TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 25030 , Date: 12/02/08 

Address: 3165 Myrtle Ave 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of property (DVD) 

B^ Executive Sximmaiy 

B^ Signed Access Agreement for subject property 

[F Painting Agreement 

D Settlement docimients (i.e., for damage or to replace plants, etc.) 

D Photographs 

0^ Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

\£ Property information from Douglas County Assessor's OfBce 

D 

D 

D 

Signatur^ Date 

40310378 imniMi 


Superfund 
PROPERTY SUMMARY 


Date: 12.02.08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address: 3165 Myrtle Ave SAID: 25030 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Information: None 

Access Date: 09/03/08 

Work Began Date: 


Closeout Date: 10/22/08 


Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOLOCIES. INC. 

mjMK ENVIRONMENTAL &

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 


Address: 3l^ f tOCf^W fiVt^ Date: ^(3/0 ? 

Phone BVID: ^d3 6 •^11 /^^hl6f( 

Plant & Permanent Landscaping To Remain In Place 

Item# 

On Map 

Description and Location i 

'6 

I 

a 


Pre-Existinpr r,nndition of Structures 

Does your Basement have a history of leaking? Yes — No ~ 

Item# Description & Localion 

On Map 6/Me u^oJ{ ^/i/i/k^e 


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Property Owner Prudent Employ 

Signature: ''^^xM^i^k^ 

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

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

Phone: (816) 363-3703 Phone: (402)604-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
25o:5C 


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, incltiding the property located at '^((p^ Dfl(Lri-[<^- /QjJ. 

The EPA requests your pennission to allow Prudent to perform TBP Stabilizatiyii attiais property. By 

signing this form, the property owner grants permission to Prudent to perform activities related to LBP 

Stabilization including scraping paint and painting of the referenced property. Further, the owner/tenant 

verifies that they have received the LBP pamphlet "Renovate Right." 

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

Adminigtrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnsnn^ 

at (402) 504-1004. 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) 

Propeity Owner Signatuie; 

(Signature) ~ ' '(bate) 

PROPERTY INFORMATION 

• (To be completed by resident tnd/or properly o^ner—please print) 

(RESIDENT ^4AME: Renter 

FiESIDENTADOi^SS •sii^<: <>N'yj 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAIUNG ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: 


NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: ^ ^ ^ NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 7 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: "&- -

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

/UTwg ^ 

AUTHORTTY 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 ofaecess tofte property isprovidedfor in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entry 

fbr "determining the needfor response, or choosing ortaldng any response action under this title, or otherwise enforcing «ie provisicns ofthe title." 

4242 Medical Drive, Suite 4250 2505 N. 24* Street, Suite 308 080 Ward Partwray, Suite 405 Omaha San Antonio, TX 78229 , Nebraska 68110 ansas City, MO 64114 Phone Phone: (210)822-9588 : (402)504-1004 hone: (816) 363-3703 Fax Fax: (210) 579-6577 : (402)504-1005 ax: (816) 363-3707 
Current Sample Pre-Renovatio •t
 n Forni 

Effective until April 2010. 

Confinmation of Receipt of Lead Pamphlet 

Q-fflave received a copy of the pamphlet, Renovate FV^t: Important Lead Hazard 

Infbmnatbn for Families, CNld Care Providers and Schods infomning 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 wort< began. 

Printed name of recipient 	 ^t e / :::^. : //^.^j 

Signature of recipient 


Self-Certification Option (for tenant-occupied dwellings onl ^ — 


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


you may check the appropriate box below. 


D Refusal to sign — I certify that I have made a good faith effbrt to deliver the 

pamphlet, flenovate FVght- Important Leexi Hamd Intormation for Families, 

CNld Cam F^vlders and Schods, to the rental dwelling unit listed below at the 

date and time Indicated and that the oocupant refused to sign the confimnation 

of receipt. I further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

•	 Unavailable fbr signaturs — I certify that I have made a good faith effort to 

deliver the pamphlet, Renovate FVght: Important Lead Hazard Infonnation for 

Families, Child Cam 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 

"vthe door. 

'MjjhmML 	 'f/s/df ^-i/if/n 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of pereon certifying lead pamphlet delivery 

?/.^r mu^M liF. 

Unit Address 

Note Regarding Mailing Option — As an altemative to delivery in person, you 


may mall 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). 

^ i^56/<^ 0 6<tfid fed- n ff^d 

pai nt match f brm"^ . . J ^r(i)foll 

Paint matching form: // . Property address: 3>iL^f^ijP-v^ pl^^ 

BVID: ^^^j ^ 

Area : U^/e ;^^'^^^^^^olor : ^ . 5-/ ^ 

Explanation: jS ' ^ d ^ft^/lw^ fiPP^^^' 

Area: Color: 

Explanation: 

Ariea: Color: 

Explanation: 

Area: color: 

Explanation: 

Area: Color: 

Explanation: 

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Douglas County Account Information Page 1 of2 

Douglas County, Nebraska Property Record - R18032S0006:: 

" - - - - " Print Report 

NEW Feature - Parcel Dimensions a^ilable @ scale 0-50 ft west of 90th St - yj.ew..OrLMag | Information is valid as of 2008-7-14 Treasurer's tax Report 

New Feature -4 -» • • Auto Sales Search 

Owner 

WORTIWAN TERRI E 

16^ \Of,V\ 


3165 MYRTLE AVE 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number: 0328 0000 18 

Account Type: Residential 

Parcel Number: 1803280000 

Parcel Address: 3165 MYRTLE AV 

OMAHA NE 68131-0000 

Legal Description: MONTCLAIR ADD LOT 120 BLOCK 0 95.15 X 96.9 

Value Informatio n 

Land Improvement Total 

2008 $3,500.00 $94,700.00 $98,200.00 

2007 $3,500.00 $94,700.00 $98,200.00 

2006 $3,500.00 $94,700.00 $98,200.00 

2005 $3,500.00 $94,700.00 $98,200.00 

2004 $3,500.00 $33,900.00 $37,400.00 

2003 $3,500.00 $33,900.00 $37,400.00 

Sales Informatio n 

Sales Date: 1996-10-23 

Deed Type: Book: 2046 Page: 662 

Price: $30,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Widtii Vacant 

0.2 9120.0 1.0 96.0 95.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?acco\]ntno=R18... 8/26/2008 
Douglas County Account Infcrmatio [i^ r n Page 2 of2 

Building 1 

1 1/2 Story Ehi!^ 3165 Myrtle Av 

^^, ^ 

DtlGingt 

i Rut noor . IS^I ^ 

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SOO 34ri FkiBuitnu halo Mi»a u 

CLICK TO ENLABGEJM.AaE CLICK TO ENLARGE IMAGE 

Square Footage: 1814.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

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

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year YearBuilt Physical Age Remodeled Remodeled Built 

1921 0% 1921 87 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Appliance Fireplace Masonry 1.0 

Basement Bsmnt Block 8 ft 1160.0 

Basement Finished 600.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 2.0 

Garage Detached 360.0 

Porch End Solid Wall 160.0 

Porch Wood Deck 400.0 

User See Notes 1.0 

http://douglasne.niapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R18... 8/26/2008 
Prudent Property Ciose-Out Form (Lead-Based Paint Stabilization} 

Owner's Name; "JhiriJ ^ 'U^^r f fY\A\} 

Performance Standards/ciose-Out Criteria 	 YES NO 

Was the entire stnjcture(s} painted wfth the exception ofthe stated, excluded areas? This would 


indude painting of other assodated features inciuding fasda, eaves, siding, ali trim, porches, box 


beams, columns, rails, and exterior surfeces of garages. 
 ^ 

2.	 Was all scraping and other preparattion worit completed satisfactorily? 5

3.	 Were altrequired areas of the structurefs) primed as needed and painted with two top coats? 

4.	 Was the paint products utilized equivaient to a 30 year product/quaiity? 

- y ^ 

Are ai! ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ deaned? ^ 

5.	 Did tiie contractor coliect/vacuum. ail failing and scraped paint chips on the entire property, 


roodvifays, alleyways, public access areas and also remove any other generated debris? y 


7.	 Is the grass area that surrounds the strjcture(s} in reasonably good condition? < 

8.	 Are all itenis such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. 


properly removed? ^ ^ y 


Is there any evidence of property damage that was done by the contractor? Any property damage 


/ needs to be completed prior to the EPA Closa-Out. 

10.	 Are there any property items that were temporatily re-located by the contractor 

/ that need to be moved bactc? 

11.fi^^e there any (known) lingering issues with the property ovmer{s) that have been left unresolved? 

Othe x ^ r Conslderatiorts?property Owner Discussions?Add!tionsl Work that is Required 

R Cri,j,^^£y ^a/^dJo-H A yt^ 

Prudent R< esentative P^A ^ }]Urv{)J!i^