## TRANSMITTA Lo f OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID : 2 9 Date : 12/27/200 8 Address : 102 4 N 4 0 S T Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S ^ Vide o o f

propert y (DVD ) s f Executiv e Summary 0 Signe dAcces s Agreemen t for subjec t property aPaintin g Agreemen t D Settlemen t

document s (i.e. , for

damag e o r

t o replac e plants , etc. )

• Photograph s [ y Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A Property informatio n firomDougla s County Assessor' s Offic e D D D 

### Ignature /

Dat e 

# m ^

4031049 1 

# MIIIII N Superfun d

### PROPERT Y SUMMAR Y Date : 12/27/0 8 LB P STABILIZATIO N EPA CONTRAT EP-R7-08-0 7

. .. . . ,.^

—I I . • —1— T 

### Propert y Address : 102

4 N 4 0 S T Montl i of : Decembe r SAID : 2 9 A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : Non e A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None A. 4 Otlie r

Relevant Inforination : None Acces s Date : 9/25/200 8 Work Began : 10/1/200 8 Closeout Date : 10/3/200 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . SignedAcces s Agreemen t 5 . Pre-Renovatio n Form 6 . Pain t Matcl i Form 7 . Trackin g Form 8 . Dougla s Count

y 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 LA CONSTRUCTION SERVICE S 

# Property Statu s For m Address : /62 ^ / O ^ 0 S- f Date : 

## Phone : BVTO : ^ ^

Iteni # QnMa p Plan t & Pennanen t

Landscapinyy T n Remai n I n Plac e Descriptio n an dIx)catio n ; 

# /^tf'tne^ r

o f ^orne. . *y^y Pr6.]^stmt ^ Conditio n o f

Strocture s Doe s you r Basement hav e ahistor

y of leaking ? Ye s -

—N o Iteni # 

## On Ma p Descriptio n & Locatio n . • . ^ . ^. \ ^ 0r.c. k £>Jr.,.c^<u.)l r

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## scree n ^.4^^9^c J o ^ <^^y ^ -^^- ^ ^^"^^"^- ^ ^|c^:>i^^r ^ ^ 

# . Soffi t ci^^^ e ^-"f^^. s ^t*(^<M^* , J ^ ( c.^y>coi^^^ ^ Propert y Owner Signatiire:^jL.?msj^ft - ^ ^^jjyAs Y 

## Prudent Employe e Signature : fff^M . lOWiWM Pvkway , 8idt * 40 8 260 8 N . 24 * Street , Sulta30 8 »s-k..^*l, » «a4A A 424 2 Medica l Drtvt , 8uH » 428 0 ft«iiAnlMnla.TX7822S

## Pruden

t Technologies , Inc . (Prudent) i s unde r contrac t (Contrac t #EP-R7-08-07 ) wit

hth e U . S . Environmenta

l Protectio n Agenc y (EPA) to stabiliz e Lea dBase dPaint

(LBP) a t anumbe r o f propertie s locatedi n Omaha , Nebraska , includin g th e propert y locate da

t ]0Z. ^ t O U. 6 y ~ The EP A request s your

pennissio n to allo w Pruden t to perfonn LB P Stabilizatio n a t thi s property . B y signing thi s form , th e propert y owne r grant s permissio n t o Prudent t o perfonn activitie s relate dt o LB P Stabilization includin g scrapin g paint andpaintin g ofth e referencedproperty . Further , th e owner/tenan t verifie s tha

t they hav e receive dth e LB P pamphlet "Renovat e Right " Ifyo u hav e an

y question s about

th e LB P stabilizatio n planne dfo r your property , pleas e contact

Prudent' s Administrativ e Cler

k fo r th e Lea dBase dPaint

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

l question s about

th e Omah aLea

dSite cleanup ca

n b e directe dt o th e EP

A Publi c Information Center s at (402 ) 731-304 5 (Sout

hOmahaoffice) or

(402 ) 991-958 3 (Nort

hOmaha office) . Propert yAcces s Grante d By : X Tlr)r,d^}l yS L ARS&^I U (Pleas e Prin t Name

) Propen y Owne r

Signature : 

# X ^ .j^xrr ^ (S i 

# i CJ^^3X.Ht ^ (Date) RESIDEN T NAME : RESIDEN T ADDRESS : PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r properl y omie r

- pleaa e print ) iTm^fk y NT . Ica-Ser i Co^i ^ Rante r

I F RENTAL , PROPERT

YOWNE D BY : OWNER' S MAIUN G ADDRESS ; 

## -^cira ^ OWNER' S TELEPHON E NUMBER-HOME : t'^^^ Y NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : _ 

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

. NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER ; 

### . J > NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT

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

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e in^>lemente db y EP A unde r thi s agreemen t

ar e pursuan t

t o Sectio n104 o f CERiCLA . 4 2 U.S.C . 9604 . EPA' s righ t ofaeces s t o th e propert y i s provide dfor i nSectio n104(e ) o f

CERCLA , 4 2 U.S . C 9605(e) . whic hprovide s entry for "determinin g th e nee dfor

response , o r

choosin g ortaldn g an y respons e actio nunde r thi s title , o r

olherwis e enforcin g fte provision s o f fte title. "

1 0 War d Parkway , Suit e 40 5 isa s City , M O 6411 4 jne : (816 ) 363-3703 : : (816) 363-3707 2505 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 Driva , Suit e 425 0 Sa nAntonio , T X 7822 9 Phone : (210)822-958 8 Fax : (210 ) 579-6577nrecnv e unti l April 2010 . Copfiffnatio n o f Receip t o f Lea d F>ampiile t 1^ 1 Iiav e received a copyof th e pamphlet , flenovate Righ t Importan t Lea d Hazard Infonnatio n torFamSes , Chil d Ca m flrovfcters an d School s informin g m e o f th s potentia l ri8l< o

f th e lea d hazar

d eixposur

e fro m renovatio n activit

yt o b e performe d i n mydwellin g unit . I receive d thi s pamphlet befor e th e worl < began . rlnte d nam e o

f recipien t Oai a ignatur e o f recipien t ^ Signatur e o f recipien t Seif-Certificatio n Optio n (fo rtenant-occupie d dweiiing s onl ^ — I f th e lead pamphle

t wa s delivere d bu t a tenan t signatur e wa s not obtainable , yo u ma ycheci cth e appropnate boxbelow . Q Refusa i t o sig n —I certif ythat I hav

e mad e a goo d fait h effor

t t o delive rth e pamphlet , Renovat

e FSght: Importan t Lea d Hazan i Infonnatto n torFamSes , CNk i Ca m Pmvkier

s an d Schools , t o th e tanta l dwellin g uni t liste d belo wa t ttt e dat e an d tim e indicate d an d that th e occupan t refuse d t o sig n th e confinmatio n o f raceipt . I furthe rcertif

ythat i hav

e lef t a copyo

f th e pamphle

t a t th e uni t wit h th e occupant . Q Unavaiiabt 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 FV^ t Importan t Lea d Hazar d Infomnatio n tor FemSea , CtS d Ca m provider s an d Schods , to 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 furtiie rcertif

yttiat I hav

e lef t a copyof th e pamphlet a t th e uni t b ysTiding i t unde rth e doqpr

) . / J Printe d nam e o

f perso n certifyin g Attempte d deliver y dat e en d time lea d pamphle

t deliver y Signatur e o f perso n certifyin g lea d pamphlet deliver y 

# Omoihct. . /t/ r UnitAddres s Not e Regardin g l^ailtn g Optio n —As a n altemativ e t o deliver

yi n person , yo u ma ymed l th e lea d pamphle

t t o tti e owne rand/b rtenant . Pamphle t must b e mailed at leas t 7 day s betor s renovatio n ([Documen

t wit h a certificat e o

f mailin g fro m th e postoffice) .

# pain t matc h far m j j , Pain t matchin g form : ^^f ^ ^ Propert yaddress : /<pa vyy^-cy^ nah^^

f ^ ' BVID : a9 Area : Color : ^ jTfc^/^^ s Explanation : reccf ^ f>or X flexor s (Utysc^ ^ Area : Color : Explanatfio n Area : color : Explanatjion : Area : color : Explanation : Area : Color : Explanation : Q . <^ci,//on %



# Pag e 1dtWi M



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## Pag e 1 of3

Dougla s County , Nebrasic a Propert yRecor d - R240647000 0 Informatio n i s vali d a s o f 2008-9- 4 Prin t Repor t NE W Featur e - Parce l Dimension s aviai'labl e @ scal e 0-5 0 f t wes t o f SOt h S t - Vie wO n Ma p Treasurer' s Ta xRepor t Ne wFeatur e ->-*- > Aut o Sale s Searc h Owne r LARSE N TIMOTH YJ ETA L 102 4 N 4 0 S T OMAH AN E 68131-000 0 

# (^o^)5y3>3^c ^ Propert yInformatio n Ke yNumber : i 064 7 000 0 2 4 Accoun t Type : Parce l Number : Parce l Address : Residentia l

240647000 0 102 4 N 4 0 S T OMAH AN E 68131-000 0 Lega l Description : WALNU T HIL L LO T 2 BLOC K1 3 N 37. 5 FTLT S 1 & 37. 5 X 100 , Valu e Informatio n

I • Lan d 200 8 200 7 200 6 $6,800.0 0 $6,800.0 0 $6,800.0 0 j Improvemen t

j $43,500.0 0 i $43,500"6 0 ; $4'3.500.0 0 

### : Tota l $50,300.0 0 $50,300_^0

0 

## iso'sooTob " 200 5 $7,600.0 0 $43,500.0 0 $51,100.0 0 200 4 200 3 $7,600.0 0 $7,600.0 0 $43,500.0 0 $43,500.0 0 $51,100.0 0 $51,100.0 0 Sale s Informatio n

Sale s Date : 1992-12-1 6 Dee d Type : Book : '. 194 2 Page : \ 42 4 Price : •- . $27,541.0 0 Grantor : ; Grantee : . Validflnvalld : ' Vali d Exc/usro n Reason : Lan d Informatio n Acre s S F 0,0 8 3800. 0 Unit a \ Dept h 

# riT^j

Widti i \

Vacan t 

### 1. 0 100. 0 38. 0 N o Lan d Attribute s 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R24.. . 9/24/200 8±.i.xu.tj.v;i x 

### Jfage2of 3 Attribut a Negativ e Influenc e Attribut e Descriptio n Traffi c1 Improvemen t Informatio n Buildin g 1

" •r, ^ •' ; /- I

CLIC KT O ENLARG E IMAG E CLIC KTO ENLARG E IMAG ^ Squar e Footage : 

### 1814. 0 Percen t Complete : I 100.0 % Perimete ri 0. 0 Uni t Type : j En d Buil t As : j 2 Stor

y Quality : i Averag e Condition : ; Averag e _HVAC : i Force d Ai r Exterior : | Fram e Sidin g Interior : Cond o Squar e Footage : i 0. 0 Rooms : ' 9. 0 Roo f Cover : Roo f Type : Floorcover : Drywal l

Compositio n Shingl e Hi p Allowanc e Units : I 2. 0 __Baths : !_2. 0 Bedrooms : '. 4. 0 Stories : ; 2. 0 Foundation : \

Bloc k Sprinide rSquar e Footage : ; 0. 0 YearBuil t 190 5 Yea r

Remodele d Percen t

Remodele d 0 0 % Adjuste d Yea r Buil t Physica l Ag e 190 5 10 4 Detai l Typ e Ad d O n ! Detai l Descriptio n : Fence , Woo d O rChai n Lin k Unit a 1. 0 Applianc e Basemen t Fixtur e Fixtur e Fixtur e Porc h Porc h Porc h i Allowanc e I Bsmn t Bloc k

8 f t j Additiona l Fixture s ! Bas e Fixture s ; Bat h Ful l '. Sla b Roo f Cei l Slabw/Step s I Woo d Dec k 1 —J. . 

### 1. 0

998. 0 2. 0 1. 0 2. 0 158. 0 60. 0 25. 0 Use r ; SIDIN G BA D 1. 0 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accotmtinfo.jsp?accountno=R24.. . 9/24/200 8

## ^..^^..x..M,.±yji i Pag e 3 o f 3 Use r I WINDOW S BA D 1. 0 |

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# ip m

Pruden t Propert yCiose-Ou t For m (Lead-Base d Pain t StabiUzation ) SAID:__2r 3 -T l Propert yAddress : i 0 2- 4 N- • ^ ^ ^ ^

' Owner s Name : " Ti A ^ o 7 \- i ^

U <^^<^.^

S fg-7> J > 

## Performanc e Standards/ciose-Ou t Criteri a YE S N O Wa s th s entir e structure(s } painte d wit h th e exceptio n ofth e stated , exdude d a.ress? Thi s woui d fnciud e paintin g o f othe rassociate d ffesture s sndudin g fascia , saves , siding , sl i trim , porches , bo x beams , coiumns , raiis , an d esterio rsurfece s o f garages . 2 . Wa s ai! scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 . Wer e al l require d areas o f th e 5tructur6{$ ) 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 equivaien t t o a 5 0 yea rproduct/quaisty ? {3 . Are al ! ofth e area

s wher e contarr'.inate d material s hav e bee n spiile d thoroughi yvacuumed /

deaned ? Di d th e contracto rcollect/vacuu m al l faiiin g an d scrape d pain t chip s or , th e en^r e property , roadways , alleyways , publi cacces s areas an d ais o remov e an yothe rgenerate d debris ? / 

# i L 

# r 

# i 7 . i s th e gras

s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? A.^ ^ al ! item s suc h a

s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? I s ther e an yevidence o f propert ydamag e tha t was don e b yth e ccntractcr ? .An ypropert ydamag e need s t o b e comoiete d prio rt o th e EP AClose-Out

^ ^ A.r g ther e an ypropert yitem s tha t wer e temporatii yre-iocate d b yth e ccr=tracto r tha t nee d t o b e move d back? 1 1 . Areper e any(known ) lingerin g issue s wit h th e propert yowner(s ) tha t have bee n ief t unresolved ? Othe rConsiderations?propertyOvme rDiscussionsfAdditiona i Wor k tha t i s Require d



## Pruden t Reipli-esentativ e J 

# \JA^OXL _ 

# r- ^ g-^A . Date ' ^