^/J^ ^ xt^ T 

BVID: S'^ScF. ^ 

The following notes are for the benefit of paint crew only. 

Paint Yes Paint No Location Paint Description 

Siding A \ r^OVvvw^ -

Soffit •> I 

Fascia I I 

Comer Trim ±y^ 

Window Trims 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

^ 

T 

r 

^ 

y

-y 

; ^ J ^ 

y r

 ,,^ Yv> 

,iy^ 

Front Porch Floor 

.^ ^ - ^ :L<*1 . 

Front Porch Railings 

y^ 

Front Porch Steps 

Siding Baseboards 

Foundation 

(n. W'«^<° - ^ , £ v ki^ ^ tO>Vg >^^ ^ py?.<>^/i 

P^ILJX^:^ ^oiJ r UL'U ^ 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signaturer.: ^^cyV^[\c\^ ^ ^A^^^» ^ Date: (b . \2'0 ^ G^^i^^ y 

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 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

pJO 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

i^ 0 

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 
TECHNOLOGIBS. INC 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

rjx' ^ NJ ^M si" 

PROPERTYADDRESS: i- / • -^ 

BVID/SAID: ^ \ \- ^ f 

PRUDENT ASSESSMENT REPERSENTATIVE: 

g^4 ¥^^ 

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 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

ijj[ I 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. 

'^ean ^ lO l3|oq 

^cipien :)ient O ^ ^ i i( n^ ^^^ Dat®e '

Signature of ^^ u

 IT 

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. 

O/^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 

below and that the occupant was unavailable to sign the confirmation of receipt. 

I further certify that I have left^ copy of the pamphlet at the unit by sliding it 

undei^he door. 

Printed namqjof person certifyir^g Jj Attempted delivery 

date and time 

lead pamphlet delivery 

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). 
TECHNOLOGIES, INC 

Checklist for the Worksite Hazard Analysis 

Address: 

\ y

Crew: Date: ^0[2,t|zJUo^ 

Item OK? Hazard Corrective Action 

Overliead Lines » u3 I^^ aiw>ft^Ve 3pfti<^/^ ^ftVL^ iH "fci Wu . ol-tbt ^U K 

In-transit Veliicle Clearance 

Levels around high wires _kk. Vehicle Clearance around 

high wires when working lOft^ 

Phone lines N ^ 

Cable lines JSU L 

Gas Line JLlr_ 

Water Line JLfe-

Sewer Line 

-KiL 

Septic Tank -HiL 

Propane/Butane 

wA 

Access to/on Property _MA_ 

Neighbor Access Required _ii*L 

High Traffic Area 

- H ^ 

Garage J ^ .AMsolxui. 

•t''--f Structures JHA-

Driveway J!4i ^ 

Sidewalk _kAL 

Foundation 

Retaining Walls 

Fences 

Trees 

Foliage 

General Condition of yard 

Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

^ ^ cSx^^e^fe' 

?rew Foreman/ Sub-Cdtatractor'' Site Safety Officer yeyoi/i 

^ Qohy,Wf?D(a{yL(7 

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 lone: (402)504-1004 Phone: (210)822-9588 

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

I^WM B I 
Douglas County Account Information http://douglasne.nianDing-online.com/DouglasCoNe/static/accountinfo. :.n^v3] .

Douglas County, Nebraska Propert y Record - R2409790000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VleW On Ma p Information is valid as of 2009-9-29 Treasurer's Tax Report 

New Feature ^ ^ •* Auto Sales Search 

Owne r 

REGAN KEVIN M 

ETAL 

1727 N 54 ST 8H9^1 

OMAHA NE 68104-0000 

Propert y Informatio n 

Key Numtyer: 0979 0000 24 

Account Type: Residential 

Parcel Number: 2409790000 


Parcel Address: 1727 N 54 ST 

OMAHA NE 68104-0000 

Legal Description: WASHINGTON HI LL LOT 6 BLOCK 2 N 63.5 W 136 FT 63.5 X 136 

Value Informatio n 

Land Improvement Total 

2009 $13,700.00 $224,700.00 $238,400.00 

2008 $13,700.00 $224,700.00 $238,400.00 

2007 $13,700.00 $224,700.00 $238,400.00 

2006 $13,700.00 $169,800.00 $183,500.00 

2005 $13,700.00 $169,800.00 $183,500.00 

2004 $13,700.00 $169,800.00 $183,500.00 

Sales Informatio n 

Sales Date: 2008-10-17 

Deed Type: WD SooAr; 2008 Page: 104141 

Price: $250,000.00 

Grantor: Genoble Brett Joseph Etal 

Grantee: Regan Kevin M Etal 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 2006-09-01 

Deed Type: WD Book: 2006 Page: 105131 

Price: $247,500.00 

Grantor: Sawyer Travis R etal 

Grantee: Genoble Brett J etal 

Valid/Invalid: Valid 

lof4 10/9/2009 10:16AM 
Douglas County Account Information http://douglasne.rnj«Bing-online.coni/DouglasCoNe/static/accountinfo. i.n^B|i .

Exclusion Reason: 

Sales Date: 

Deed Type: 

Price: 

Grantor 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Sales Date: 

Deed Type: 

Price: 

Grantor: 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Sales Date: 

Deed Type: 

Price: 

Grantor: 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Sales Date: 

Deed Type: 

Price: 

Grantor: 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Sales Date: 

Deed Type: 

Price: 

Grantor: 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Land Information 

Acres SF 

2005-07-29 

WD BooAr; 2005 Page: 093291 

$239,750.00 

Jeffrey Metzner etal 

Travis R Sawyer etal 

Valid 

2002-05-15 

WD Book: 2211 Page: 441 

$195,000.00 

Valid 

1999-02-20 

D Book: 2119 Page: 742 

$180,000.00 

Valid 

1996-11-21 

D Book: 2050 Page: 326 

$139,500.00 

Valid 

1995-04-23 

D Book: 2003 Page: 297 

$118,500.00 

Valid 

Units Depth Width Vacant 

2 of 4 10/9/2009 10:16 AM 
Douglas County Account Information http://douglasne.maMaing-online.com/DouglasCoNe/static/accountinfo. rn^Mai .

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.19 8704.0 1.0 136.0 64.0 No 

Improvemen t Informatio n 

Building 1 

-mr 

Verified 

» >k Second fkKT _. _ 

" 9S50FP » " 

,(y»OFT- (0­

not 

_S2J!_ 

TWO STORY 

10090 FT 

CLICK TO ENLARGE IMAGE 

Square Footage: 1994.0 Percent Complete: ! 100 0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Masonry Common Brick Units: 1.0 

Interior: Drywall Baths: 3.5 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Hip Stories: 2.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1938 1938 71 

Detail Type Detail Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Appliance Fireplace Masonry 1.0 

Basement Bsmnt Block 8 ft 1069.0 

Basement Finished 445.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 3.0 

3 of 4 10/9/2009 10:16AM 
Douglas County Account Information http://douglasne.maii3ing-online.com/DouglasCoNe/static/accountinfo. i.m^mi] .

Fixture Bath Half 1.0 

Garage Attached 240.0 

Porch End Screen 96.0 

Porch Slab Roof Ceil 96.0 

4 of 4 10/9/2009 10:16 AM 
sss^iffisr 

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

SAID: ^^-^J ^ 

Property Address: ^-^^I? - x / .^^ X S 7 ^ 

Owner's Name: 

y/y-^-ypY >^^g^>o»^ 

S.NO Performance Standards/close-Out Criteria 

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

excluded areas? This would include painting of other associated 

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

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

2 Was all scraping and other preparation work completed 

satisfactorily? 

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

painted with two top coats? 

4 Are all 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 

and also remove any other generated debris? 

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

condition? 

7 Was the paint products utilized equivalent to a 30 year 

product/quality? 

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

cones, barrier tape etc properiy removed? 

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

contractor? Any property damage needs to be completed prior to 

the EPA Ciose-Out 

10 Are there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

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

that have been left unresolved? 

12 Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Prudent Representative Signature 

Date: 

Property Owner Signatup \(:J}ip[\r~~^ 

Date: 

Yes NO 

y 

/ 

y, 

v / 

v/ 

y 

v/ 

\ y ' 

y 

\ y " 

y 

y 

y 

8080 Ward Parkway, Suite 405 250S N. 24" street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City; fMO 64114 Omatia, 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