## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID : 2021 4 Date : 12/27/200 8 Address : 132 5 S 2 6 S T Remediatio nContractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S ^ Vide o o f propert y (DVD ) ?f

Executiv e Summary w Signe dAcces s Agreemen t for subjec t property 0

^ Paintin g Agreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D Photograph s Sf

Satisfactory restoratio nsigne db y Property Owne r 0 Property close-ou t chec k lis t signe db y EP A H' Property informatio nfromDougla s County Assessor' s Offic e D D D

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### "Signa^S e Date 4030800 7 Superfun d

### PROPERT Y SUMMAR Y Date : 12/27/0 8 LB PSTABILIZATIO NEP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r

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### Propert y Address : 132 5 S 2 6 S T SAID : 2021 4 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : Non e A. 2 Issue s Resolved : Non e

A. 3 Uniqu e Findings : Non e A. 4 Othe r Relevan t Information : Non e Acces s Date : 11/17/200 8 Wor k Began : 11/19/200 8 Closeou t Date : 12/1/200 8 Enclosures : 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 . Tracldn g For m 8 . Dougla s Count y Assesso r Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES , INC .• • 

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O^- j s ' AJ o JV^ ^ ENVIRONMENTAL ^ CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address:/33^ ^ S 3i Q S ' Date : Phone : 

# BVID : aoaN 3H$-"7 5 1.5' Plan t & Pennanen t Landscapin g T o Remai nI nPlac e Iteiii # 

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### Propert y Owne r Pruden t Employe e Signature ^ Signature : 808 0 Wtar d ParkMy , Suit e 40 S 260 8 N . 24* " Strtat , Sifi b 308 4242 Medica l Oitve , Suit e 428 0 nmah a MAhrasIr a M11 A Sa n Antnnl n TVTe49 0

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Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t (Contrac t #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectia nAgenc y (EPA ) t o stabiliz e Lea dBase dPain t (LBP ) a t anumbe r o f propertie. ^ locate di nOmaha , Nebraska , includin g th e property locate dat__l225_ S ^^ . ' ^ Th e EPA request s you r pennissio nt o allo w Pruden t t o perfor mLB PStabilizatio nat Ai s property . B y signin g thi s form , ^ e propert y owne r grant s pennissio nt o Pruden t t o perfor mactivitie 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/tensat verifie s tiiat the y hav e receive dth e LB Ppamphle t "Renovat e Right. " I f

yo u hav e any question s abou t th e LB Pstabilizatio nplanne dfo r you r property , pleas e contac t Pruder.1' s /^rfminii^tiv e Clerk for th e Lea dBase dPam t Stabilization , Mrs . Debora hAkerele^ohnson . at

(402 ) S04-1004 . Genera l question s abou t tiie Omah aLeadSit e cleanu p ca nb e directe dt o the EP A Publi c hifonnatio nCenter s a t (402 ) 731-304 5 (Souti i Omah aoffice ) o r (402 ) 991-958 3 (Nort hOmaha . office) . (Please'PrintNtunl l PfMiMtvOwnerStoudmr . 2y^^JJ^t^-^i^U ^ ^y^.^'d^ ^ U (Signature ) ^ U ' ( 7 'O H (Date ) PROPERT YINFORMATIO N (T o b e cenplelc d bj rrcttdCBt aad/o rpropert yowne r­ please priDt ) 

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^4 - I P RENTAL , PROPERT YOWNE D BY : OWNER«IIAIIINOAODRE88 ; ^^- ^ < ^ OWNER' S TELEPHON E NUMBER . HOME : <Voa > ? ^ "T-75'/^RK ! J )_ NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : O NUMBE R O F OCCUPANT S 7 YEAR S OL D AND OLDER : <3 > NUMBE R OPCHILDRE N UNDE R 7 YEAR S OL D WH O PUYI N TH E YAR D FO R 8 HOUR S O R MOR E PE R WEEK : ^ COMMENT80R8PECIA L INSTRUCTIONS : (l-E . DOOS , ENTR YOATES , ETC. )

AtJTHOIUT Y FO RENVIR(>NMErn'A LRBSPOHS B ACTIONS ; Ti naettvUe t t o b e implcmentet f l>

y OfCERCLA , 4 2 U.&C . 9604 . EPA' s righ t o f

acces s t o th e property isprovide dIb r i nSectio n104(e ) ofCERCLA . 4 2 U.S . C 9605(e) . whichpnvide s eet v fb

r "deteiminin g the need(b r lesponsc , o r dumlfl g ortaUo g an y lespons e actio nunder Ihi s title , o r otherwis e ei ^

# if^.=^ c\ pain t matc h .ferm : Pain t matchin g form : - 7 Propert yaddress : \^^ S ' ^ sv ^ ^ . BViD:5oai U ^oJ r t v ^ 

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# Curren t Sampl e Pre-Renovatio n For m Effectiv e unti l Apri l 2010 . Confinmatlo n ofReceip t ofLea d Pamphle t ^

I hav e receive d a cop y ofth e pannphlet , Fienovat e Right : Importan t Lea d Hazar d

Infonnatio n for FamBies , CNI d Car e Provider s an d School s infonnin g me of th e potentia l ris kofth e lea d hazar d exposur e fro m renovatio n activit y to be perfomie d in mydwellin g unit , i receive d thi s pamphie t tjefor e th e wor k began . r/'<auAog: S Ga>-y.^y:>e:. ^ /t ' / I - O & 

### Printe d nam e ofrecipient Dat e signatur e ofrecipien t // ^ Seif-Certiflcatlo n Optio n (fo rtenant-occupie d dwelling s only ) — Ifth e lea d pamphle t wa s delivete d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e appropriat e bo xbetow . Q Refusa l to sig n — I certif ytha t I hav e mad e a goo d fait h effor t to delive rth e pamphlet , flenovate F^t : Importan t Lea d Hazar d informatio n for FamSes , Cha d Car e Provider s an d Schools , to th e renta l dweiiin g uni t liste d belo w at th e dat e an d tim e indicate d an d tha t th e occupan t refuse d to sig n th e confinnatio n ofreceipt . I furthe rcertif ytha t I hav e lef t a cop y ofth e pamphle t at th e uni t v ^ th e occupant . Q Unavaiiablefbrsignature— I certif ytha t I hav e mad e a goo d fait h effor t to delive rth e pamphlet , Renovat e Righ t Importan t Les d Hazar d Inkmatfo n for FamSes , CNk i Car e provlder a an d Schods , to th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e to sig n th e confitTTBtlo n ofreceipt. I furthe rcertif ytha t I hav e lef t a cop y ofth e pamphle t at th e uni t byslidin g it underthedoor . (jpg^aAi l QLov.y^Va^y v//-/' ? -Of i /C3 0 

### Printe d nam e ofperso n certifyin g Attempte d deliver deliver y dateandtim e e lea d pamphie t delivery 

# A-.x/ro- ^ Signatur e ofperso n certifyin g lea d pamphle t deliver y 130-- ^ <> • ^^^- ^ S ^ 

## (^r^.J^.. ^ .M ^ (^^iO ^ UnitAddres s Not e Regardin g Mailin g Optio n — As an aitematlv e to delivet y in person , yo u ma ymai l th e lea d pamphle t to th e owne rand/o rtenant . Pamphle t mus t be maile d at leas t 7 day s befbr e renovatio n (Documen t vvit h a ceitlficat e ofmailin g fro m th e postoflice) .

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ttDouglas Count y Account Informatio n http://douglasne.mi a|A|g-a|fe i e.com/DouglasCoNe/static/ECCOuntinfo. , Dougla s County , Nebrask a Propert yRecor d - - R221S90000 0 j Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t of 90t h S t - Vie W O P iVIa p * Informatio r 1 i s vali d a s o f 2008-11- 5 Treasurer' s Ta xRepor t i Ne wFeatur e -*-*' * Aut o Sale s Searc h !.__.

Owne r CAMPSE YFRANCE S ETA L 1 132 5 S 2 6 S T OMAH AN E 68105-000 0 i Propert yInformatio n j Key/Vumber : 1 189 0 000 0 2 2 | Accoun t Type : Residentia l 1 Parce l Number : \ 221890000 0 Parce l Address : 132 5 S 2 6 S T OIVIAHAN E 68105-000 0 Lega l Description : SHULL S 2N D AD D LO T1 6 BLOC K1 0 5 0 X 12 7 1 ­ I Valu e Informatio n 1 Lan d > Improvemen t i Tota l 200 8 $4,900.0 0 $75,000.0 0 $79,900.0 0 200 7 $4,900.0 0 ' $75,000.0 0 $79,900.0 0

, „ ' 200 6 1 $4,900.0 0 $63,600.0 0 1 $68,500.0 0 200 5 $4,900.0 0 $63,600.0 0 ! $68,500.0 0 200 4 ! $4,900.0 0 $63,600.0 0 1 $68,500.0 0 j 200 3 $4,900.0 0 $63,600.0 0 $68,500.0 0

'• • •" • ­ 1 Lan d Informatio n Acre s 1 S F 1 Unit s j Dept h 1 Widt h , Vacan t 0.1 4 i 6350. 0 1. 0 ' 127. 0 50. 0 1 N o Improvemen t Informatio n Buildin g 1 ]

# w- w e.com/DouglasCoNe/static/accountinfo. , Dougla s Count y Account Informatio n http://douglasne.ma||g i Squar e Footage : 1520. 0 Percen t Complete : 100.0 % ; J Perimete r 0. 0 Quality : i Averag e Uni t Type : . Condition : Averag e

Buil t As : 1 1/ 2 Stor yFi n : Cond o Squar e Footage : 0. 0 1 HVAC : Centra l Ai rt o Ai rj Rooms : ' 8. 0 Exterior : Fram e Shingl e Units : 

### 1 1. 0 Interior : Piaste r\ Baths : ; 2. 0 Roo f Cover : Compositio n Shingl e ! Bedrooms : : 3. 0

Roo f Type : Gabl e | Stories : ! 1- 5 Floorcover : Allowanc e \ Foundation : ^ Bloc k 1 i „ , „ _. 1 ! 1 j Sprinkle rSquar e Footage : i0. 0 YearBuil t \ „ ^^^ ^ ^ i /^'T! ^ Remodele d 1 Remodele d 

# 1 '"r.i"'' ' ; '^^'«'-« - ! 189 0 j 0 j 0 % \ 189 0 i 1 11 8 1 j i Defa/ 7 Typ e 1 Detai l Descriptio n Units ] i Applianc e \ Allowanc e 

## „ . .-"-oJ Basemen t Bsmn t Bloc k 8 f t 966. 0 ; Basemen t 1 Finishe d 

### 600. 0 1 Fixtur e 1 Bas e Fixture s 1 1. 0 Fixtur e Bat h Ful l 2. 0 ! 

## 1 ^ Garag e Detache d 

## i 384. 0 : Porc h Soli d Wal l ; 120. 0 Use r Atti cFul l Finis h 554.0 J L .

I 1 /»'>i'^/\/\ 0 •I'^.r* ^ T^ » MDougla s Count y Account Infonnatio n http://douglasne.manwog-Mliie.com/DouglasCoNe/static/accountinfo. , aoHog-^ljii i -1 ;3pi i Firs t Floo r See.Oi q t? . 1 i=f Secora l Floo r 55 < 0 s q n ; Jt " ' ' ^ 

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CLIC KT O ENLARG E IMAG E

1 1 / I -> /^r-A O m.A- ^ n i gJtiii e 26 , 200 8 Oatcs t revision ) 

# EP A Propert y Close-Ou t Form(Lead-Base dPain t Stabilization ) Blic k an dVeitc hPropert y I D Nnnit>e n . ^ ^ ^ Prop«Tt y AdJim * OwniR^iiNaaMi : 

# Perfofmatic e Standard s /Close-Oti t Criteri a..______ _ ye s n o 1 .Wa i to attir e stmcture(s ) paintei dwh hth e exc«ptionof (bt stated , cxcludt dareas ? Thi s woul d includ e paintin g o f othe r associate dfoaturei includin g fascia , caves , siding , al l triin , porches , box /

. .baBtt.ooltinntt,ndla.^an dexterio r surface s of garages . ' 2 .WiaaUscraiHi Q sn dOthe r preparatio n work cotnpletedsatis&ctor i / 3 .

We na U require dapeias o f th e stroctupe(s ) prime da s neede dan dpainte dwithtw o to p coats ? / 4 .Wi i th e pain t product s utilize dequiv-alcnt tc a3 0 ysai produa/qualiry ? / 5 .Art al l o f tli e area s wher e contamiiraitc dmaterial s hav e bee nspille dthoroughl y vacuumed'cleaned ? / 6 .Dk l Ib e ctintrectiorcoUect/vaciia mal l Min g andscrape dpai mchip s o nth e entir e i»^ ^ / nMdwgyg.allq^^imys.pnblt e acces s area s an dals o remove any otiiC T generate ddebi ^ 7 .b fte gras s ve atha t stntound s di e stracture(s ) i nreasonabl y goo dcondition ? / 8 ,Ar aa

U Item s suc ha s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r tape , etc . properly / rtOJovcd?. _•- .. . . . _. 9 .U ther e any evidenc e o f propert y damag e tha t wa s don e by th e contractor ? An y propett y damag e / "

. . Jeat e t o ti » ewnpliite dprio r t o di e EP A Close-Ou t . 10 . A ntiiat an y propeit y hem s tha t wer e temporaril y re>locatedb y th e contracto r tha t nee dt o b e / ntovedbadc ? ll i Arethere an y (known ) Ungenit g issue s wit htbe propcm - ownsr^s ) Lha t hav e bee nlef t unresolved ? / Othe r Considerations/Propert y Owne r Discussions/Additiona l Wor k tha t i s Require d

EP A COR/RcSpt^s^entatiVi e ,^^,..-,,-A a 

### Date . ..jxi./.'//o:i- .• •



## Pruden t Propert yClose>Ou t For m (Lead-Base d Pain t Stabilization ) SAID:_J04t j Propert yAddress ; 13RS ^ S ' ^U > S"T ~ Owner' s Name ; ^Ku>yvC£. S . <C!^.inr\J3SPJ U 

## Performanc e Standards/close-Ou t Criteri a YE S 

### N O Wa s th e entir e structure(s ) painte d vi/rt h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d 

### l y includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , colunnns , rails , an d exterio rsurface s o f garages . 2 .Wa s al l scrapin g an d othe rpreparattio n vtfork complete d satisfactorily ? 3 .Were al l require d areas o f th e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 .Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 

## l ^ 5 .

Are al l o f th e areas wher e contaminate d material s hav e bee n spille d 

# u thoroughl yvacuumed / cleaned ? 6 .

Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , 

## L ^ roadways , alleyways , publi cacces s areas an d als o remove an yothe rgenerate d debris ? 7 .I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? L.*:: ^ 8 .

Are al l tten u suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . 

### i ^ properl yremoved ? 9 .

I s ther e an yevidence o f propert ydamag e tha t was don e byth e contractor ? An ypropert ydamag e 

# m L ' need s t o b e complete d prio rt o th e EP AClose-Out . 10 . Are ther e an ypropert yitem s tha t wer e temporatii yre-locate d byth e contracto r

tha t nee d t o b e move d back? 11 .Are ther e an y(known ) lingerin g issues wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? L ^ Othe rConsiderations?propert yOwne rDiscussions?Additiona l Wor k tha t i s Require d



## CLJ\J W <gX ^ 

## esentativ e 

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