## TRANSMITTA L of OMAH A LEAD SIT E PAIN T STABILIZATIO N FIL E FOLDE R
SAI D #: -7^f>^.3>- 7 Date : 

# O^I^L^ j la _ Address : ?>l l °) ^ ^ AH Stabilizatio n Contractor : Pruden t Technologies , Inc . Year : 201 0 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S Vide o of propert y (DVD ) prg ^ /^.f\Q . phSP T Executiv e Summar y S/ Signe dAcces s Agreemen t for subjec t propert y Pre-Renovatio n Formsigne d by Propert y Owne r 

## • Pre-Renovatio n Formfor Occupant/Tenant , if applicabl e Paintin g Agreemen t 

## • Settlemen t document s (i.e. , for damag e or to replac e plants , etc. ) Renovatio n Recordkeepin g Checklis t signe dby Certifie dRenovato r Photograph s Satisfactory close-ou t chec k lis t signe dby Property Owne r Property close-ou t chec k lis t signe dby EP A Property informatio n fro mDougla s Count y Assessor' s Offic e Hazar danalysis , if prepare d D 

### Safet y Audi t 3020399 0 D 

### Othe r (describe) : Superfun d c^Jjuu j 

### PrudentTecnnology , fnc . Signatur e 

# lohj l Oat / ie file folae (afte r r file folde r r review

review ) )TBCHNOLOGIBS . INC . 

# Propert y Summar y Date : 6/29/201 0 LB P STABILIZATIO N EP A CONTRAC T EP-R7-08-0 7 Mont h of : Jun e Propert > Address : 311 ^ N 4 9 Av . SAI D # : 7423 7

A . Executiv e Summary : a . Issue s Encountered : NON E b . Issue s Resolved : NON E c . Uniqu e Findings : NON E d . Othe r Relevan t Information : i . Acces s Date : 04/28/201 0 ii . Wor k Began : 05/05/201 0 iii . Close-Ou t Date : 05/06/201 0 B . Enclosures : 1 . Pre-Stabilizatio n Vide o 2 . Post-Stabilizatio n Vide o 3 . Signe dAcces s Agreemen t For m 4 . Advance-Notic e For m 5 . Pre-Stabilizatio n Vide o Agreemen t For m 6 . Acces s Trackin g For m 7 . Propert y Acces s Assessmen t For m 8 . Neighbo r Acces s Agreemen t For m 9 . Propert y Pain t Matc h For m 10 . Pre-Stabilizatio n Propert y Safety Assessmen t For m 11 . Work-Sit e Hazard s Analysi s Checklis t 12 . Pre

- Stabilizatio n Propert y Hazar dAssessmen t Photograph s 13 . Dougla s Count y Assesso r Propert y Informatio n 14 . Signe dPropert y Completio n Agreemen t For m 15 . Propert y Close-Ou t Chec k Lis t Signe dB y EP A40L0CIBS , INC . 

### Pruden t Technologies , hic . (Prudent ) i s imde r

contrac t (Contract #EP-R7-08-07 ) wit h th e U . S . Environmenta l Protectio n Agenc y (EPA) to stabiliz e Lea dBasedPain t (LBP) a t anumbe r

of propertie s locate din Omaha , Nebraska , including th e propert y locatedat : j0\/ f Q ' ^fi.^' ^ ^ 

## 3 ( H 

## A ) L{. ^ U(( l 

## ' ^

' ' Th e EP A request s you r

permissio n t o allo w Pruden t to perfor mLB P Stabilizatio n a t thi s property . B y signing thi s form, the propert y owne r

grant s permissio n to Pruden t to perfor mactivitie s relate dto LB P Stabilizatio n including scraping pain t an dpaintin g o f th e referencedproperty . Further , the owner/tenan t verifie s tha t the y hav e receive dth e LB P pamphle t "Renovat e Right. " B y signin g thi s docimien t I agree t o allo w a n EP A contractor to conduct asoi l cleanu p a t m y propert y followin g completion of lead-basedpain t stabilization , i f th e soil cleanu p ha s not alread y been performed . I understandtha t th e stabilizatio n contracto r

cannot provid e assurance s o f

which contractor will b e boun dto the soil cleanup . I fiutherunderstandtha t th e soi l cleanu p contractor wil l mak e all reasonabl e efforts to addres s concem s tha t I , a s the propert y owner , ma y hav e regardin g soil cleanu p a t m y property . tV l Yes , 1 hav e rea dan dunderstandthe paragraph above . Propert y Owner' s Signatur e Dat e If

yo u have an y question s abou t th e LB P stabilizatio n planne dfo r

you r

property , pleas e contac t Prudent' s Custome r

Relations/Offic e Manage r

fo r

th e Lea dBasedPain t Stabilization , Mr . Chandr a Sheka r a

t 402

- 504-100 4 o r 402-889-3821 . Genera l question s abou t th e OmahaLea dSit e cleanu p ca n b e directe dto th e EP A Publi c hiformation Center s a t (402 ) 731-304 5 (Sout h Omahaoffice) or (402 ) 991-958 3 (Nort h Omahaoffice) . Propert v Acces s Grante dBv :
Propert y Owner' s Signatur e Dat e 

# Clf k Uaf<i h Pleas e Prin t Nam e

808 0 War d Parkway , Suit e 40 5 250 5 N
. 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omalia , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Plione : (816 ) 363-370 3 Phone : (402)504-100 4 Ptione : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402 ) 504-100 5 Fax : (210 ) 579-657 7

# 2 TBCHNOLOCIBS . IN C 

### PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r ~ pleas e print ) RESIDEN T NAME : CUfl S l^a^^ k (Qymex y Tenan t RESIDEN T ADDRESS : __3Ll^_Jsl^Jd3ik^Ay£ ^

IF RENTAL , PROPERT Y OWNE D BY : OWNER' S MAILIN G ADDRESS :
OWNER' S TELEPHON E NUMBER : Home : ^O>93^-'Z07 ^ Work : _ Cell : ^Z-IQC-^07 ^ NUMBE RO F OCCUPANTS UNDE R7 YEAR S OLD : A/ o TOTA L NUMBE RO F OCCUPANTS : 7 NUMBE RO F CHILDRE N UNDE R7 YEAR S OL D WH O PLA Y I N TH E YAR D FOR5 HOUR S O

RMOR E PE RWEEK : COMMENT S O RSPECIA L INSTRUCTION S (suc h a s does , entr v gates , etc.^ ; 

# yjo^- ^

AUTHORIT Y FO RENVIRONMENTA L RESPONS E ACTIONS : Th e activitie s t o b e unplemente d by EP A unde r

thi s agreemen t ar e pursuan t to Section 10 4 o f CERCLA , 4 2 U.S.C . 9604 . EPA' s righ t of

acces s to th e propert y i s providedfo r

in Section 104(e ) of CERCLA , 4 2 U.S . C 9605(e) , which provide s entr y fo r

"determinin g th e needfo r

response , o r

choosing o r

takin g an y respons e actio n unde r thi s title , o r

otherwis e enforcing th e provision s o f th e title. " Propert y Owne r

Signature : 

# V-2^-/ 0 slifmafiir^ ^ ' 

### (Signature ) Dat e 808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " street . Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4
. Phone : (210 ) 822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7'TBCHNOLOGIBS , IN C 

## PR E & POST PAIN T STABILIZATIO N VIDE O AN D PICTURE S I understan d tha t pruden t Technologie s (Prudent ) wil l be comin g ou t to shoot a Pre Stabilizatio n vide o an d to take picture s of my property . Pruden t wil l us e th e video s an d picture sto documen t th e curren t propert y status/condition
. Also , Pruden t wil l shoo t a vide o shot followin g th e completio n of th e pain t stabilization
. I giv e permissio n to video s an d picture s of my property . Pleas e lis t an y specia l condition s tha t Pruden t employee s nee d to be awar eof before shootin g a vide o (suc has pets , prio rnotice , etc.)
.



## 3 1 N A/o.^^ ^ A\/^
. Propert y Addres s 

# ct CIS
. Owner' s Nam e e Ti Signature Dat e 

## ADVANC E NOTIC E REQUIREMEN T Afte rsignin g th e acces s yo u allo w Pruden t to begi n Lead Base d Pain t Stabilization
. Al l Plants , weed s an d an y vehicle s oritem s on ope n porc h (enclose d porche s wil l NO T

be stabilized ) must be remove d prio r to stabilization
. Al l Pets mus t be ou t of yard durin g stabilization
. Pleas e indicat e below ho w muc h advance notic e yo u nee d to have th e above mentione d tasks completed
. If yo u ar e a landlor d yo u wil l nee d to contac t th e tenan t as Pruden t wil l onl y infor m th e propert y owners . Do yo u hav e an y pet s that resid ein yard : 

# Ve s Notice needed : 

# I da y Phon e numbe r to cal l to give notice : v^3""2^Z- ^ Who m we are givin g notic e to : 

# ^ I P

808 0 War d Parkway , Suit e 40 5 250 5 N. 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , MO 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

# £ Curren t Sampl e Pre-Renovatio n For m Effectiv e unti l Apri l 2010
. Confirmatio n o f Receip t o f Lea d Pamphle t M I hav e receive d a cop y o f th e pamphlet , Renovate Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d School s informin g m e of th e potentia l ris k of th e lea d hazar d exposur e fro m renovatio n activit y t o b e performe d i n my dwellin g unit
. I receive d thi s pamphlet befor e th e wor k began
. Printe d namao f recipien tDat e Signatur e of recipie i Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — I f th e lead pamphlet wa s delivere d bu t a tenan t signatur e wa s not obtainable , yo u ma y chec k th e appropriat e bo x below
. •Refusa l t o sig n —I certif y tha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovate Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d Schools , t o th e renta l dwellin g uni t liste d below a t th e dat e an d tim e indicate d an d that th e occupan t refuse d t o sig n th e confirmatio n of receipt
. I furthe rcertif y that I hav e lef t a cop y of th e pamphlet a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e — I certif y tha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovate Right : importan t Lead-Hazar d Informatio n fo r Families , Chil d Car e provider s an d Schools , t o th e renta l dwellin g uni t liste d below an d tha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n of receipt
. I furthe rcertif y tha t I hav e lef t a cop y of th e pamphlet a t th e uni t b y slidin g i t unde rth e doo r Printe d nam e of perso n certifyin g Attempte d deliver y dat e an d tim e lead pamphlet deliver y Signatur e of perso n certifyin g lead pamphlet deliver y 

# .?ff ^ 

# A /

^ 9 /H ^ Uni t Addres s Not e Regardin g Mailin g Optio n —As a n alternative t o deliver y i n person , yo u ma y mai l th e lead pamphlet t o th e owne rand/o rtenant . Pamphle t must b e maile d a

t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e of mailin g fro m th e pos t office)
.iNC T 

### PAIN T MATCHIN G FORM : 1 .

T O B E FILLE D OU T ONL Y I F MATCHIN G COLO R PROPERT Y ADDRESS : 3 | I ^ M L{ ^ A V BVID : 

# q q > ? 3 > Th e followm g note s ar e fo r th e benefi t o f pain t cre w only . Pain t Ye s Pain t N o Locatio n Pain t Descriptio n Siding 

### ^Ooc J 

## y ^ Soffi t 

### Vv) o e c t Fasci a 

# ptro d Come r Tri m 

## N/ A Windo w Trim s ^^0 0 

# J L Doo r Trims 

## ^cr p (A Fron t Porc h Ceiling ^^oc k Fron t Porc h Ceiling Beams 

## K«JM ^ Fron t Porc h Floor CjgVMlX-AK - Fron t Porc h Railing s 

# I^OrtKX ^ Fron t Porc h Step s (^..gVvO'v^J ^ Siding Baseboard s 

## 9^/f ^ Foimdatio n r_,,/yJl>^^-»J ^ "GloQC ­ 

## • )9t,rJ k 1 C<;^>,« , Vi, ) 

## ^^:;(^ ^

K.^kJ l 

# (



# F \ c>o- r ^!6^/03*--€J ^ 

### Xyeii U 

## M.ei^ ? ^ 

### |M,e>-^^ ( (1€AIA« ^ ©A^SM-.- ^ 

### •I UNDERSTAN D SHERWI N WILLIAM S WIL L MATC H M Y CURREN T COLORS .
Homeowne r signature : ^—^^* 0 /^y^ytA^y_ ^ Date : V

- ^2-^ ^ /( O 808 0 War d Parkway , Suit e 40 5 250 5 N
. 24" ' Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402 ) 504-100 5 Fax : (210 ) 579-657 7ACCES S ASSESSMEN T FORM : Hous e sidin g (circl e al l applicable ) *Transit e i s sam e a s ast)esto s **Als o calle d aluminu m sidin g ***Als o calle d roo f shingle s I f th e sidin g i s aluminu m (metal) , i s i t origina l factory finish o rpainte d over ? Circl e one . I f th e sidin g i s Wood/Asphalt/Roo f shingles , i s i t painted ? Circl e one . Doe s thi s propert y requir e lot s o f scrapping ? Doe s thi s propert y requir e a lif t o rscaffoldin g t o reac h uppe rlevels ? Doe s thi s propert y hav e lot s o f plants/iv y o ritem s i n th e area s wher e paintin g i s required ? I f ye s explain
. Doe s thi s propert y hav e an y significan t structura l damage ? I f yes , EXPLAIN ? Doe s thi s propert y hav e a : Garag e / She d Garage : ^;e§ > N o Shed : Ye s /(So ) I f yes , describ e th e locatio n & sidin g materia l o f garage/shed
. ^<t>»v> ^

W^.-6 V "^U ^ I s thi s propert y vacan t o roccupie d - circl e on e Ar e ther e an y pet s a t thi s property ? I f ye s explain
. Ar e ther e an y lo w hangin g powe rlines ? D o w e nee d neighbor' s access ? I f ye s pleas e explai n an d ge t neighbor' s propert y addres s an d owne rinformation
. m^ l Transite * / Viny l / Pre-finishe d Metal* * / Bric k /

Concret e / Concret e block s / woo d shingle s / Asphal t shingles** * / Stucc o /
Origina l Factory Finis h 

### K J 

# 1 ^ Paintgd-Qiffi L 

# c ^ •"^^''"nifii ^ paintPd—- ^ Shingle s no t painte d

Yes / 

# € J

Yes / Garage : Attache d Garag e siding : WoodTTfansite * / Viny l / Pre finished Metal* * / Bric k /

Concret e / Concret e block s / woo d shingle s / Asphal t shingles** * / Stucc o / Shed L Occupiec r/ Vacan t 

### es/ / N o

e s tlH o Yes / ^
808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " street . Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax:(816)363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 75t«>»i-.j ;

TEOINOLOGIES, ] 

## ACCES S INFORMATIO N TRACKIN G SHEE T S t
.



## BVID : ^i{^3 ^ Propert y Owne dBy : (I f new propert y owner ) PROPERT Y ADDRESS : 3 ) / ^ h J L\ ^ A- ^

Owner s Phon e No's : Home : Cell : - Work : Fax : — Acces s Contractor : AS W PD A ME S P E Othe r (Prudent ) DAT E 

# k\^ &

V I " '-« ' 

## TIM E 

# 4:cf > ACCESSO R ^'x/O

- 

## CONRAC T DETAI L

Comments :

808 0 War d Parkway , Suit e 40 5 Kansa s City , M O 6411 4 Phone : (816 ) 363-370 3 Fax : (816 ) 363-370 7 250 5 N
. 24' " Street , Suit e 30 8 Omaha , Nebrask a 6811 0 Phone : (402)504-100 4

Fax : (402)504-100 5 424 2 Medica l Drive , Suit e 425 0 Sa n Antonio , T X 7822 9 Phone : (210)822-958 8 Fax : (210 ) 579-657 7RENOVATIO N RECORDKEEPIN G CHECKLIS T 

### Nam e oi Firm : / ^ ^i t )/r^yyrf,Uh/ , "J^fyM/ y Z^^

­ " lan dLocatio n

of Renovation : brie f Descriptio n

of Renovation: . 

# ynf-yy^r/U . 4f^/iyt ^\Lh^i/zzj^-y/a /

) Nam e

of Assigne dRenovator : 

# : (?i^ f ly'JfoJ^ ^ Name(s ) of Traine dWorkers ,if used : 

## yy^e/yyi i Nam e

of Dus t Samplin g Technician , Inspector,or Ris k

Assessor, if used :_ 

# /^^>^/;/^//^r . ^23^ . .•Xopie s of renovato r an ddus t sampling technicia n qualification s (trainin g certifications , certification s on file . \X^rtifie drenovato r providedtrainin gto worker s on (chec k

al

l tha t apply ) _vxPostin g warnin g sign s »^..<8ettin g

up plasti c containmen t barrier s LxKiaintainin g containmen t u^voidin g sprea d

of dus t to adjacen t area s lyWaste handlin g u-rost-renovatio n cleaning Tes t kits use d

by certifie drenovator to determin e whethe r iea dwa s presen t on components affecte d by renovatio n (identit y kit s use dan ddescrib e samplin g location s an dresults) : ^.•Warnin g sign s poste d

at entranc eto wor k

area . •wor k

areacontaine d

to preven t sprea dofdus t an ddebri s ^Al l object s in th e wor k

are aremove d

or covere d(interior ) HVA C duct sin th e wor k

are aclose d an dcovere d(interior ) ^Window s in th e wor k

are aclose d(interior ) kjX^Window s in an dwithin 20 fee t of th e wor k

areaclose d(exterior ) Door s in the wor k

are aclose dan dseale d(interior ) j^/Door s in an dwithi n

20 fee t of th e wor k

are aclose dan dsealed(exterior ) ypoQt s tha t must be use d

in the wor k

are acovere d

to allow passag e bu t preven t sprea dofdus t Floor s in th e wor k

are acoveredwit h taped-dow n plastic (interior ) "groun dcovered by plasti c extending ID fee t fro mwor k

are a(exterior ) ^^asti c anchored to buildin g an dweighe ddow n

by heav y object s (exterior ) »^ f necessary , vertica l containmen t installe d

to preven t migration ofdus t an ddebri s (exterior ) jyyiasX t containe don-sit e an dwhile bein g transporte dofT-sit e j/Wor k sit e properl y cleanedafte r renovation y%\ \chi p an ddebri s picke dup , protective sheetin g misted , folde ddirt y sid e in , & tape dfo r remova l Wor k

are asurface s an dobject s cleane dusin g HEP A vacuu mand/or we t cloth sor mop s (interior ) Certifie drenovato r performe dpost-renovation cleanin g verificatio n (describ e results , includin g the numbe r of we t an d dr

y cloth s used) : ^ (f

dust clearanc e testin g wa s performe d instead , attach acop y of report . JM certif y unde r penalt y

of la

w tha t th e above informatio complet e brmatio n n i s true an dcomplete . Niim c iin dTid e / / y / Oati. '

V ' d 9099-S0S-30 ^

# cb y y-y/ y ivddA-i: t s-^-/ ^ li^ t y^i y y\. y RENOVATIO N RECORDKEEPIN G CHECKLIS T A NameoflMrm : i XJ' ) ^ Y ;! • y r / Xr y ^1^ } t , w^/^^^ . /^^/-d

­ ' T andLocatio n o f Renovation : yy U • /C / > ^'^ / r i J^^Jt ^ t ^ , . j brie f Descriptio n o f Renovation : .- / -^V- / -/!/

- 7-^ 1 ^ LH : '.."^^^ ^ //JZy^T^'^ / J Name o f Assigne dRenovator : ;'///',' / .. • ..••//'.-•/^-•'^.-.•^ / N Name(s ) o f Traine dWorkers , i f used : 'ylA^/f j Ay ? ^yy^lO/f ' ) Nameo f Dus t Samplin g Technician , r .''/ , • ' / / / • / / — . Inspector , o r Risk Assessor , i f used : Y-fliy^/C t yd/l/fJ/j/yiJ/J^ C "//>" , -^•^opie s o f renovato r an ddus t samplin g technician qualitlcation s (trainin g certifications , certification s o n file . ^•Certifie drenovato r provide dtrainin g to worker s o n (chec k al l tha t apply ) vxPbstin g w<imin g sign s vgettin g u p plasti c containmen t barrier s ^Maintainin g containmen t j^^voidin g sprea do f dus t t o adjacent area s i>Wast e handlin g i-^ost-renovatio n cleanin g Tes t kit s use db y certifie drenovato r t o determin e whethe r leadwa s presen t o n component s affecte d b

y renovatio n (identif y kit s use dan ddescrib e samplin g locations an dresults) : .^•^amin g sign s poste da t entranc e t o wor k

area . I/wor k are acontaine dt o preven t sprea dofdus t an ddebri s ^Al l object s i n th e wor k

are aremove do r covere d(interior ) HVAC duct s i n th e wor k

are aclose dan dcovere d(interior ) Window s i n th e wor k

are aclose d(interior ) .^-"Window s i n an dwithi n 2 0 feet o f th e wor k

are aclose d(exterior ) Door s in th e wor k

are aclose dan dseale d(interior ) ^ yXJQQT S i n an dwithi n 2 0 fee t o f th e wor k

are aclose dandseale d(exterior ) t- ^ Door s tha t mus t b e use din th e wor k

are acovere dt o allo w passag e bu t preven t sprea dofdus t Floor s i n th e wor k

are acoveredwit h taped-dow n plasti c (interior ) ^^roun dcovere db y plasti c extendin g 1 0 fee t fro mwor k

are a(exterior ) >^asti c anchore dt o buildin g an dweighe ddow n b y heav y object s (exterior ) yj f necessary , vertica l containmen t installe dt o preven t migratio n ofdus t an ddebri s (exterior ) jyf^asl e containe don-sit e an dwhil e bein g transporte doff-sit e _v/\Vor k site properl y cleane dafte r renovatio n v^l l chi p anddebri s picke dup , protectiv e sheetin g misted , folde ddirty sid e in , & . tape dfo r removal Wor k

are a.surface s an dobject s cleane dusin g HEP A vacuu mand/o r we t cloth s o r mop s (interior ) Certifie drenovato r performe dpost-renovatio n cleanin g verificatio n (describ e results , includin g th e numbe r o f we t an d dry cloth s used) : ; ( f dus t clearanc e testin g wa s performe dinstead , attac h acop y o f report . J_ I certif y under penalty o f la

w tha t th e abov e informatio n i s tru e an dcomplete . 

# Cyy/y:y.f: , Mnjy:. . LyOA,...

_y^ykz/. ^ Nam e aiul Titl e ' . " . D:»t c

9099-S0S-30 VTECHN(nX)GIBS, 1 

# Checklis t fo r th e Worksit e Hazar dAnalysi s Addres s Crew : 

# Date : 'JS p -f b Ite m OK ? Hazar d Correctiv e Actio n Overhea dLine s 

### ViyOy i JiXae y In-transi t Vehicl e Clearanc e OjriyiQy i Level s aroun dhig h wire s Vehicl e Clearanc e aroun d hig h wire s whe n workin g Phon e line s 

### UAM^pR^tfrtLn^ie - Cabl e line s Ga s Lin e Wate r Lin e Sewe r Lin e Septi c Tan k Propane/Butan e Acces s to/o n Propert y ^ ^ ^_~ Neighbo r Acces s Require d Hig h Traffi c Are a Garag e Structure s 

# H .Uy^^ ^ uy ^ LiuJ ^ 

# n^M / Drivewa y 5 ^ j dpj^J ^ C > Sidewal k Q/\j^ ^ Foundatio n Retainin g Wall s . .^—

- 

# 'rGckl\ ^ -^f ^ \v^j^jz-..---iW^i^i6b?

_-idfJc^

- .^ : Fence s Tree s dty*^"* - Foliag e 

### k^r&JL ^ 

# J , Genera l Conditio n o f yar d Damage dAreas : sin k holes/rotte dwoo d)Ottr ^ 

## l£n ^ Sprinkle r Syste m Pet s ^ ^ Insect s ^ Weathe r Condition s Unsaf e drivin g condition s Unsaf e neighborhoo d 

# *- Vu> ^ i^i^ys^^^-'Yi^ ^==>e>iy4 A ^cJU ^

808 0 War d Parkway J 250 5 N
. 24* " Street , Suit e 30 8 : Medi f a l Drive , Suit e 425 0 Kansa s City , M O 6 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7 

# L

^

### 201 0 

# t # ENVIRONMENTA L & CONSIRHCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

### OMAH A LEA D BASE D PAIN T REMEDIATIO N Propert y Owne r Close-Ou t For m (Lead-BasedPain t Stabilizatio n EP A Contract EP-R7-08-07 ) SAID : -^(Jj^^' ^ 

### Propert y Address : 

## 111 ^ 

## K J l\. ^ M/ ^ Ovmer' s Name : 

# Qkffs^Aars U Performanc e Standards/Close-Ou t Criteri a YE S N O 1 . Wa s th e entir e structiire(s ) paintedwit h the exceptio n o f the stated , excludedareas ? Thi s woul dinclud e paintin g of othe r

associate dfeature s including fascia , eaves , siding , all trim , 

# X porches , bo x beams , columns , rails , an dexterior surface s of garages . 2 . Was all scraping an dothe r

preparatio n wor k

completedsatisfactorily ? 

# x 3 . Wer e all requiredarea s of th e structure(s ) primeda s neededan dpainte dv^dt h tw o top coats ? 

# y 4 . Wa s th e pain t product s utilize dequivalen t to a2 5 yea r

product/quality ? 

# K 5 . Ar e all o f

th e area s wher e contaminatedmaterial s hav e been spille dthoroughl y vacuumed / 

# X cleaned ? 6 . Didth e contractor collect/vacuumall falling an dscrapedpain t chip s on the entir e property , 

# x : 1 roadways , alleyways , publi c acces s area s an dals o remove an y othe r

generateddebris ? 7 . I s th e gras s are atha t surround s the structure(s ) i n reasonabl y goo dcondition ? 

## X 8 . Ar e al l item s suc h a s polyethylene sheeting , ladders , pain t brushes , cones , barrie r

tape , etc . properl y removed ? 

# M 9 . I s ther e an y evidenc e ofpropert y damag e tha t wa s don e by the contractor ? An y propert y ^ 

# A damage need s to b e completedprior to th e EP A Close-Out . 10 . Ar e yo u satisfiedwit h the wor k

performed ? 

# X 11 . Ar e ther e an y propert y item s tha t wer e temporaril y re-locate dby th e contractor tha t need t o b e move dback ? 12 . Ar e ther e an y (known) lingering issue s wit h th e propert y owner(s ) tha t have bee n lef t uiu-esolved ? / 

### Othe r

Considerations/Propert y Owne r

Discussions/Additiona l Wor k

tha t i s Required : 1 Ckri s f^<sys L -i o I d<? B no- f f o pcff^i^ -fK e skrp£ice s o f f^<

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# g-/^-/ n Propert y Owne r

Signatur e Dat e ^-^-/ ^ 

### Dat e

808 0 War d Parkway , Suit e 40 5 250 5 N
. 24 " Street , Suit e 21 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7 

# XDougla s Count y Accoun t Informatio n Pag e 1 of 3 Dougla s County , Nebrask a Propert y Recor d - R160260000 0 Prin t Reoor t NE W Featur e - Parce l Dimension s availabl e &
. scal e 0-5 0 f t wes t of 52n d S t - Vle W O H Ma P Informatio n i s vali d a s o f 2010-3-1 6 Treasurer' s Ta x Reoor t Ne w Featur e -¥- ¥f! ¥Aut o Sale s Searc h Owne r i^ARS H CHRISTOPHE R A ETA L 311 9 N 4 9 AV E OMAH A N E 68104-000 0 Propert y Informatio n Ke y Number : 026 0 000 0 1 6 Accoun t Type : Residentia l Parce l Numbe r 160260000 0 Parce l Address : 3119N49A V OMAH A N E 68104-000 0 Lega l Description : LAK E JAME S PAR KLO T 7 BLOC KJ 5 0 X 13 6 Valu e Informatio n Lan d Improvemen t Tota l 200 9 $6,500.0 0 $62,400.0 0 $68,900.0 0 200 8 $6,500.0 0 $62,400.0 0 $68,900.0 0 200 7 $6,500.0 0 $62,400.0 0 $68,900.0 0 200 6 $6,500.0 0 $62,400.0 0 $68,900.0 0 200 5 $6,500.0 0 $44,100.0 0 $50,600.0 0 200 4 $6,500.0 0 $44,100.0 0 $50,600.0 0 Sale s Informatio n Sale s Date : 2009-03-1 6 Dee d Type : W D Sooilr : 200 9 Page : 02478 2 Price : $89,000.0 0 Granto r Bruckne rJoshu a Eta l Grantee : Mars h Christophe rA Eta l Valid/Invalid : Vali d Exclusio n Reason : Sale s Date : 2007-01-2 3 Dee d Type : W D Book : 200 7 Page : 01071 3 Price : $ 82,000.0 0 Granto r Hubbar d Jaso n C eta l

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R160260000 0 3/22/201 0Dougla s Count y Accoun t Informatio n Pag e 2 of 3
Grantee : Bruckne rJoshu a eta l Valid/Invalid : Vali d Exclusio n Reason : Sale s Date : 1997-10-2 9 Dee d Type : Book : 207 8 Page : 43 3 Price : $42,500.0 0 Granto r Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 5 6800. 0 1. 0 136. 0 50. 0 N o Improvemen t Informatio n Buildin g 1 Muit i Leve l 3119N49AV mi r

• i r ni r n r n t F W Floo r

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• a - L , S I 

## V

• • ta * BaiwIBIoefca t 1 »

lOJlf f ag o S q R Ft i Bsm t 1 CLIC KT O ENLARG E IMAG E | CLIC KT O ENLARG E IMAG E Squar e Footage : 1233. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Fai r

Buil t As : Mul t Leve l Cond o Squar e Footage : 0. 0

HVAC : Centra l Ai rt o Ai r Rooms : 5. 0 Exterior : Fram e Sidin g Units : 1. 0 Interior : Drywal l Baths : 1. 5 Roo f Cover : Compositio n Shingl e Bedrooms : 2. 0

Roo f Type : Gabl e Stories : 1. 0 Fioorcover : Allowanc e Foundation : Sprinkle rSquar e Footage : 0. 0
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Yea rBuil t 194 9 Detai l Typ e Applianc e Basemen t Fixtur e Fixtur e Fixtur e Fixtur e Garag e Porc h Use r yea r Percen t Adjuste d Yea r Physica l Ag e Remodele d Remodele d Buil t 0 0 % 194 9 6 0 Detai l Descriptio n Unit s Allowanc e 1. 0 Bsmn t Bloc k 8 ft 1033. 0 Additiona l Fixture s 1. 0 Bas e Fixture s 1. 0 Bat h Ful l 1. 0 Bat h Hal f 1. 0 Basemen t Singl e 1. 0 Sla b w/Step s 63. 0 Ha s A C no t workin g no w 1. 0

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