TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 29 Date: 12/27/2008 

Address: 1024 N 40 ST 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of property (DVD) 

sf Executive Summary 

0 Signed Access Agreement for subject property 

a Painting Agreement 

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

• Photographs 

[y Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

Property information firom Douglas County Assessor's Office 

D 

D 

D 

Ignature/ Datme 

^ 

40310491 

MIIIIIN 

Superfund 
PROPERTY SUMMARY 

Date: 12/27/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 

. .. . . ,.^ — II . • — 1— T 

Property Address: 1024 N 40 ST 

Montli of: December 

SAID: 29 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

A.4 Otlier Relevant Inforination: None 

Access Date: 9/25/2008 

Work Began: 10/1/2008 

Closeout Date: 10/3/2008 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Matcli 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 A 

CONSTRUCTION 

SERVICES 

Property Status Form 

Address: /62 ^ /O ^ 0 S-f Date: 

Phone: BVTO: ^ ^ 

Iteni# 

QnMap 

Plant & Pennanent Landscapinyy Tn Remain In Place 

Description and Ix)cation ; 

/^tf'tne^r o f ^orne.. *y^yPr6.]^stmt^ Condition of Stroctures 

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

Iteni# 

On Map 

Description & Location . • . ^ . ^. \ 

^ 0r.c.k £>Jr.,.c^<u.)lr ^^^-^"" ^ {eai>^ ^ <i€?oy^;> 

screen ^.4^^9^cJ o ^ <^^y^ -^^- ^ ^^"^^"^-^ 

^|c^:>i^^r ^ ^ 

. Soffit ci^^^e ^-"f^^.s 

^t*(^<M^* , J ^ ( c.^y>coi^^^ ^ 

Property Owner 

Signatiire:^jL.?msj^ft- ^ ^^jjyAsY 

Prudent Employee 

Signature: fff^M. 

lOWiWM Pvkway, 8idt* 408 2608 N. 24* Street, Sulta 308 

»s-k..^*l, » «a4A A 

4242 Medical Drtvt, 8uH» 4280 

ft«iiAnlMnla.TX7822S 
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 ]0Z.^ tO U.6 y~ 

The EPA requests your pennission to allow Prudent to perfonn LBP Stabilization at this property. By 

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

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

verifies that they have received the 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 the EPA 

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

office). 

Property Access Granted By: X Tlr)r,d^}l y S L ARS&^I U 

(Please Print Name) 

Propeny Owner Signature: X ^ .j^xrr^ (Si i CJ^^3X.Ht^ 

(Date) 

RESIDENT NAME: 

RESIDENT ADDRESS: 

PROPERTY INFORMATION 

(To be completed by resident and/or properly omier - pleaae print) 

iTm^fk y NT. Ica-Seri Co^i ^ Ranter 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAIUNG ADDRESS; 

-^cira ^ 

OWNER'S TELEPHONE NUMBER-HOME: t'^^^Y 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: _ 

, ,m,5^3-S^U> WORK: J L 

. NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER; . J> 

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.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be in^>lemented by EPA under this agreement are pursuant to Section 104 

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

for "determining the need for response, or choosing ortaldng any response action under this title, or olherwise enforcing fte provisions of fte title." 

10 Ward Parkway, Suite 405 

isas City, MO 64114 

jne: (816) 363-3703 

:: (816) 363-3707 

2505 N. 24*^ Street, Suite 308 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

4242 Medical Driva, Suite 4250 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577 
nrecnve until April 2010. 

Copfiffnation of Receipt of Lead F>ampiilet 

1^1 Iiave received a copy of the pamphlet, flenovate Right Important Lead HazardInfonnation tor FamSes, Child Cam flrovfcters and Schools informing me of 

ths potential ri8l< of the lead hazard eixposure from renovation activity to be 

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

rlnted name of recipient Oaia 

Signatur ignaturee o off recipien recipient t ^ 

Seif-Certification Option (for tenant-occupied dweiiings onl^ — 

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

you may checic the appropnate box below. 

Q Refusai to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, Renovate FSght: Important Lead Hazani Infonnatton tor FamSes, 

CNki Cam Pmvkiers and Schools, to the tantal dwelling unit listed below at ttte 

date and time indicated and that the occupant refused to sign the confinmation 

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

the occupant. 

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

deliver the pamphlet, Renovate FV^t Important Lead Hazard Infomnation tor 

FemSea, CtSd Cam providers and Schods, to the rental dwelling unit listed 

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

I furtiier certify ttiat I have left a copy of the pamphlet at the unit by sTiding it 

under the doqpr) . / J 

Printed name of person certifying Attempted delivery 

date end time 

lead pamphlet delivery 

Signature of person certifying lead pamphlet delivery 

Omoihct.. /t/r 

UnitAddress 

Note Regarding l^ailtng Option — As an altemative to delivery in person, you 

may medl the lead pamphlet to ttie owner and/br tenant. Pamphlet must be mailed 

at least 7 days betors renovation ([Document with a certificate of mailing from the 

postoffice). 
paint match farm j j , 

Paint matching form: ^^f^ ^ 

Property address: /<pav y y^-cy^ nah^^f ^ ' 

BVID: a 9 

Area: Color: ^ jTfc^/^^s 

Explanation: 

reccf^ f>orX flexors (Utysc^ ^ 

Area: Color: 

Explanatfion 

Area: color: 

Explanatjion: 

Area: color: 

Explanation: 

Area: Color: 

Explanation: 

Q . <^ci,//on% 

Page 1 
dtWiM 

ACCESS lfJPOl^HA^iof^'n^AOKa^Q SHEET 

a? /Ooti A/ WJ-/ . 

] 

PlopBdyOiBMBfi /yMo'l'hy ^ Lcus^'tyi 

OMvOoiMHoe tteiw^^g-^^^^^^^ ^ vyferK 

Oeft Jg& 

yvHHPW ^VinV^HMI^w tryJtAJ-

\W/W''^i 

CcUrHCrOETUVR. 

X Pkc^sr <fiue ^tjoner ^ /6A /\<=>i'K^^ 

M M 
.kv .a.AAAV/J.AXAI.4>l>lWXl Page 1 of3 

Douglas County, Nebrasica Property Record - R2406470000 

Information is valid as of 2008-9-4 

Print Report 

NEW Feature - Parcel Dimensions aviai'lable @ scale 0-50 ft west of SOth St - Vie w O n Ma p 

Treasurer's Tax Report 

New Feature ->-*- > Auto Sales Search 

Owner 

LARSEN TIMOTHY J 

ETAL 

1024 N 40 ST 

OMAHA NE 68131-0000 (^o^)5y3>3^c^ 

Property Information 

Key Number: i 0647 0000 24 

Account Type: 

Parcel Number: 

Parcel Address: 

Residential 

2406470000 

1024 N 40 ST 

OMAHA NE 68131-0000 

Legal Description: WALNUT HILL LOT 2 BLOCK 13 N 37.5 FT LTS 1 & 37.5 X 100, 

Value Information 

I 

• Land 

2008 

2007 

2006 

$6,800.00 

$6,800.00 

$6,800.00 

j Improvement 

j $43,500.00 

i $43,500"60 

; $4'3.500.00 

: Total 

$50,300.00 

$50,300_^00 

iso'sooTob" 

2005 $7,600.00 $43,500.00 $51,100.00 

2004 

2003 

$7,600.00 

$7,600.00 

$43,500.00 

$43,500.00 

$51,100.00 

$51,100.00 

Sales Information 

Sales Date: 1992-12-16 

Deed Type: Book: '. 1942 Page: \ 424 

Price: •-. $27,541.00 

Grantor: ; 

Grantee: . 

Validflnvalld: ' Valid 

Exc/usron Reason: 

Land Information 

Acres SF 

0,08 3800.0 

Unita \ Depth riT^j Widtii \ Vacant 

1.0 100.0 38.0 No 

Land Attributes 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R24... 9/24/2008 
±.i.xu.tj.v;ix Jfage2of3 

Attributa 

Negative Influence 

Attribute Description 

Traffic 1 

Improvement Information 

Building 1 

" •r, ^ •' ; /- I 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAG^ 

Square Footage: 1814.0 Percent Complete: I 100.0% 

Perimeter i 0.0 

Unit Type: j End 

Built As: j 2 Story 

Quality: i Average 

Condition: ; Average 

_HVAC: i Forced Air 

Exterior: | Frame Siding 

Interior: 

Condo Square Footage: i 0.0 

Rooms: ' 9.0 

Roof Cover: 

Roof Type: 

Floorcover: 

Drywall 

Composition Shingle 

Hip 

Allowance 

Units: I 2.0 

__Baths: !_2.0 

Bedrooms: '. 4.0 

Stories: ; 2.0 

Foundation: \ Block 

Sprinider Square Footage: ; 0.0 

YearBuilt 

1905 

Year 

Remodeled 

Percent 

Remodeled 

0 0% 

Adjusted Year 

Built Physical Age 

1905 104 

Detail Type 

Add On 

! Detail Description 

: Fence, Wood Or Chain Link 

Unita 

1.0 

Appliance 

Basement 

Fixture 

Fixture 

Fixture 

Porch 

Porch 

Porch 

i Allowance 

I Bsmnt Block 8 ft 

j Additional Fixtures 

! Base Fixtures 

; Bath Full 

'. Slab Roof Ceil 

Slabw/Steps 

I Wood Deck 

1 

—J. . 

1.0 

998.0 

2.0 

1.0 

2.0 

158.0 

60.0 

25.0 

User ; SIDING BAD 1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accountno=R24... 9/24/2008 
^..^^..x..M,.±yjii Page 3 of 3 

User I WINDOWS BAD 1.0 | 

http://douglasne.mapping-onlme.com/DouglasCoNe/static/accountinfo.jsp?accoxintno=R24... 9/24/2008 
ipm 

Prudent Property Ciose-Out Form (Lead-Based Paint StabiUzation) 

SAID:__2r 3 -Tl 

Property Address: i 0 2- 4 N- • ^ ^ ^ ^ ' 

Owners Name: "T i A^ o 7 \-i ^ U <^^<^.^S fg-7>J > 

Performance Standards/ciose-Out Criteria YES NO 

Was ths entire structure(s} painted with the exception ofthe stated, exduded a.ress? This wouid 

fnciude painting of other associated ffestures snduding fascia, saves, siding, sli trim, porches, box 

beams, coiumns, raiis, and esterior surfeces of garages. 

2. Was ai! scraping and other preparattion work completed satisfactorily? 

3. Were all required areas of the 5tructur6{$) primed as needed and painted with two top coats? 

4. Was the paint products utilized equivaient to a 50 year product/quaisty? 

{3. Are al! ofthe areas where contarr'.inated materials have been spiiled 

thoroughiy vacuumed/ deaned? 

Did the contractor collect/vacuum all faiiing and scraped paint chips or, the en^re property, 

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

/ 

iL 

r 

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

A.^^ al! items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. 

properly removed? 

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

needs to be comoieted prior to the EPA Close-Out^ ^ 

A.rg there any property items that were temporatiiy re-iocated by the ccr=tractor 

that need to be moved back? 

1 1 . Arepere any (known) lingering issues with the property owner(s) that have been ieft unresolved? 

Other Considerations?property Ovmer DiscussionsfAdditionai Work that is Required 

Prudent Reipli-esentative J 

\JA^OXL_ r-^ g-^A. 

Date 

' ^