TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SA1D#; 3P^^\ ^ Date; -?/ ^i^ | rdrr^ 

Address: ^ "^nit- N U-o AV 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD): Pre-Stabilization & Post-Stabilization Videos 

Executive Summary 

Signed Access Agreement Form 

y Advance Notice Form 

y Pre-Stabilization Video Agreement Form 

y Access Tracking Form 

^ Property Access Assessment Form 

Neighbor Access Agreement Form 

Paint Match Form 

a/ Pre-Stabilization Property Safety Assessment Form 

M Work-Site Hazards Analysis Checklist 

M Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

Douglas County Assessor Property information 

y Property Completion Agreement Form Signed by Property Owner 

Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature Date 

EPA Signature Date" 

30054882 

IIU 

Superfund 
TBCHNOLQCIBS. INC 

Property Summary 

Date; 7/23/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: July 

Property Address; 4304 N 40 AV SAID #; 33919 

A. Executive Summarv; 

a. Issues Encountered; NONE 

b. Issues Resolved; NONE 

c. Unique Findings: NONE 

d. Other Relevant Information; 

i. Access Date; 6/23/2009 

ii. Work Began; 6/30/2009 

iii. Close-Out Date; 7/06/2009 

B. Enclosures; 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Advance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracking Form 

7. Property Access Assessment Form 

8. Neighbor Access Agreement Form 

9. Property Paint Match Form 

10. Pre-Stabilization Property Safety Assessment Form 

11. Work-Site Hazards Analysis Checklist 

12. Pre- Stabilization Property Hazard Assessment Photographs 

13. Douglas County Assessor Property Information 

14. Signed Property Completion Agreement Form 

15. Property Close-Out Check List Signed By EPA 
#83II f 

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 ^3/) ^ //> ^ d fifjE, 

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 indudiig 

scraping paint and painting ofthe referenced property. Further, the owner/tenant verifies that they have received 

the LBP pamphlet "Renovate Right." By signing this document I agree to allow an EPA contractor to conduct a 

soil cleanup at my property following completion of lead-based paint stabilization. I understand that the 

stabilization contractor cannot provide assurances that the soil cleanup contractor will be bound to. I further 

understand that the soil cleanup contractor will make all reasonable efforts to address concems that I, as the 

property owner, may have regarding soil cleanup at my property. 

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

Relations/Office Manager for the Lead Based Paint Stabilization, Mrs. Shannon Holt, at (402) 504-1004 or 

(402)812-0223. 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). 

;7>/*^e& V ryiac>y^^ Property Access Granted By: 

(Please Print Name) 

Property Owner Sigtiature: 

(Signature) (Date) 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner - please print) 

RESIDENT NAME: ^M/njS. ^ U fftUiJ r /Owner ^ Renter 

RESIDENT ADDRESS: 

IF RENTAL, PROPERTY OWNED BY: - ^ ^ ^ » ' 

Si A TnJc- OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER-HOME: ( ) V^ ^ '/•^'^7fORK : ( ) PK ^ 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: O NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: ^ 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHOM 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 implemented by EPA under this agreement are pursuant to Sectioi 104 

ofCERCLA, 42 U.S.C. 9604. EPA's right ofaccess to the property is provided for in Section 104(e) ofCERCLA, 42 U.S. C 9605(e), which provides entiy 

for •'determining the need for response, or choosing or taking any response action under this title, or otherwise enforcing the provisions ofthe title." 

abso Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

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

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Pay (filfil •Kf.-X.Xira P=v- iAr\t\ enyi.ir^nc " — - •-'-. — 
Advanced notice needed. 

After signing the access you allow Prudent to begin Lead 

Based Paint Stabilization. All Plants, weeds and any 

vehicles or items on open porch (enclosed porches will 

NOT be stabilized) must be removed prior to 

stabilization. All Pets must be out of yard during 

stabilization. How much notice do you need to have 

above mentioned tasks completed? Ifyou are a landlord 

you will need to contact the tenant as Prudent 

Technologies will only inform you. 

Do you have any pets that reside in yard? AJ^ 

Noticeneeded:^^ ^ ^^ / 

Number to call to give notice: ^ ^ ' /) i 

Whom we are giving notice to: 

Home Owner's Signature ^^^ i^jilUifJirfl^ 
i 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING OUT 

TO SHOOT A PRE-STABILIZATION VIDEO AT MY PROPERTY. THE VIDEO 

IS JUST A TOOL USED TO DOCUMENT THE CURRENT PROPERTY 

STATUS/CONDITION. A POST VIDEO WILL ALSO BE SHOT PRIOR TO 

COMPLETION OF STABILIZATION. 

OWNERS '^*'^^-- J^&y^^(5/c^A i^O^C 

PROPERTY ADDRESS: 4J^ V r^^ ^ /^l/t 

BVID/SAID: '^3^ 1 ^ 

HOMEOWNERS SIGNATURE: WTU^ k f '^l^^^O^^''^'^ 

PRUDENT REPRESENTATIVE SIGNATURE: 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING VIDEO: 

(I.E. PETS, NOTICE NEEDED): /Ud/rC 
SGSscssasaESCs 

ACCESS INFORMATION TRACKING SHEET 

BVID: , 33f/ ^ 1^^^ . ^3o4 A. </d^ Auz 

Properly Owned By: ^lfirrA^.<> -^ /^//lAi f f)f\P(l(f 

Owners Phone No,«' . Home. HSf-I^O- ^ Work: 

Celt: Fax; 

Access Contractor. ASW FDA MES PE Other ^afMht' 

(QkctoOtMi; 

DATE TIME Accessor COffTACr DETAIL 

^^/^ 4 ^'Wfi. mj ^7^ih/ip kl lllf>WtJtk 

Comments; 

Ptoase wrftefoflfflMy 
Access Assessment Form: (Must be completed for every property. Information 

must be obtained from a property walk thru, not given by owner) 

Is the property stucco or asbestos? 

Ifyes, is any ofthe stucco or asbestos damaged or cracked? 

Ifyes, stop as we can't stabilize this property. It requires special preparation 

techniques. It will be retumed to EPA and they will assign at a later date. 

Does this property require lots of scrapping^* 

/nod^mkj 

Does this property require a lift or scaffolding to reach upper levels? 

Does this property have lots of plants or items in areas where painting is required? 

Does this property have any significant structural damage? 

Ifyes, EXPLAIN? 

Does this property have a garage? 

Ifyes, describe location of garage 

Coffny^ ifj fy-^(lu&hid^­
Does this property have aluminum siding? 

If yes, is it original factory finish or has it been painted over? 

Does this property have any other type of structural components? (i.e. roof shingles 

as siding)? 

Ifyes, EXPLAIN? 

Is this property vacant or occupied? J 

Are there any pets at this property? . 

Are there any low hanging power lines? 
Is there a neighboring property that needs to be accessed along with assigned 

property to complete stabilization process? 

If so, get a signed access from all necessary neighboring properties. 
'1^60 S ^^' W 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

Paint matching form: 

Property address: ^3^ i J^' HP ^ Aod 

BVID: OSH i 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: ^^j^^^t^ f/ jyfotxsi.-^ 

/Ifjdct Cdlo/l^ ON l^oo^e ^/^m6{y 

P m f m^^^fk^ds ifioo/A) &hjiy^ 

Page I 
ua 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: ^3d ^ f^' ^ ^ ^^ ^ 

BVID/SAID: -93^ if 

PRUDENT REPRESENTATIVE DOING ASSESSMENT: 

7^ 

****IF SAFETY RISK PROPERTY MUST BE TURNED OVER 

TO KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A 

CREW/SUB. 

REPRESENTATIVE REMARKS/FINDINGS (POWER-LINE 

PROXIMITY TO HOUSE, SCAFFOLDING/LADDERS/LIFT 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.): 

3K, 

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 
/V30 ^ r#AO*^AV(L. 

TBCHNOLOGIBS I 1 

Checklist for the Worksite Hazard Analysis 

Address: 

Crew: 

Item 

Overhead Lines 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required 

High Traffic Area 

Garage 

Structures 

Driveway 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Foliage 

General Condition of yard 

Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

Crew Foreman 

MO 

8080 VVardTarkway 

Kansas City, MO & 

Phone: (816) 363-37< 

Fax: (816) 363-3707 

Date: 

OK? Hazard 

* ^ yV\ulhpis 1,1^ ma 

1 

1 

\

Vk. 

2505 N. 24'" Street, Suite 308 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

Corrective Action 

i w . ,^>9C/>^r ^ . Uftrsr >1«7*t C?**-/-*.^ ^ e 

/^,>a^^4»/x i**^ g«iit.y».^<fr««r 

Site Safety Officer 

4242 IVIedical Drive, Suite 4250 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577 
^?>otf N Ac AV<«: 
Current Sample Pre-Renovatio TO- n Form 

Effeo9v8Wittl April 2010. 

Confinnation of Receipt of l.ead Pamphlet 

A i \\merecdNei a ooip^d(^i)eparnpti^. Renovate Rls^lmp(xtant Lead Hazard 

Information forFmSes, ChSd Care Providers arxl Schools Infomiing me of 

ttie potentiai risk of the lead hscanj eoqxsijre fityn renovation actlvify 

performed in my dvif^ing mitJ receKred this pampNet t)0fbre the worit t)ega^ 

Printed name of recipient Date 

Iture of rec^ilert 

8eif-Certifieal)Qn Option (Ibr tenant-occupied dwellinga only) — 

tf the lead pamphlet was delivered but a tenant signature was not olstainable, 

you may check the appropriate box below. 

Q Refusal to sign—I certify that i have made a good M h effort to deliver the 

panphlet, /lenovafe F^g/nt: Important Lead Hazard Infomiation for FamOea, ChSdCaraProvldera and School, to the rental dwaiiing unit Usted below at the 

date and time indicated and that the occupant refused to ^ the confirmation 

of iBOB^st I further certity that I have left a copy of the pamphlet at the unit with 

theocoupanL 

Q Unavailable fbr signature—I certify that I have made a good feith effort to 

deliusr the pampMet, Renovate Ri£^ t Important LaexJ Hazanj hfonwSan for 

Faroes, O M Care prcvidera ancf Schoofs, tb the rental dwelling unit listed 

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

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

Printe d namame! of person certHyir certifying^ Attempte Attempted delivery 

date and time 

6u^^­ lead pamphlet delivery 

Signature of pe(8ork»(tiiying lead pamphlet detiveiv 

UnltAddress 

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

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

at least 7 cteiys bdbre renG^nA]o^ (Documern \Arith a certificate of maTing from the 

post office). 
Douglas County Account Infonnation iittp://dougiasne.nnK)ing-oniine.conVDouglasCoNe/static/accountinfo.. .vmao 

Douglas County, Nebraska Property Record - R2034500000 

I Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west ot 52nd St - VleW On Ma p Information is valid as of 2009-5-12 Treasurer's Tax Report 

New Feature -»-•-> Auto Saies Search 

Owner 

IWIOORE JAMES V 

4304 N 40 AVE sm - 33^1 ^

OI\/iAIHANE68111-0000_ 

Property Information 

Key Number: 3450 OOOO 20 

Account Type: Residential 

Parcel Number: 2034500000 

i Parcel Address: 4304 N 40 AV 

OMAHA NE 68111-0000 

Legal Description: RADFORD HEIGHTS REPLAT LOT 18 BLOCK 0 40 X 280 

' Value Information 

' 

Land Improvement Total 

2009 $5,300.00 ! $26,700.00 j $32,000.00 

2008 $5,300.00 $26,700.00 1 $32,000.00 

; 2007 $5,300.00 $26,700.00 $32,000.00 

1

! 2006 $5,300.00 $26,700.00 $32,000.00 

2005 $5,300.00 $21,500.00 1 

1 $26,800.00 

2004 $5,300.00 $19,500.00 $24,800.00 

Land Inform lation 

, 4cres SF Units Depth i Width j Vacant 

0.25 11200.0 1.0 280.0 40.0 No 

Improvemei rat Information ... " -- - -^^—^-^ 

Building 1 

- '-'- - ' • — 

lof 2 6/8/2009 11:04 AM 
Douglas County Account Information 

Square Footage:

Perimeter 

Unit Type: 

Built As:

HVAC:

Exterior:

Interior:

Roof Cover:

Roof Type:

Floorcover: 

„ -.^ Year Built _, Remodeled Remodeled 

1925 

Deta/7 Type 

Add On 

Appliance 

Basement 

Fixture 

Fixture 

Porch 

littp://douglasne.n]jaDing-online.coni/DouglasCoNe/static/accountinfo.. .m^^i 

r 

Rrst Boor 

•* 

RAt+CH tl.'^ia:,! fl*

 936.0 

0.0 

 Ranch 

' Central Air to Air 

 Frame Siding 

 Drywall 

 Composition Shingle 

 Hip 

Allowance 

 Year Percent .. . 

L_ „ „ ..,._ - 1 

0 0% 

Deta/7 Description 

Fence Chain Link 

Allowance 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

End Solid Wall 

CLICK TO ENLARGE IMAGE 

Percent Complete:

Quality:

Condition:

Condo Square Footage:

Rooms:

Units:

Baths:

Bedrooms:

Stories:

Foundation:

 100.0% 

 Fair 

 Average 

' 0.0 

 5.0 

 1.0 

 10 

 2.0 

 1.0 

 Block 

Sprinkler Square Footage: | 0.0 

Adjusted Year

Built

 ' „., ­ , ^ 

 Physical Age 

1925 84 

Units 

1.0 

1.0 

936.0 

1.0 

1.0 

208.0 

2 of 2 6/8/2009 11:04 AM 
WliitePages.com - Online Directory Assisi littp://www.wl]j|Maages.com/searcli/ReverseAddress?street=+4304+.. 

2 Results matching "4304 N 40 Ave, Omaha, NE". 

Sort by: - SelectGloria V Moore SPONSORED LINO I 

HouMhold: James V Moore '-~''"P Background mib for Gloria Moore. 4304 N 40th Ave 

Omaha, NE 68111-2183 

phone number unavailable 

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James V Moore Sr SPONSORED UMCS 

1 

4304 N 40th A\ e HouuhoM : Qpria V Mgpre ^^^" P Background Intb fbr Jam n Moore. 

Omaha, NE 68111-2183 

phone number unavailable 

LjstinQ Details 

SPONSORED UM(S 

1 Hm Rttgrtt fgr eiQrH Hvin 

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Gloria Moore Omaha NE View Details 

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lof l 6/8/2009 11:04 AM 
# 

TECHNOLOGIES. INC. 

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

SAID: ^^^' ^ 

^3o(/ ]/^ </Q Av e Property Address: 

Owner's Name: V^i^^ ^ l/> /^^^v g 

S.NO Performance Standards/close-Out Criteria Yes NO 

1 Was the entire structure(s) painted with the exception of the stated, 

excluded areas? This wouid include painting of other associated 

features inciuding fascia, eaves, siding, ail trim, porches, box 

beams, coiumns, raiis, and exterior surfaces of garages. 

2 Was all scraping and other preparation work completed 

satisfactorily? j y 

3 Were all required areas of the structure(s) primed as needed and 

i^^ ^ painted with two top coats? 

4 Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? i ^ 

5 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? 

6 Is the grass area that surrounds the structure(s) in reasonably good 

condition? 

7 Was the paint products utilized equivalent to a 30 year 

product/quality? ly 

8 Are all items such as polyethylene sheeting, ladders, paint brushes, 

^ _ ^ - ­ cones, barrier tape etc properly 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 temporarily 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? 

12 Other Considerations? Property Owner Discussions? Additional C - Work that is Required 

Prudent Representative Signature: 

Date: \\Jp 

Property Owner Signature: 

8080 Ward Parkway, Suite 405 

KansasCity, MO 84114 

Phone: (816) 363-3703 

Fax: (816) 363-3707 

Jl-tnryU) nr <s-ye-i^-_^ 

2505 N. 24'" Street, Suite 308 

Omaha, Nebrasica 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

4242 IVIedical Drive, Suite 4250 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577 
TECHNOLOGIES, 1 

EPA Close-Out Form (Lead-Based Paint Stabilization) 

BVID:^3ai_ 2 

Property Address: l^'^ O L j "^ /-(O f]M(2_. 

Owner's Name: KJCky^P. <? t'V7<T»or/o 

S.NO 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 y beams, columns, rails, and exterior surfaces of garages. 

Was all scraping and other preparation work completed i X satisfactorily? 

Were all required areas of the structure(s) primed as needed and 

painted xy with two top coats? 

Are all of the areas where contaminated materials have been spilled 

l y thoroughly vacuumed/ cleaned? 

Did the contractor collect/vacuum all failing and scraped paint chips 

on the entire property, roadways, alleyways, public access areas i X 

and also remove any other generated debris? 

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

Was the paint products utilized equivalent to a 30 year 

^ y product/quality? 

Are all items such as polyethylene sheeting, ladders, paint brushes, 

u ^ 

cones, barrier tape etc properly removed? 

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 temporarily 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? 

12 Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

7/<-p.^.Vc< ofV" IcOer -fni*^ ooo-f^ <^J r ^cOL^ L cJtJr ,r p u).f|- cf j 

\ y ^ , W - s^ C -5- ^ 0^ \>c^ ^ - i^ H 't^^'=^ 

YO.CCU,'. 

EPA COR/ Representative Signattrfe" 

Date = Vi^M