## TRANSMITTA Lof OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R S AI D # : 1852 7 Address : 62 0 Dorca s 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 ) Executiv e Summary Signe dAcces s Agreemen t for subjec t propert y Paintin g Agreemen t D 

### Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D 

### 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 fromDougla s Cotmt y Assessor' s Offic e D D D



### _ . Qa mAt ^ 

# Muks — Signatur e ^ Dat e

4031040 8 

# H i Superfun d

### PROPERT Y SUMMAR Y Date : 10/03/0 8 LB P STABILJ7ATIO N EP A CONTRAT EP-R7-08-0 7 Monthof : Decembe r Propert y Address : 62 0 Dorca s S t SAID : 1852 7 A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : None A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 09/30/0 8 Wor k Bega n Date : 10/09/0 8 Closeou t Date : 11/11/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio n For m 6 . Pain t Matc hFor m 7 . Trackin g For m 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 .ENVIRONMENTA LA CONSTRUCTION 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ( ^ Z O ^\:^o^-C.cx V 5f . ^^' ' (C^f'^f/c^ S Plan t & Pennaneii t T .andaeapln RT o Remai nI nPlac e Iteiii # Descriptio nan dLocatio nr \/ i f

\ , OnM(q[ > I Svshe^s ^ Cu^e$t ) <ih<?dJc ^ nd ^ it e fif^^^hkm.

Pre'Existin g Conditio n o f Structure s Doe s you r Basement hav e ahistor y of leaking ? Ye s — No- ~ Itein# 

## Descr^o n& Locatio n OnM{Q)

Propert y Owne r Xy Pruden t Employe e Signature : t^^'Signature : ^^ae,^ ^ 808 0 Wu dPailwiy , 8iit » 40 5 260 8 N . 24 * Straet , Suite 30 8 424 2 Medica l Drive . Suite 428 0

• a n AIOMHI M TVTSM O

# [2^ 5 ^ 1

Pruden t Technologies , Inc . (Pnident ) is unde r

contract (Contract #EP-R7-08-07 ) wit hth e U.S. Environmenta l Protectio n Agenc y (EPA ) to stabiliz e Lea dBase dPaint (LBP a pLnumbe r of p^pertie s im(Lt3P ) ) at t anumoe r oi propertie s locate d in Omaha, Nebraska , includin g ^ e propert y located at 

## f^ ^ Lh^ i ^ - The EP A requests your pemiissio nto allo w Pruden t to perfor mLB P Stabiiizatio n at thi s property . By signing thi s form, th e propert y owner grant s permissio nto Pruden tto perfon n activitie s related to LB P Stabilization including scrapin g pain t andpaintin g of th e referenced property . Further , th e owner/tenan t verifie s tiiat they hav e receive dtiie LB P pamphle t **Renovat e Right. " Ifyo u have an y question s abou t th e LB P stabilizatio n planne dfo r

your property , pleas e contact Prudent' s Administrative Cler k

fo r

th e LeadBase dPaint Stabilization , Mrs . Debora hAkercie-Johnson . at

(402 ) 504-1004 . Genera l question s about the OmahaLea dSit e cleanup ca nbe directed to tiie EP A Publi c Informatio n Center s at (402 ) 731-304 5 (Soutii Omah aofEice ) or (402 ) 991-958 3 Q^Iorti i Omaha office) . . ^ PnwertvAceeiianntadBv : A* ^ L-^C^V^KJH ^ r \IT A;^/ \ » (Ptepif j Print Name ) Propat y Owne r Signabre : (Date ) PROPERT Y INFORMATIO N (T o becomplctt d by midentand/o r praptrt y owocr - picaa e print ) RESIDEN TNAME : L^rcu O Kf^ao/ i /"^Jmar ) Rente r RESIDEN TADDRESS : 

## d?Q( ^ Uorc^a ^ IF RENTAL . PROPERT YOWNE D BY : 

# ^n\e ^ OVmER' 8 MAIUN O ADDRESS : OWNER' S TELEPHON E NUMBER . HOME : l'^'^ ^ '^ ' ^^^WORK ; J _ NUMBE ROF OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE ROF OCCUPANT S 7 YEAR S OL D AN D OLDER : 

# . S NUMBE R OPCHILDRE N UNDE R 7 YEAR S OL D WH O PLAY IN TH E YAR D FO R 6 HOUR S OR MOR E PE R WEEK : COMMENT S ORSPECIA LINSTRUCTIONS : (I. & DOOS . ENTRY QATES . ETC. )

AUniOIUT Y POI t ENVIRONMBNTA LKBSPONS EACllONS ; Th e acthriiie i to be implemente d by EPAunde r 1 ^ of CERCLA , 42 U.& C 9604 . EPA' i figh t of aeoet i to lh e property isprovide d forinSectio n104(e ) of CERCLA , 42 U.S . C 960S(e) . whichptovide t entry Ib r

"determinin g th e nee dfb r response , or chooain g ortaldng any reiponi e aclk munder thi t title , or odierwiae enforcin g di e provisi ^

08 0 War d Paikway , 8ldt » 40 8 280 8 N. 24 * Stravt , Suit e 30 8 424 2 MMllcalDifv»,8ultf t 428 0 I CHy , MO 8411 4 Oniaha , Nebrask a 6811 0 Se n Antonio , TX7ft9 M

# »rPk < Curren t Sampl e PrdM^^enovatio n For m Effectiv e unti l Apri l 2010 . Ctmflmiatlo n ofReceip t ofLoa d Pamphle t srI hav e received a c»p yofth e pamphlet , Fienovat e Righ t Importan t Lea d Hazen i Infonnatio n fo rFamSies , ChS d Ca m Provkler s an d School s informin g me of th e potentia l ris k ofth e lea d hazar d exposur e fro m renovatio n activity to be perfbrme d in tn ydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . 

# 1/7 - f - o< i Dat e SeK-Certificatio n Optio n (fo rtenant-occupie d dwelling a only ) — Ifth e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ydiec k th e appropriat e bo xbek>w . Q Refuaa l to sig n —I certifytha t I hav e mad e a goo d M h effbr t to delive rth e pamphlet , FiencNate FUght : Importan t Lea d Hazan i Infonratio n fo rFamSies , ChS d Car e Pny\^der s an d Schools , to th e renta l dwellin g uni t liste d belo w at th e dat e an d tim e indicate d an d tha t th e oocupan t refuse d to sig n th e confirmatio n ofreceipt . I furttie rcertifytha t I hav e lef t a cop yofth e pamphle t at th e uni t wit h th a occupant . Q Unavailabl e fo rsignatur e —I certif ytha t I hav e mad e a goo d felth effor t to delive rth e pamphlet , fWiovat e FV^ t Importan t Lea d Hazan i Intonnatio n fb r f^tnlSes , ChS d Care provki& van d Schools , to tti e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e to sig n th e confirmatio n ofreceipt . I furthe rcertifytha t I hav e left a cop yofth e pamphle t at th e uni t byslidin g it unde rth e dQ^ . Printe d nam eofperso n certifyin g Attempte d deliver y dateandtim e yf lea d pamphle t deliver y 

## /M^i^^^ ^ Signatur e ofperso dertifyln to n

n oertnyin g g leadpamphle

leadpamphle t t deliver

delivery y, 

# n/iA/ji/ic^. . £/ ^

# iUnitAddres s Not e Regardin g Mailin g Optio n —As an altemativ e to deliver y

In person , yo u ma ymai l th e lea d pamphle t to th e owne rand/o rtenant . Pamphle t mus t be maile d at leas t 7 day s before renovatio n (Documen t wit h a certificat e ofmailin g fro m th e pos t office) .

# pain t matc h ferm /Vv>f/ ^ Pain t matchin g form : —^- ^ propert yaddress : ^^ o Pr:*/^cct i ^ - BVID : i^^a i Area : Color : /<^<z//c?) ^ 

# Explanation : Area : Ba^en^c/i f ^//iJ^a^ir^t/coior : ^ ocr/U^ ^ Explanation : Area : Color : Explanation : Area : color : Explanation : Area : color : Explanation : Pag e 1

# ACCES S i^P O / ? HfiiT i O N TRAcmi G SHEE T

OmrOoiMllo i ^tam^^-^'/^-'^l^ ^ VM c.

p^^^^^^ W^WWiW^^^^W B 

# mI to e I tomr I CotirwcTDenra i

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# W^ ^ 16 < Y^.-muMuu O ^fe ^ /.'Chifr/ n 

# Yi n \i,:^ W ' l^^^^'^^^J^:^?^^---^'^^^ !

### Dougla s Count y Accoun t Infi^n i ation Pag e 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R022233000 0 Prin t Repor t NE W Faatur e • Parca l Oimension s availabl e Q scal e 0-5 0 ft was t o f OOt h S t - yjevy.P. n ..Ma p Informatio n i s vali d a s o f 2008-9- 4 Treasurer' s fa xRepor t Ne wFeatur e ••-•• • Aut o Sale s Searc h Owne r REGA N TIMOTH Y J ETA L 62 0 DORCA S S T OMAH AN E 68108-000 0 Propert yInformatio n Ke yNumber : 223 3 000 0 0 2 Accoun t Type : Residentia l Parce l Number : 022233000 0 Parce l Address : 62 0 DORCA S S T OMAH AN E 68108-000 0 Lega l Description : U^ND S SEC-TWN-RG E 26-15-1 3 W 4 0 E 23 4 F T SU B LT 5 LO T 6 4 0 X 90. 5 Valu e Informatio n Lan d Improvemen t 

### Tota l 200 8 200 7 200 6 200 5 200 4 200 3 $3,700.0 0 $3,700.0 0 $3,700.0 0 $3,700.0 0 $3,700.0 0 $3,700.0 0 $69,700.0 0 $71,400.0 0 $71,400.0 0 $71,400.0 0 $48,600.0 0 $48,600.0 0 $73,400.0 0 $75,100.0 0 $75,100.0 0 $75,100.0 0 $52,300.0 0 $52,300.0 0 Sale s Informatio n Sale s Data : 1993-04-2 7 Dee d Type : Book : 194 9 Page : 42 2 Price : $ 38,750.0 0 Grantor : Grantee : Validflnvalld : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit a Dept h Widti i Vacan t 0.0 8 3600. 0 1. 0 90. 0 40. 0 N o Improvemen t Informatio n

1 . ..... . .11 3 1 . . I I lrt../*lrtn/^/xXT^/fifrt+./\/ort/>/\iir»+i*^fi ^ 1 o»^0*»/»/»/\il«+n/\^Ort O on/innnf i

### uougia s v-ouni y Accoun t iniormauo n fag e / o r

z Buildin g 1 2 STORY 620OOftCAaS T 3HT ti l 720. 0 3<mni)fW' < 1 1 <,?J i ;« ; 5, 1 *«»».l^^lb.- .

CL1CK..TP. ENLARQEJMAS E CLIC KIQ.£MLAME-IMAg E Squar e Footage : 1392. 0 Percen t Complete : 

### 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Averag e

Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0

HVAC : Centra l Ai rt o Ai r Rooms : 8. 0 Exterior : Fram e Viny l Units : 1. 0 interior : Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 4. 0

Roo f Type : Hi p 

### Stories : 2. 0 Floorcover : Allowanc e Foundation : Blocl ( Sprinide rSquar e Footage : 0. 0 YearBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r B u m Physica l Ag e 192 0 0 % 192 0 8 9 Detai l Typ e Detai l Descriptio n Unit a Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 f t 672. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Porc h Sla b Roo f Cei l 120. 0 Porc h Sla b w/Step s 40. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R02.. . 9/24/200 8

### Pruden t Propeit yClose-Ou t For m (Lead-Base d Pain t Stabilization ) 

## SAID : \?'^X 1 _ ^ ^ Propert yAddress : (rtH ^

ptnyft^CU:iJ > ^SJ 7 Owner' s Name : .SL^f^h ^ 

### Performanc e Standards/ciose-Ou t Criteri a YE S M O Wa s th e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s inciudin g fascia , saves , siding , al l trim , porches , box 

# i beams , columns , rails , an d exterio rsurface s o f garages . 2 .Wa s al l scrapin g an d othe rpreparattio n wori ccomplete d satisfactorily ? -JX 3 .

Wer e al l require d areas ofth e strueture{s ) prime d a s neede d an d painte d wit h tw o to p coats ? 

# X . 4 .Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 

# A Are al l ofth e areas wher e co.ntaminate d material s hav e bee n spille d thoroughl yvacuumed / deaned ? 

# i 5 .Di d th e contracto rcotiect/vacuum . al i failin g an d scrape d pain t chip s o n th e entir e property , roadways , aiieyways , publi cacces s areas an d ais o remove an yothe rgenerate d debris ? 7 .I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# i

8 .

Are ai l Item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? 

# t 9 .

I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . 10 . Are ther e an ypropert yitem s tha t wer e temporatil yre-locate d b yth e contracto r tha t nee d t o b e move d back? 11 .Are ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? Othe rConslderations?propert yOwne rDiscussions?Additlona l Wor k tha t i s Requi.^e d 

# i

Cctj,^^ ^ 

# ihu- m Pruden t Re^esentativ e OA/K^-— Dat e ll//f^if ^