## TRANSMITTA Lo f OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAI D # : 150 9 Date : 12/02/0 8 Address : 610 9 N 24 * S t Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S mVide o o f

propert y (DVD ) E ^ Executiv e Summary s f Signe dAcces s Agreemen t for subjec t propert y \ EPaintin g Agreemen t D Settlemen t

docimient s (i.e. , for

damag e o r

t o replac e plants , etc. ) D Photograph s 0 Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A mProperty informatio n fromDougla s County Assessor' s Offic e D D D " 

### Signatur e /

Da

### Date : 12.02.0 8 PROPERT Y SUMMAR Y LB PSTABILIZATIO N EP A CONTRAT EP-R7-08-0 7 Monthof : December Propert y Address : 610 9 N 24" " S t SAID : 1509 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 Infomiation : Homeowne

r requestedtha

t the Eas t an dSouthsid e of garag e b e lef

t "A s Is. " Acces s Date : 10/20/0 8 Wor k Bega n Date : Closeou t Date : 11/15/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio n Form 6 . Pain t Matc hFor m 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES . INC .

## TECHNOLOGIES , INC . ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Propert y Statu s For m Address : ^/^? f

/ ^ ^ ^ ^/ . Date : g^di^-O S Phone : ^o 2 ' H^^ 3 ^ ^^3 ^ BVID : f^ Q ^ Item # O nMa p Plan

t & Pemianen

t Landscapin

g T o Remai n I nPlac e Descriptio n an dLocatio n

Pre-Existin g Conditio n o f Structure s Does you r Basemen t hav e ahistor y o f leaking ? Ye

s ^ — N o 

# y Descriptio n & Locatio

n .^ ^juc hf^.A-y^i-ci ^ ^iJittc ,



# X o)«c A/)«• " * - ^' ' ^¥pyyfi ^ J . fe, l l Uv/f ^ i^itidciw i ciB.j*>i: ' 

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# ove r—> ^ Propert y Owne r Signatur e 

# ^idf/lfJ^ ^ Pruden t Employe e Signature : f^^f » 808 0 War

d Parkway , Suit e 40 5 Kansa s City , MO 6411 4 Phons : (816 ) 363-3703 Fax:(816)363-370 7 250 6 N . 24* ^ Street , Suit s 30 8 Omaha , Nebrasks 6811 0 Phone : (402)604-100 4 4242 Msdica l DrIvs , Suit s 425 0 Sa n Antonio , T

X 7822 9 Phons : (210)822-988 8

# 4^?3'^53>! - PROPERT Y SUMMAR

Y - ^ , Date ; / 0 - ? ^ | LB PSTABILIZATIO N EPA CONTRAT EP-R7-08-0 7 I Monthof : Qc J ^y=^fiH-^ Propert y Addreas : (o)C> ^ |\J . J-* ^ Sj ^ A . EXECUTIV

ESUMMAR

Y A l bsne s Encountered :

VIAR Y 

# /)^ l /T l S&t^^> ^ k l Issne s Resolved :

A 3 Uniqu e Findings :

122A. 4 Otlie r

Rdevan t infomiation :

Enclosmea :

ECHNOLOCIES . INC .

# 15 ^

Pruden t Technologies , Inc . (Prudent) i s unde r contract (Contract #EP-R7-08-07 ) wit

hth e U . S . Environmenta

l Protectio n Agenc y (EPA) t o stabiliz e Lea dBasedPaint

(LBP ^ a t anumbe r o f propertie s locatedin Omaha, Nebraska , includin g th e propert y locateda

t CriC/ ^ AJ . ^ ^ %i - . Th e EP A request s you

r permissio n t o allo w Pruden t t o perfor mLB P Stabilizatio n a

t thi s property . B y signing thi s form, th e propert y owner grant s permission t o Pruden t t o perfor mactivitie s relatedt o LB P Stabilization including scrapin g paint andpaintin g of

th e referencedproperty . Further , th e owner/tenan t verifie s tha

t they hav e receive dtiie LB Ppamphle t "Renovat e Right. " Ifyo u have an

y question s about

th e LB Pstabilizatio n plannedfo r your property , pleas e contact

Prudent' s Administrative Cler

k fo r th e Lea dBase dPaint

Stabilization , Mrs . Debora hAkerele-Johnson . a t (402) 504-1004 ; Genera

l question s about

the OmahaLea

dSit e cleanup ca

n b e directe dt o tiie EP

A Publi c Informatio

n Center s at

(402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nortii Omaha office) . y f PtopefOrAccessGnmtedBy : y/\l/S\ylf1r\S/x^*' ^ leas e Prin t Name ) Propeit y Owne r Signature :

RESIDEN TNAME : RESIDENTADDRESS : 

# ^^^S ' (Date) PROPERTY INFORMATIO N (T o b e coaplete dbjr

residen t a^d/o r property owner

- pleai e print ) y j ^oDecoapieieamrresiaenta^ c Owns r Rents r

I F RENTAL , PROPERT

Y OWNE D BY : OWNER' S MAILIN G ADDRESS ; 

## S><9nf M



# ^iJ^ll^^K : t s OWNER' S TELEPHON E NUMBER . HOME : ( ""^^ S 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 : o l NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 6 HOUR S O R MOR E PE R WEEK : / COMMENT

S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YQATES , ETC. )

AUTHORrr

Y FO RENVIRONMENTA

LRESPONS EACTIONS ; Th e activitie s t o b e implemente db y EP A unde r thi s agreemen

t ar e punuant l o Sedio n 10

4 o f CERCLA, 4 2 U.S.C . 9604 . EPA' s righ t ofaeces s to the propert

y isprovidedfo

r i n Sectio n 104(e ) of CERCLA . 4 2 U.S . C 9605(e) , whichprovide s entiy for "deteinuningfl

w nee dfor response , o r

cboosing ortakin g an

y respons e actio

n unde r thi s title , or

otherwis e enforcing th

e provision s ofth e tifle. "

08 0 War d Parkway , Suit e 40 6 ansa s City , M O 6411 4 hone : (816 ) 363-3703 250 5 N . 24** Street , Suit s 30 8 Omaha , Nebrask

a 6811 0 Phone : (402)504-100 4 424 2 Medica l Drive , Suit s 4260 Sa n Antonio , T

X 78229 Phone : (210) 822-9588

# Curren t Sampl e Pre-Renovatio n For m

Effec*Jv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t • 1 hav e receive d a cop yo f th e pamphlet , Renovat e Right : Importan t Lea d Hazan i lntonr)atio n fo rFamilies , CNl d Ca m Pmvlde m an d Schoo/s infonnin g m e o f th e potentia l risk

o f th e lea d hezar 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 wort < began .

Signatur e o f Seif-Certiflcatlo n Optio n (fo rtenant-occupie d dwelling s only ) — I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k

th e appropriat e bo xbelow . • Raftisa J t o sig n —I certifytha t I hav e mad e a goo d fait h effoi t t o delive rth e pamphlet , Fienovat e fV^ t Importan t Lea d Haza d infbnnatio n fo rFamilies , CNl d Ca m Providers an d Schools , t o th e renta l dwellin g uni t liste d belo wa t tli e dat e an d tim e Indicate d an d tha t th e oocupan t refuse d t o sig n th e confiimatio n o f receipt . I furthe rcertifytha 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 effor t t o delive rth e pamphlet , Renovat e FVgh t Importan t Lea d Hazar d Intonnatio n fo r FaniHes , Chil d Ca m pmvlder s an d Schools , 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 furthe rcertifytha t I hav e left a cop yo f th e pamphle t a t th e uni t b yslidin g i t unde rth e d c l e dpor . - 7 Printe d nam e o f perso n certHyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver

y Signatur s o f perso n certifyin g lea d pamphle t deliver y 

# 6,10 ^ A / Q^^s/ , 

# ^/^r/./fr/ , A^ f

•f Unl t Addres s Not e Regardin g Mailin g Optio n —A s a n altemativ e t o deliver yi 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 before rsnovatio n (Documen t wit h a certificat e o f mailin g fro m th e |30S t office) .

# pain t matc h for m Pain t matchin g form : /Uv^^a, - 3 Propert yaddress : (pi0 9 11 / flf^^s/ , f BVID : f^O f

f^'Z/^ ^ S,</,^ ^ 5 6 A / I l ^ y 

# Area : po^^

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# Area : Color : f^.c^r A-^/c^cv f Explanation : ^ f^A^i s Area : color : Explanation : Area : color : Explanation : Area : color : Explanation : Pag e 1

# [ ACCES S INPOmHAVO N TRACKIN G SHEE T

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# mpm v

ADPRB88 ; 

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f V Q^^hs/ , 1 f ^

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## Fax :

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# f^udeii i OONWTOETW l 

# ^OT^ ^ r g 1 /»1tg / ouune/ ct,i - o^v:^/^. ^

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### Dougla s Count y Accoun t

Ij||Dnnatio n I||n r Pag e 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R184345000p ; Informatio n i s vali d a s o f 2008-7-1 4 - —Prin t jRepor t NE W Faatur * - Parce l Dimension * availabl e Q scal e 0-5 0 f l wea t tit 90t h S t - Vi@.W..0. n .Map . Treasurer' s Ta xReport . Ne wFeatur e ^

« • - • AutoSaie s Searc h Owne r SWAI N CLIFFOR D L ETA L 610 9 N 2 4 S T OMAH AN E 68110-000 0 

# ^,5<i,S^3'2 . Propert yInformatio n Ke yNumber : 

### 434 6 000

0 1 8 Accoun t Type : Residentia l Farce / Number : 184346000 0 Parce l Address : 610 9 N 2 4 S T

OMAH AN E 68110-000 0 Lega l Description : NORWOO D AD D LO T1 5 BLOC K1 4 4 X 16 5 Valu e Informatio n

Lan d Improvemen t Tota l 200 8 $5,100.0 0 

### $60,000.0 0 $65,100.0 0 200 7 $5,100.0 0 $53,100.0 0 $58,200.0 0 200 6 $5,100.0 0 $53,100.0 0 $58,200.0 0 200 5 $5,100.0 0 $53,100.0 0 $58,200.0 0 200 4 $5,100.0 0 $38,800.0 0 $43,900.0 0 200 3 $5,100.0 0 $38,800.0 0 $43,900.0 0 Lan d Informatio n Acre s 

### S F Unit s Dept h Widti i Vacan t 

### 0.1 6 7260. 0 

### 1.0 165. 0 44. 0 

### N o Improvemen t Informatio n Buildin g 1

http://douglasne.mapping-online.com/DouelasCoNe/static/accountinfo.isn?af;r.niiTitnn=i ? i » anf^nnn n

## Dougla s Count

y Accoun t b|£pmiatio n 

# |g> r Pag e 2 of 2 \

• ••' a 

# . 1 

# J H

1 CUCJ^TD£l!lLAE(G£JMAQ E 1 Squar e Footage : Perimete r Uni t Type : Buil t As : HVAC : Exterior : Interior : Roo f Cover : Roo f Type : Floorcover : YearBuil t 191 5 1226. 0

0. 0 1 1/ 2 Stor yFi n Force d Ai r Fram e Viny l Drywal l Compositio n Shingl e Gabl e Allowanc e yea r Remodele d 0 Detai l Typ e Applianc e Applianc e Applianc e Basemen t Basemen t Fixtur e Fixtur e Fixtur e Garag e Porc h Porc h Use r Use r «109hC34SX . . "'TT"i(;" j •< V ''•'i ' Pin t Fine r 654. 0 «q . ft . 

# :L^ : i- , 11 1

1 1/ 2 STOR Y

*••"'*•"***• ' C.UCKm..EN|LABfiElMASE . 1

Percen t Complete :

Quality : Condition : Cond o Squar e Footage :

Rooms : Units : Baths : Bedrooms : Stories : Foundation : Sprinkle rSquar e Footage : Percen t Remodele d 0 % Adjuste d Yea r

Buil t 191 5 100.0 % Averag e Averag e 0. 0 6. 0 1. 0 1. 5 3. 0 1. 5 Bloc k 0. 0 Physica l Ag e 9 3 Detai l Descriptio n Allowanc e Fireplac e Masonr

y SecuritySyste m Bsmn t Bloc k

8 ft Finishe d Bas e Fixture s Bat h Ful l Bat h Hal f Detache d Sla b Roo f Cei l Sla b w/Step s LOCKE D GAT E PARKVIE W Unit s 1. 0 1. 0 1. 0 594. 0 297. 0 1. 0 1. 0 1. 0 324. 0 132. 0 48. 0

. 1. 0 1. 0



### httn://douBlasne.manninp-nnHnp i rnm/Dniiaia«!rnNp/ctnt i -DI O on^i'^nn a

## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization )

SA.D : l^l> ^

. ^ PropertyAddress ; ^l^f i V ' ^^ ^ ^ ' Owner' s Name ; £lUu ^ ^f ) • J^fU^-r U 

## Performance Standards/close-Ou t Criteri a 1 . Wa 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 indud e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al i trim , porches , bo x beams , columns , rails , an d exterio rsurfece s o f garages . 2 . Wa s al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 . Wer e al l require d area s 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 ? Are al l ofth e areas wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed /

deaned ? 6 . Di d th e contracto rcollect/vacuu m al l felling 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 ? 7 . I s th e gras

s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 8 . Are al l item s suc h a

s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et c properi yremoved ? YE S N O 

# X 

# I X . 

# t X I s ther e an yevidenc e o f propert ydamag e tha t was don e byth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . 10 . /\r e ther e an ypropert yItem s tha t wer e temporatil 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 ) iingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? Othe rConsiderations?propertyOv>me rDiscussions?Additiona l Wor k tha t i s Require d



# E L 

# m Pruden t R e Date esentativ e 0 .

. y