TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 23392 Date: 12/22/2008 

Address: 3419 Davenport St 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

0' Video of property (DVD) 

[ZT Executive Suminary 

m Signed Access Agreement for subject property 

[F Painting Agreement 

D Settlement dociunents (i.e., for damage or to replace plants, etc.) 

D Photographs 

B^ Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

W Property information from Douglas County Assessor's Office 

D 

D 

D 

ijni/of 

Date 

40309520 |ni 

Superfund 
PROPERTY SUMMARY 

Date: 12/22/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address: 3419 Davenport St SAID: 23392 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Infonnation: None 

Access Date: 12/04/08 

Work Began: 12/10/08 

Closeout Date: 12/17/08 

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 

TEChhlOLOCIES. INC. 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: 3 4 1 ^ *T>C^\*4Jjn^X/>r^ 34. Date: /;? ^ '3-(P ? 

Phone: BVID: p339 p 

iJJf^vk ' ^frO'^ " ^H?^ ' 36S I 

Plant & Permanent Landscaping To Remain In Place 

Item# 

Description and Location 

On Map 

Pre-Existing Condition of Structures 

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

Item# Description & Location 

On Map ^ /fern' M^i r?e)^i^ <, kx^ii-^ ^i^i^i>i-) 

Property Owner Prudent Employee 

Signature: Signature: 

a,^i;<.l .Ar. 7i: .c.nc 

8080 Vlterd Parkmy, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Sulta 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)604-1004 Phone: (210)822-0588 JJAn \ eA J 4AA K Bav <9im i:7Q.Af;77 
2".V3^Z 

Pnident 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 ofproperties 

located in Omaha, Nebraska, including the property located at ^h/' Y /^^^f'/i /iGf-y- 2^ . 

The EPA requests your permission to allow Prudent to perform LBP Stabilization at this property. By 

signing this form,tiie property owner grants permission to Prudent to perfonn activities related to LBP 

Stabilization including scraping paint and painting ofthe referenced property. Furtiier, the owner/tenant 

verifies that they have received tiie LBP pamphlet "Renovate Right." 

If you 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^ohnson., 

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

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

office). r 

Propetty Acoess Qianted By: 

(Please Print Name) 

Propeity Owner Signatore: A/s'O.j ^ ^ . .oiu ;? . r\yi..Y\ r {cy>>/(y<^ 

^ ' ' (Signature) ' (Kte) 

PROPERTY INFORMATION 

(To bS completed lyy resident and/or property omier - please prinQ 

RESIDEMTNAME: /(A9i'J^/tAd f ^.^f<ig> t C> ( ^ Owngr^i Renter 

RESIDENT ADDRESS: JV/ ^ i7^u^eAfic/:/ ^ -

IF REKTAt.. PROPERTY OWNED BY: 

OWNER'S MAIUNG ADDRESS; ^Me , 

OWNER'S TELEPHONE NUMBER. HOME: (/^-^t 7^ 0 ^^ ' f WBORK! if*'^ \ -^ ^ 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: / 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

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

AUTHORrrV FOR ENVIRONMENTAL RESPONSE ACnONS; Tlw aetivitiet to be implemented by EPA under das agreement are pumant to Section 104 

ofCERCLA, 42 U.S.C. 9604. EPA's right of acoess to die property is providedfot in Section 104(e) ofCERCLA. 42 U.S. C 960S(e), wfiicii provides entry 

ftr "detenniningdie needfor lesponse. or choosing ortaking any response action under this title, ox odwiwise enfincing tie provisions of die title." 

i080 Wain Pattovay, Sulta 405 2505 N. 24*^ Straet, Suite 308 4242 Medical Drive, Suite 4250 

'ansa* CHy MO 64114 Oinaha, Nebrasica 68110 San Antonio, TX 76229 

'hone-(816) 363-3703 Plione: (402)504-1004 Plione: (210)822-9588 
Current Sample TO-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

Q I have received a copy of the pamphlet, Renovate Right: Important Lead Hazard 

Infonnation for Families, Child Care Providers and Schools infoiming me of 

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

performed In my dwelling unit. I received this pamphlet tjefore the w/ork t»egan. 

Printed name of recipient . Date 

y, ;-7..->r. -^ . y . \nc . 

Signature of recipient 

Self-Certification 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. 

• Refusal to sign — I certify that i have made a good faith effort to deliver the 

pamphlet, fienovate F^ht: Important Lead Hazard Infbrmatton for Families, 

0)3d Cam Pmviders and Schools, to the rental dwelling unit listed below at the 

date and time indicated and that the occupant raffused to sign the confirmation 

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 Fiight: important Lead Hazard Infonnation for 

Families, Child Cam pmviders and Schools, to the rental dwelling unit listed 

below and that the occupant was unavailable to sign the confirmation of receipt. 

I ftjrther certify that I have left a copy of the pamphlet at the unit by sliding it 

underthedoor. ^ 

J ^ r Ipe^^ns /? " 3'-€>^ 

Printed name of person certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person'certifying lead pamphlet delivery 

/PtA^h^, 

Unit 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 renovation (Document with a certificate of mailing from the 

post office).. 
Paint matching form; 

Property address: 3W9/:^eyi/i^r)f 

BVID: 533? ^ '^ 

Area: Color:

Explanation: 

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Area: Color: 

Explanation: 

Area: Color: 


Explanation: 


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Area: color: 


Explanation: 


Area: color: 

Explanation: 

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Page 1 

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uougias uouQiy Account iciormation Page 1 of2 

Douglas County, Nebraska Property Record - R1305120000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-SO ft west of 90th St - Vie W O n Ma p Information is valid as of 2008-9-4 Treasurer's fax Repjort 

New Feature -»-*- » Auto Sales Search 

Owner 

TAPIA-SALAZAR MAURILIO •?(J J - '^C / 

3419 DAVENPORT ST 199 " /^l l 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number: 0512 0000 13 

Account Type: Residential 

Parcel Number: 1305120000 

Parcel Address: 3419 DAVENPORT ST 

OMAHA NE 68131-0000 

Legal Description: HAWTHORNE ADD LOT 5 BLOCK 8 48 X 110.6 

Value Informatio n 

Land Improvement Total 

2008 $5,800.00 $59,500.00 $65,300.00 

2007 $5,800.00 $49,700.00 $55,500.00 

2006 $5,800.00 $49,700.00 $55,500.00 

2005 $5,800.00 $49,700.00 $55,500.00 

2004 $5,800.00 $49,700.00 $55,500.00 

2003 $5,800.00 $32,000.00 $37,800.00 

Sales Informatio n 

Sales Date: 1996-05-20 

Deed Type: D Book: 2034 Page: 252 

Price: $35,900.00 

Grantor: 

Grantee: 

Validllnvalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Deptii Widtii Vacant 

0.12 5280.0 1.0 110.0 48.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R13... 9/24/2008 
ijougias L^ouniy Account miormation Page 2 of2 

Building 1 

2 1/2 Story Unfin 

34tS Daver.pott St 

•'•-"•j

I

 First Flool 

 770.0 sq ft 

Sec50r.d Floe 

672.0 S.F 

•Jt.0 

31»lf«i)!m/)itT 

CLICK TO ENLARGE IMAG^ 

CLICK TO ENLARGE IMAGE 

Square Footage: 

Perimeter 

Unit Type: 

Built As: 

HVAC: 

Exterior: 

Interior: 

Roof Cover: 

Roof Type: 

Floorcover: 

1442.0 

0.0 

2 1/2 Story Unfin 

Forced Air 

Frame Aluminum 

Drywall 

Coniposition Shingle 

Allowance 

Percent Complete: 

Quality: 

Condition: 

Condo Square Footage: 

Rooms: 

Units: 

Baths: 

Bedrooms: 

Stories: 

Foundation: 

100.0% 

Average 

Average 

0.0 

6.0 

1.0 

1.5 

3.0 

2.5 

Block 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Sprinkler Square Footage: 0.0 

Adjusted Year 

Built Physical Age 

1921 0% 1921 87 

Detail Type Detail Description Uni ^ 

Add On 

Appliance 

Basement 

Basement 

Fixture 

Fixture 

Fixture 

Garage 

Porch 

Unfinished Attic W/floor 

Allowance 

Bsmnt Block 8 ft 

Minimal Finish 

Base Fixtures 

Bath Full 

Bath Half 

Detached 

Slab Roof Ceil 

672.0 

1.0 

672.0 

200.0 

1.0 

1.0 

1.0 

160.0 

160.0 

http://douglasne.inapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R13... 9/24/2008 
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Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID:. (-13 3 TO N 

PropeiityAddress: ST/ 9 .DaiJO^^i-i ' ^-4^ ­

Owner's Name; V . Cjfp^stLi ^ ^Y l G^r^-. ^ 

Performance Standards/close-Out Criteria 

YES NO 

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

include painting of other associated features including fascia, eaves, siding, all trim, porches, box 

beams, columns, rails, and exterior surfaces 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? 

5. Are ;all of the areas where contaminated materials have been spilled t 

thoroughly vacuumed/ cleaned? 

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

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

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

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

proprerly removed? 

9.

 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. Are there any property items that were temporatiiy re-located by the contractor 

that'need to be moved back? 

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

Other Considerations?property Owner Discussions?Addltionai Work that is Required 

Prudent Representative Signature: 

/^fiy/o<t 

Date i/^J/c^^'''^^^ 

Properjty Owner Signature: 

p J ^ -^Ib