7 

TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: ni^^ \ Date: Ci&j Si\'2 fief) 

Address: ifSl ^ ft»/^C^PTTF . CT . 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

y Executive Summary 

Signed Access Agreement Form 

Advance Notice Form 

Pre-Stabilization Video Agreement Form 

Access Tracking Form 

Property Access Assessment Form 

Neighbor Access Agreement Form 

Paint Match Form 

Pre-Stabilization Property Safety Assessment Form 

Work-Site Hazards Analysis Checklist 

ef Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

Douglas County Assessor Property information 

Property Completion Agreement Form Signed by Property Owner 

Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. SiIgnatur ; e 

4l:2jijio 

^ f Date 

30055202 

iHUIIII 

Superfund 
TBCHNOLOCIBS, INC 

Property Summary 

Date: 8/3*72009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of; Aug. 

Property Address: 4516 Burdette St. SAID #: 57991 

A. Executive Summarv; 

a. Issues Encountered; NONE 

b. Issues Resolved: NONE 

c. Unique Findings; NONE 

d. Other Relevant Information; 

i. Access Date: 7/20/2009 

ii. Work Began: 7/27/2009 

iii. Close-Out Date; 8/18/2009 

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 Tracldng 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 
inSfNOLOGIBS. IN C 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. Environmental Protection 

Agency (EPA) to stabiUze Lead Based Paiiit/LB^ at anumber ofproperties located in Omaha, Nebraska, including the 

property located at A-^i U ^Uuu&g ^ j r dAuMt.^ fJ ^ 

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

cleanup at my property. 

Yes, I have read and understand the paragraph above. 

ature of Property Owner 

Date 

Ifyou 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 Grmted By IS Granted By: 

^ (Please Print Name) 

Property Owner Signature: 

"? [^»/fl°l 

(Date) 

8080 Ward Parkway, Suite 405 2505 N. 24"* Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 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 
TECHNOLCXSIBS, INC 

PROPERTY INFORMATION 

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

RESIDENT NAME: ^OpZ — ioCM 2 Owner ^eitei O 

RESIDENT ADDRESS: 

^S\( 0 G>Vjrc3€V\:€. S ^ 

IF RENTALL,, PROPERT PROPERTYY OWMG
 0WM5DD BYBY:: / 


fAi7^K^eslt\ t 

OWNER'S MAIUNG ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: tWlx - \ d X 4 CKTyWORK: (4Q2-^ \0l) . "H H l ^ 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 2 . 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.) 

MO 

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. %04. EPA's right ofaccess to the property is provided for in Section 104(e) ofCERCLA, 

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

otherwise enforcing the provisions ofthe title." 

I 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 

i Phone: (816) 363-3703 

I 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? Ifyou 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: r - z K m^u^ 

Number to call to give notice: '^ ^ 6- ^ * ^ l\J\ 

Whom we are giving notice to: J^ ^ f^ ' b ( a ? 

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 
^^'"'''^ ^ 

R 

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: ^AQ^K ^T^sVe ^ 

 ^S\Q> ^oTfd^Ue ^ \ PROPERTY ADDRESS :

BVID/SAID: S7^^ 1 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVE SIGNATURE: 

0^£i±H ^ 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

^ujliAS^ ^ 

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 
-STwsnj; 

(2) % 

TECHNOLOGIES ay , INC 

ACCESS INFORMATION TRACKING SHEET 

BVID: 5 7^9 1 PROPERTY ADDRESS: M S | G RU3Z.(^€AXC Sd 

l%ik fyfaWt 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 ACCESSO ! R CONRACT DETAIL a|n £iOc\uL. .^'p ^ vnism OYtrp^y ^ 

tOi^A 4(S4Aft«Afe VtM^Jl^ 

l\v>\n W'iS^r) Kh^v^ ' ^r^h-J ^7 fiv!>>\M^. 

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, 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? 

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? 

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, 1 

Does this property have a garage? 

If yes, describe location of garage. 

Does this property have aluminum siding? 

yKj:) 

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? 

Is this property vacant or occupied? 

t>c<uy07 -—o/ 

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 
TECHNOLOGIBS, INC 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

y ^ 

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 
TEC3INOLOGIBS, ] 

PAINT MATCHING FORM: 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: ^5IG> fburde^tl e 6 + 

BVID: Sl^^ t 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature LMM^jd^ 

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,] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 

BVID/SAID: Sl^^fl 

PRUDENT ASSESSMENT REPERSENTATIVE: 

******IF SAFETY RISK PROPERTY MUST BE TURNED OVER TO 

KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A CREW/SUB. 

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.) 

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 

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 

Checklist for the Worksite Hazard Analysis 

Address •.^J^lk 

Crew: Date: 

Item Hazard Corrective Action 

Overhead Lines fe^E 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Oearance around 

high wires when working 

Phone lines 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 01 ^ 

Neighbor Access Required U^O—CJA^dayxji ^ "^K^utAJt tm : r uJiAJt "p^r 

High Tralfic Area 

Garage fc 

Structure '^<7^r,ry 

Driveway 

Sidewalk 

Foundation •<a"> 

Retaining Walls 

roi^o-^^ife*^'V^ b^u^A^pL >t- du:-^ Qft>/-._Sk-^ Fences ^^^2^^^ 

Trees 

Foliage 

General Condition of yard O i ^ 

Damaged Areas: sink ff^ a-­ holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

^dcL<j dCL^r^ r)^^r ^ dc^oy 

Crew icer 

8118O Ward Parkway. Suite 405 2505 N. 24" Street, Suite 308 4242 Medical Driv/e, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

F lone: '816) 363-3703 Phone: (402)501-1004 Phone: (210) 822-9588 

F.!X(8i-3) 363-3707 Fax: (402)504-1006 Fax: (210)579-6577 



Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

Q^l have received a copy of the patnphlet, 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. 

1^ >^. CA \^^CK . 

&inted 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. 

Q 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. 

ij^Unavailable 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 a copy of the pamphlet at the unit by sliding it 

under the door. 

gonj^el: fiA\M)c&h^ 7-17- ot 

PrinteoTnam 301 e of person certifying 

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). 
Douglas County Account Infoj(»tion Page 1 of3 

Douglas County, Nebraska Property Record - R0533010000 

!«*«,«,-,•;«« ;» w-,i;^ ^ o « * onn o

Information is valid as of 2009

 c

-6-16

 -ie .vEW Fesiura - Parcel Dimens

Print Report 

ions available @ scale 0-50 tt west of 52nd St - Vie w o n Ma p 

 Treasurer's Tax Report 

Xs'jy : Scij-^rs ->-5-> Auto Sales Search 

Owne r y \ 

BRESLEY MARK E

14468 TIBBLES ST

OMAHA NE 68116-0000

 '^*-' \

 ^ ^ ^ 

J 

 v ^/ \ V \ f­

^n^'M 

Property Informatio n 

Key Number: 33010000 05 

Account Type: Residential 

Parcel Number: 0533010OOO 

Parcel Address: 4516 BURDETTE ST 

OMAHA NE 68104-0000 

Legal Description: BAKER PLACE LOT 22 BLOCK 5 44 X 128 

Value Informatio n 

Land Improvement Total 

2009 $6,000.00 $55,700.00 $61,700.00 

2008 $6,000.00 $55,700.00 $61,700.00 

2007 $6,000.00 $55,700.00 $61,700.00 

2006 $6,000.00 $55,700.00 $61,700.00 

2005 $6,000.00 $53,700.00 $59,700.00 

2004 $6,000.00 $53,700.00 $59,700.00 

Sales Informatio n 

Sales Date: 2006-08-14 

Deed Type: SWD Book: 2006 Page: 097941 

Price: $51,300.00 

Grantor: Centex Home Equity Company 

Grantee: Bresley Mark E etal 

Valid/Invalid: valid 

Exclusion Reason: 

SalesDate: 2006-01-05 

Deed Type: TRD Book: 2006 Page: 002910 

Price: $64,000.00 

Grantor: Eric H Lindquist 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R053... 7/7/2009 
f s^'S,':^^'Vr' n'-^y* w/i.i^-'iti.A'J * --w--*''! '*'''^«fi"-^-7fr.'' ••• 'f^'i.^^'tr^i'iifcT,??!*' 

Douglas County Account Infoj^fction Page 2 of 3 

Grantee:

Valid/Invalid:

Exclusion Reason:

 Centex Home Equities 

 invalid 

 sale to Mortgage - Bank 

SalesDate:

Deed Type:

Price:

Grantor: 

 1998-04-30 

D | 

 $55,889.00 

Book: 2090 Page: 321 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Valid 

SalesDate:

Deed Type:

Price: 

Grantor: 

 1997-06-12 

D I 

$27,574.00 

Book: 2088 Page: 130 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Valid 

Land Informatio n 

Acres

0.12

 SF 

 5632.0 

Units 

1.0 

Depth 

128.0 

Width 

44.0 

Vacant 

No 

Improvemen t Informatio n 

Building 1 

»r '•"a\v^' 

y l':iu 

W{j^iBCLICK TO ENLARGE IMAGE 

Square Footage: 844.0 Percent Complete: 100.0% 

Perimeter 1 0.0 Quality: Fair 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R053... 7/7/2009 
Douglas County Account Infogfctio W n Page 3 of3 

Unit Type: Condition: Average 

Built As: 1 1/2 Story Unfin Condo Square Footage: 0.0 

HVAC: Central Air to 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: 1.5 

Floorcover: Allowance Foundation: Bloc! c 

Sprinkler Square Footage: 0.0 

w.ar a„nt ^®^'' Percent 

rearauni Remodeled Remodeled '"'•tS'/'" '^y-""*^' 

1925 1989 0% 1925 85 

Detail Type Detail Description Units 

Add On Unfinished Attic W/floor 824.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 824.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 216.0 

Porch Slab Roof Ceil 100.0 

Porch Wood Deck 144.0 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R053... 7/7/2009 
TECHNOLOGIBS. INC. 

EPA Close-Out Form (Lead-Based Paint Stabilization) 

BVID: .'ll'^^ l 

Property Address: Lj^ U ilurJ^y^ C^ 

Owner's Name: T^l^rk 'Rr^sl^y 

S.NO 

Performance Standards/close-Out Criteria 

1 

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

excluded areas? This would include painting of other associated 

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

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

2 Was aii scraping and other preparation woric completed 

satisfactorily? 

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

painted with two top coats? 

4 Are all ofthe areas wherie contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

5 

Did the contractor collect/vacuum ail 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 properly 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 Close-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 

EPA COR/ Representative Signatur^ii^^^^pj/^^-^^^^^VcAfl ^ 

Date: ^/tt>lo'J 

Yes 

^ 

y 

y 

y 

y 

y 

y 

y 

NO 

y 

K 7 

y 

7 
TECHNOLOGIES. INC. 

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

SAID: £11^1 

Property Address: v.r/z IS/jfiJf^ g F 

Owner's Name: /^Mife l f^/?S<kr { 

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 ofthe 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 properly 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 Close-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 

Yes 

t 

\ 

i 

t 

X 

X 

X 

y 

NO 

X 

)< 

X 

> 

Prudent Representative Signature 

Date: 

Property Owner Signature: 

Date: ^If^f o 7 

80a0 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebrasl<a 68110 San Antonio, TX 78229 

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

Fax: (813) 363-3707 Fax: (402)504-1005 Fax: (210)579-6577