## TRANSMITTA Lof OMAHA LEA D SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAI D # : 2661 8 Date : 12/02/0 8 Address : 242 1 Decatu r S t Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S

^ Vide o o f propert y (DVD ) H Executiv e Summar y mSigne dAcces s Agreemen t fo r subjec t propert y I ZPaintin g Agreemen t D Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc. ) D Photograph s 0 ^ Satisfactor y restoratio n signe db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A [ 7 Propert y informatio n fromDougla s Count y Assessor' s Offic e D D , D

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4031037 9 

# 11 1 Superfun d

### PROPERT Y SUMMAR Y Date : 12.02.0 8 LB PSTABILIZATIO NEPA CONTRAT EP-R7-08-0 7 Monthof : December Propert y Address : 242 1 Decatu r S t SAID : 2661 8 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : None A. 2 issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 10/15/0 8 Work Bega nDate : Closeout Date : 11/20/0 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 nForm 6 . Pain t Matc hFor m 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio nPag e 9 . EP A Propert y Closeout for m 10 . Propert y Completio nAgreemen t

TECHNOLOCIES . INC .ENVIRONMENTA L& CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : '^QZ I T::i£C^ai W r_c..^_^^ri^ . 3 1 Date : I W

## r y OT - *^»V^ . 

## /^V^"'^ ? - Phone : %2Mq ^ j^.p^I^JQ-^WTD : ^ZL?U>i ? Plan t & Pennanen t Landscapin g T o Remai n I n Plac e Item # Des c riptio n an dLocatio n O

n Ma p 

# (iM l^o0'l \- foo/j c

Pre-Existin g Conditio n o f

Structure s Does yo ^ Basemen t hav e ahistor y o f

leaking ? Yes ^ - N o Item # Descrip t o

n & Locatio n O

n Ma p i l 

# n U \p(f S < ^ ' 

## t l 

# u 

# J^QTC ^ Pruden t Empjoj^e e Signature : 

# 'k^A^_­ t . 808 0 War d Parlovay , Slit s 40 5 260 5 N . 24* * Street , Sult a30 8 424 2 Medica l Drive , SuH e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a6811 0 Sa n Antonio , T X 7822 9 Phona : (816 ) 363-370 3 Phone : (402 ) 504-100 4 Phone : (210 ) 822-958 8 Fax : (816 ) 363-370 7

# Z(-e(^l % Pruden t Technologies , Inc . (Prudent) i s unde r

contrac t (Contract #EP-R7-08-07 ) wit hth e U , S . Environmenta l Protectio nAgency (EPA) t o stabiliz e Lea dBasedPaint (LBP) a t anumbe r

o f propertie s locatedi nOmaha , Nebraska , includin g tiie propert y locateda t 'Z.QZ- I T-Vryt^LL r ,S- f The EP A request s you r

pennissio nt o allo w Pruden t t o perfor mLB PStabilizatio na t thi s property . B y signing thi s form , th e propert y owne r

grant s pennissio n t o Pruden t t o perfor mactivitie s relate dt o LB P Stabilizationincluding scraping paint andpainting ofth e referencedproperty . Further , th e owner/tensn t verifie s tha t they hav e receive dIhe LB Ppamphle t "Renovat e Right. " Ifyo u have an y question s about th e LB Pstabilizatio nplannedfo r

your property , pleas e contact Prudent' s Administrative Cler k

fo r

tiie Lea dBase dPaint Stabilization , Mrs . Debora hAkerele-Johngnn^ a

t (402 ) 504-1004 . Genera l question s about th e OmahaLea dSit e cleanu p ca nb e directe dto the EP A Publi c InfonnationCenter s a t (402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nortii Omaha 

## office) . . y Propeit y Acces s Gitnte dBy : lis e Prin t Name ) Propeit y Owne r Sigaatuie : 

# Qcddj^^:! ^ PROPERT YINFORMATIO N ccomplete d b yresiden t and/o rpropert yowne r- pleas e print ) RESIDEN TNAME : Rente r RESIDEN TADDRESS : I F RENTAL , PROPERT YOWNE D BY ; OWNER' S MAIUN G ADDRESS ; 

## ••i^?^=^ ( ^o.(^^< ^ ' OWNER' S TELEPHON E NUMBER . HOME : (^^ J ^3 ^ Y* .f*»*»'**< = (49 L \ S Q ^" ^ f ^ NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : # NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : 5L ^ > t

>-- ^ NUMBE R 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. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente db y EP Aunde r tK s agreemen t ar e pursuan t t o Sectio n14 4 o f

CERCLA , 4 2 U.S.C . 9604 . EPA' s righ t ofaeces s t o th e propert y i s provide dfbr hSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entry for "determinin g th e nee dfor response, o r choosin g ortakin g an y response acfio nunde r thi s title , o r otherwis e enforcin g fee provision s ofth e title. "

424 2 Medica l Drive , Suit e 425 0 250 5 N . 24 * Street , Suit e 30 8 0 War d Partnvay , Suit e 40 5 Sa n Antonio , T X 7822 9 Omaha , Nebrask a 6811 0 na s City , M O 6411 4 Phone : (210)822-958 8 Phone : (402)504-100 4 me : (816 ) 363-370 3 Fax : (210 ) 679-657 7 Fax : (402)504-100 5 : (816 ) 363-370 7

# Curren t Sampl e Pre#enovatio n For m Effectiv e unti l Apri l 2010 . Conflnmalio n o f Receip t c f Lea d Pamphle t j ^

I hav e receive d a cop yo fth e pamphlet . Renovat e FVgh t Importan t Laa d Hazan i

Infbrmatio n fo rFamilies , Chil d Ca m Rnowder s an d Sdmd s infonnnin g m e o f th e potentia l risk o fth e lea d hazar d exposur e fro m renovatio n activit yt o b e performe d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . 

# ^^^f<^cA$2>/ ^ ,£l/ /

^/^ ^ Printe d nam e o f reolpient, -Dat e / 

## ^/ l fl^ . (^C.^-rJfQl9''•y\ | Signatur e o f recipien t ^ Self-Certificatio n Optio n (fo rtenant-occupie d dweiiing s only ) — I fth e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychecl < th e appropriat e bo xbelow . •Refusa l t o sig n —I certif ytha t I hav e mad e a goo d fait h effort t o delive rth e pamphlet , Remavat e FVgh t Importan t Lea d Hazar d Intonnatio n fo rFamSies , Chil d Ca m Provider 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 tiia t th e occupan t refuse d t o sig n th e confirmatio n o freceipt . I furthe rcertif ytha t I hav e lef t a cop yo f th e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e — I certif ytha t I hav e mad e a goo d fait h effort t o delive rth e pamphlet , flenovate Righ t Importan t Lea d Hazar d Intonnatio n fo r F^amMes , Chil d Ca m provider s an d Schods , t o th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I fuill ^ certif yVre X I hav e lef t a cop yo f th e pamphle t a t th e uni t b yslidin g i t 

# nu%i(>/j/f/r . i/)'K-d 9 //-/fif m Printe d nam e o f pdr^ n certifyin g Attempte d delivet y dat e an d tim e lea d pamphle t delivery Signatur e o f persorVoertifyin g lea d pamphle t delivery 

# ava. 1 parA-ht P ^r - Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n altemativ e t o deliveryi 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 befor e renovatio n (Documen t v\nt h a certificat e o f mailin g fro m th e pos t office) .

# pain t matc h form ' Q^$li0^ l Pain t matchin g form : « ^ / propert yaddress : ^y^ / 0^^ ^ ^f . ^ r, 

# Are a 

# • M e Hem e color : Sf^i cM ^ a-h"-' ^ Explanation : ^Pfn'l ^ 

# I?-0-/1 fiy ^ Area : Color : Explanation: ^ Area : color : Explanation : Area : Color : Explanation : Area : color : Explanation : 

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# ACCBS S typ o R M AT I or/TR AOKIN G SHEE T 

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### ^^*^unt y Accoun t Infwinatio n Pag e 1 of 2 jia s County , Nebrask a Propert yRecor d - R194653000 0 Prin t Repor t NE W Faatur e - Parce l Dimension i availabl e @ scal e 0-S O f t wes t of 90t h S t - VleVi rO n Ma p jrmatio n i s vali d a s o f 2008-9- 4 Treasurer' s Ta xRepor t Ne wFeatur e - * - > - ^ Aut o Sale s Searc h 

### Owne r JACKSO N ANDREW " 242 1 DECATU R S T Or\/IAHANE68111-000 0 Propert yInformatio n Ke yNumber: , 465 3 000 0 1 9 Accoun t Type : : Residentia l Parce l Number : \ 194653000 0 Parce l Address . 242 1 DECATU R S T OMAH AN E 68111-000 0 Lega l Description : , PARKER S AD D LO T4 BLOC K1 2 W1/ 2 3 0 X 12 8 Valu e Informatio n Lanc T Improvemen t Tota l 200 8 $900.0 0 

### " $50,600.0 0 $51,500.0 0 200 7 i $900.0 0 • ' $50,600,0 0 $51,500.0 0 _2006

__; 5900.0 0 $50,600.0 0 $51,500.0 0

2005 ~ " $900.0 0 ' ] $50^600.0 0 $51,500.0 0 200 4 $900.0 0 $7,900.0 0 $8,800.0 0 200 3 $900.0 0 $7,900.0 0 $8,800.0 0 Lan d Informatio n Acre s ] S F Unit s Dept h widt h ' -Vacan t 0.0 8 3840. 0 

### 1. 0 

# m. o 30. 0 N o Improvement Informatio n Buildin g 1

## Douglas Count y Accoun t In^^iatio n Page 2 of 2

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Squar e Footage : | 1344. 0 Percen t Complete : ; 100.0 % Perimete r; 0. 0 Quality : ; Fai r Uni t Type : ' Condition : i Fai r

Buil t As : f 2 Stor y Cond o Squar e Footage : ; 0. 0 HVAC : i Force d Ai r Rooms : ; 6. 0 Exterior : 1 Fram e Sidin g Units : • 1. 0 Interior : j Drywal l Bathsj^ : 1. 0 Roo f Cover : | Compositio n Shingl e Bedrooms : '. 3. 0 Roo f Type : | Gabl e Stories : : 2. 0 Floorcover : ; Allowanc e Foundation : ' Bloc k Sprinide rSquar e Footage : \ 0. 0 Yea r Percen t Adjuste d Yea r YearBuil t Physica l Ag e Remodele d i Remodele d Buil t 188 8 • 0 % 188 8 12 0 Detai l Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 

## T. o Basemen t Bsmn t Bloc k 8 f t 686. 0 Fixtur e Bas e Fixture s Fixtur e Bat h Ful l Porc h Enc l Soli d Wai l 

### 140. 0 Porc h Sla b Roo f Cei l 

### 30. 0 Use r Partia l Basemen t 

### 329. 0

./r\.^„^i„„#^„xTTM/-,*„*:TM/„„«„,,_+:_^ « ;„.»o ^ .•.-^.MA—T > 1 ( \ n/^4nrv\ o 1. 0

### \I-



## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) SAtP; ^/nfpl YJ ^ PropertyAririra<« . f^QO. ! hs>r^TUr .St OVW I !r* S Name ; J^/p/KJ^* ^ ^MC'^'\6i J 

## Performanc e Standards/close-Ou t Criteri a IYE T N O V ^a s th e entir e structure{s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d 

## 1 . i rdud e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al i trim , porches , box b^ams , columns , rails , an d exterio rsurface s o f garages . 

# 1 I S al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 

# X re 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 .

Wp s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 

# X 5 .A I e ai i ofth e areas wher e contaminate d material s hav e bee n spille d thproughl yvacuumed / cleaned ? 

# X D H th e contracto rcollect/vacuu m al l faiiin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s areas an d als o remove an yothe rgenerate d debris ? 

# X 7 .

i s ^h e gras s are a tha t surround s th e structure{s ) i n reasonabl ygoo d condition ? 

# t 8 .

Ar ^

al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . prj>perl yremoved ? 

# K 9 .

I s ther e an yevidence o f propert ydamag e tha t was don e b yth e contractor ? An ypropert ydamag e nqed s t o b e complete d prio rt o th e EP AClose-Ou t 

# 1 10 . Ar e ther e anypropert yitem s tha t wer e temporatil yre-locste d b yth e contracto r tha t nee d t o b e move d back? 

# X 11 .Ar i ther e any(known ) iingerin g issues wit h th e propert yowner(s ) tha t hav e bee n lef t unresoived ? Otne rConsiderations?propert yOwne rDiscussions?Addition5 l Wor k tha t i s Require d 

# X

^ 

## Prucfein t Re^esentativ e 

## .CAA^r^--^^( \ / 

# n~zo~^ f Dat e \il ' 2J J ' 0 \