TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 1509 Date: 12/02/08 

Address: 6109 N 24* St 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

m Video of property (DVD) 

E^ Executive Summary 

sf Signed Access Agreement for subject property 

\E 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 

m Property information from Douglas County Assessor's Office 

D 

D 

D " 

Signature / Da 
Date: 12.02.08 

PROPERTY SUMMARY 

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

Property Address: 6109 N 24"" St SAID: 1509 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Infomiation: Homeowner requested that the East and Southside of garage be left "As 

Is." 

Access Date: 10/20/08 

Work Began Date: 

Closeout Date: 11/15/08 

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. 
TECHNOLOGIES, INC. 

ENVIRONMENTAL & 

CONSTRUCTION 

SERVICES 

Property Status Form 

Address: ^/^? f / ^ ^ ^ ^/ . Date: g^di^-OS 

Phone: ^o 2 ' H^^3 ^ ^^3 ^ BVID: f^ Q ^ 

Item# 

On Map 

Plant & Pemianent Landscaping To Remain In Place 

Description and Location 

Pre-Existing Condition of Structures 

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

Description & Location .^ ^juch f^.A-y^i-ci^ ^iJittc, 

X o)«cA /)«•" *- ^'' ^¥pyyfi ^ 

J. fe, ll Uv/f^ i^itidciwi ciB.j*>i:' 

Till, to Uufkr^^ ff"-'^ ^'"'-^ 

Item# 

On Map 

$tr:ie\jytH bOff-, 

over —>^ 

Property Owner 

Signature ^idf/lfJ^ ^ 

Prudent Employee 

Signature: f^^f» 

8080 Ward Parkway, Suite 405 

Kansas City, MO 64114 

Phons: (816) 363-3703 

Fax:(816)363-3707 

2506 N. 24*^ Street, Suits 308 

Omaha, Nebrasks 68110 

Phone: (402)604-1004 

4242 Msdical DrIvs, Suits 4250 

San Antonio, TX 78229 

Phons: (210)822-9888 
4^?3'^53>!-

PROPERTY SUMMARY - ^ , 

Date; / 0 - ? ^ | LBP STABILIZATION EPA CONTRAT EP-R7-08-07 I Month of: Qc J ^y=^fiH-^ 

Property Addreas: (o)C>^ |\J. J-*^ Sj ^ 

A. EXECUTIVE SUMMARY 

Al bsnes Encountered: 

VIARY 

/)^ l 

/Tl S&t^^> ^ 

k l Issnes Resolved: 

A3 Unique Findings: 

122A.4 Otlier Rdevant infomiation: 

Enclosmea: 

ECHNOLOCIES. INC. 
15^ 

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, including the property located at CriC/^ AJ. ^ ^ %i- . 

The EPA requests your permission to allow Prudent to perform LBP Stabilization at this 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 tiie LBP pamphlet "Renovate Right." 

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

Administrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (402) 504-1004; General questions about the Omaha Lead Site cleanup can be directed to tiie EPA 

Public Information Centers at (402) 731-3045 (Soutii Omaha office) or (402) 991-9583 (Nortii Omaha 

office). 

yf 

PtopefOrAccessGnmtedBy: y/\l/S\ylf1r\S/x^*' ^ 

lease Print Name) 

Propeity Owner Signature: 

RESIDENT NAME: 

RESIDENT ADDRESS: 

^^^S ' 

(Date) 

PROPERTY INFORMATION 

(To be coapleted bjr resident a^d/or property owner - pleaie print) y j ^oDecoapieieamrresiaenta^c 

Ownsr Rentsr 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

S><9nfM 

OWNER'S TELEPHONE NUMBER. HOME: ( ""^^ ^iJ^ll^^K S : ts 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: o l 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 6 HOURS OR MORE PER WEEK: / 

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

AUTHORrrY FOR ENVIRONMENTAL RESPONSE ACTIONS; The activities to be implemented by EPA under this agreement are punuant lo Sedion 104 

of CERCLA, 42 U.S.C. 9604. EPA's right ofaecess to the property isprovided for in Section 104(e) of CERCLA. 42 U.S. C 9605(e), which provides entiy 

for "deteinuningflw need for response, or cboosing ortaking any response action under this title, or otherwise enforcing the provisions ofthe tifle." 

080 Ward Parkway, Suite 406 

ansas City, MO 64114 

hone: (816) 363-3703 

2505 N. 24** Street, Suits 308 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

4242 Medical Drive, Suits 4260 

San Antonio, TX 78229 

Phone: (210) 822-9588 
Current Sample Pre-Renovation Form 

Effec*Jve until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

• 1 have received a copy of the pamphlet, Renovate Right: Important Lead Hazani 

lntonr)ation for Families, CNld Cam Pmvldem and Schoo/s infonning me of 

the potential risk of the lead hezard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the wort< began. 

Signature of 

Seif-Certiflcatlon Option (for tenant-occupied dwellings only) — 

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

you may check the appropriate box below. 

• RaftisaJ to sign — I certify that I have made a good faith effoit to deliver the 

pamphlet, Fienovate fV^ t Important Lead Hazad infbnnation for Families, 

CNld Cam Providers and Schools, to the rental dwelling unit listed below at tlie 

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

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

the occupant. 

Q Unavailable for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Renovate FVght Important Lead Hazard Intonnation for 

FaniHes, Child Cam pmvlders 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 

under the dc le dpor. -7 

Printed name of person certHying Attempted delivery 

date and time 

lead pamphlet delivery 

Signaturs of person certifying lead pamphlet delivery 

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

^/^r/./fr/, A^ f •fUnlt Address 

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

may mail the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

at least 7 days before rsnovation (Document with a certificate of mailing from the 

|30St office). 
paint match form 

Paint matching form: /Uv^^a,- 3 

Property address: (pi09 11/ flf^^s/, f 

BVID: f^Of 

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Douglas County Account Ij||Dnnatio I||nr n Page 1 of2 

Douglas County, Nebraska Property Record - R184345000p; 

Information is valid as of 2008-7-14 

- — Print jReport 

NEW Faatur* - Parcel Dimension* available Q scale 0-50 fl weat tit 90th St - Vi@.W..0.n .Map. 

Treasurer's Tax Report. 

New Feature ^ «• -• AutoSaies Search 

Owner 

SWAIN CLIFFORD L 

ETAL 

6109 N 24 ST 

OMAHA NE 68110-0000 

^,5<i,S^3'2. 

Property Information 

Key Number: 4346 0000 18 

Account Type: Residential 

Farce/ Number: 1843460000 

Parcel Address: 6109 N 24 ST 

OMAHA NE 68110-0000 

Legal Description: NORWOOD ADD LOT 15 BLOCK 1 44 X 165 

Value Information 

Land Improvement Total 

2008 $5,100.00 $60,000.00 $65,100.00 

2007 $5,100.00 $53,100.00 $58,200.00 

2006 $5,100.00 $53,100.00 $58,200.00 

2005 $5,100.00 $53,100.00 $58,200.00 

2004 $5,100.00 $38,800.00 $43,900.00 

2003 $5,100.00 $38,800.00 $43,900.00 

Land Information 

Acres SF Units Depth Widtii Vacant 

0.16 7260.0 1.0 165.0 44.0 No 

Improvement Information 

Building 1 

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Douglas County Account b|£pmiation |g>r Page 2 of2 

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• ••' a 

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1 CUCJ^TD£l!lLAE(G£JMAQE 1 

Square Footage: 

Perimeter 

Unit Type: 

Built As: 

HVAC: 

Exterior: 

Interior: 

Roof Cover: 

Roof Type: 

Floorcover: 

YearBuilt 

1915 

1226.0 

0.0 

1 1/2 Story Fin 

Forced Air 

Frame Vinyl 

Drywall 

Composition Shingle 

Gable 

Allowance 

year 

Remodeled 

0 

Detail Type 

Appliance 

Appliance 

Appliance 

Basement 

Basement 

Fixture 

Fixture 

Fixture 

Garage 

Porch 

Porch 

User 

User 

«109hC34SX. . 

"'TT"i(;"j 

•<V ''•'i ' 

Pint Finer 

654.0 «q. ft. 

:L^: 

i-, 111 

1 1/2 STORY 

*••"'*•"***• ' 

C.UCKm..EN|LABfiElMASE. 1 

Percent Complete: 

Quality: 

Condition: 

Condo Square Footage: 

Rooms: 

Units: 

Baths: 

Bedrooms: 

Stories: 

Foundation: 

Sprinkler Square Footage: 

Percent 

Remodeled 

0% 

Adjusted Year 

Built 

1915 

100.0% 

Average 

Average 

0.0 

6.0 

1.0 

1.5 

3.0 

1.5 

Block 

0.0 

Physical Age 

93 

Detail Description 

Allowance 

Fireplace Masonry 

Security System 

Bsmnt Block 8 ft 

Finished 

Base Fixtures 

Bath Full 

Bath Half 

Detached 

Slab Roof Ceil 

Slab w/Steps 

LOCKED GATE 

PARKVIEW 

Units 

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 

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Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SA.D: l^l> ^ . ^ 

Property Address; ^l^f i V ' ^^ ^ ^ ' 

Owner's Name; £lUu ^ ^f ) • J^fU^-r U 

Performance Standards/close-Out Criteria 

1. Was the entire structure{s) painted with the exception of the stated, excluded areas? This would 

indude painting of other associated features including fascia, eaves, siding, ali trim, porches, box 

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

2. Was all scraping and other preparattion work completed satisfactorily? 

3. Were all required areas of the structure{s) primed as needed and painted with two top coats? 

4. Was the paint products utilized equivalent to a 30 year product/quality? 

Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ deaned? 

6. Did the contractor collect/vacuum all felling and scraped paint chips on the entire property, 

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

7. Is the grass area that surrounds the structure(s) in reasonably good condition? 

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

properiy removed? 

YES NO 

X 

I 

X. 

t 

X 

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

needs to be completed prior to the EPA Close-Out. 

10. /\re there any property Items that were temporatily re-located by the contractor 

that need to be moved back? 

^ 

11. Are there any (known) iingering issues with the property owner(s) that have been left unresolved? 

Other Considerations?propertyOv>mer Discussions?Additional Work that is Required 

EL m 

Prudent Re 

Date 

esentative 0 . 

. y