TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: y^^^; ^ Date: n^/^rO./^a//y 

Address: sfypTtyf /?y:y9yxy/^ .^7- . 

Stabilization Contractor: Prudent Technologies, Inc. Year: 2010_ 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

y Z Video of property (DVD) ' 

y Z Executive Summary 

y Signed Access Agreement for subject property 

yy\ Pre-Renovation Form signed by Property Owner 

• Pre-Renovation Form for Occupant/Tenant, ifappiicable 

z Painting Agreement 

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

yyf Renovation Recordkeeping Checklist signed by Certified Renovator 

y Z Photographs 

y Satisfactory close-out check list signed by Property Owner 

D Property close-out check list signed by EPA 

JG Property information from Douglas County Assessor's Office 

j t Hazard analysis, if prepared 

D Safety Audit 

n Other (describe): 

K. Signature Date 

(afierfile folder review) 

30218115 

HI HMNl l 

Superfund 
TECHNOLOGIES^ INC 

Property Summary 

Date: 8/11/2010 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: August 

Property Address; 1210 Blaine St. SAID #: 12327 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 06/13/2010 

ii. Work Began: 06/29/2010 

iii. Close-Out Date: 06/29/2010 

B. Enclosures: 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Pre - Renovation Form signed by Property Owner 

5. Pre - Renovation Form signed by Occupant/ Tenant, if applicable 

6. Advance-Notice, Stabilization Video Agreement Form 

7. Property Paint Match Form 

8. Property Access Assessment Form 

9. Renovation Recordkeeping Checklist signed by Certified Renovator 

10. Signed Property Completion Agreement Form 

11. Property Close-Out Check list Signed by EPA 

12. Douglas County Assessor Property Information 

13. Work-Site Hazards Analysis Checklist 

14. Pre- Stabilization Property Hazard Assessment Photographs 
TECHNOUXSIBS, INCT 

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 ofproperties 

located in Omaha, Nebraska, including die property located at: /g^lQ J^hjiyi^ S ^ 

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 including 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, if the soil cleanup has not already been 

performed. I imderstand that the stabilization contractor cannot provide assurances of which 

contractor will be bound to the soil cleanup. 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. 

[rZ\ Yes, I have read and understand the paragraph above. 

0^-1'^'1^/ 0 

wner's Signature Date 

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, Mr. Chandra 

Shekar at 402- 504-1004 or 402-889-3821. 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). 

Propertv Access Granted Bv: 

OlzIhWD 

Property Owner's Signature Date 

n o«^ir , V \A J <»vVhrA (L cA f^/d 

Please Print Name 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 IVledical Drive, Suite 4250 

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

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

Fax: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577 
TBCHNOUXilBS.TNC 

PROPERTY INFORMATION 

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

RESIDENT NAME: Mr^/Tc- \/(iA<^Tif\ C- (^e ^ Tenant 

RESIDENT ADDRESS: )1}7 ) l^lcc ( r^g- ^ 7~ 

IF RENTAL, PROPERTY OWNED BY: /^r^^cIcA l/rjJ.^r\ J I < \ ( ^ 

OWNER'S MAILING ADDRESS: J'^I H "^{c^yrv^ S' : 

OWNER'S TELEPHONE NUMBER: 

Home: Work: cd\:yy^2 706r-^y^d 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 3 

TOTAL NUMBER OF OCCUPANTS: ^ 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS 

OR MORE PER WEEK: 3 

COMMENTS OR SPECIAL INSTRUCTIONS (such as dogs, entry gates, etc.); 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented 

by EPA under this agreement are pursuant to Section 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 entry for "detennining the need for response, or choosing or taking any response action under 

this title, or othenvise enforcing the provisions ofthe title." 

Property Owner Signature: OIP-12 - tCl^ 

(Signature) Date 

8080 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 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
PRE & POST PAINT STABILIZATION VIDEO AND PICTURES 

I understand that prudent Technologies (Prudent) will be coming out to shoot a PreStabilization video and to take pictures of my property. Prudent will use the videos and 

pictures to document the current property status/condition. Also, Prudent will shoot a video 

shot following the compietion of the paint stabilization. I give permission to videos and 

pictures of my property. 

Please list any special conditions that Prudent employees need to be aware of before 

shooting a video (such as pets, prior notice, etc.). 

iiiz) 1^;^.^^

Property Address 

 s i 

Owner's Name Signature 

n6-ll-%f?/d 

Date 

ADVANCE NOTICE REQUIREMENT 

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. Please indicate below how much advance notice you need to have the abovementioned tasks completed. If you are a landlord you will need to contact the tenant as 

Prudent will only inform the property owners. 

Do you have any pets that reside in yard: 

Notice needed: 

Phone number to call to give notice: W f - '^0{ Q \y)^^'0 O 

Whom we are giving notice to: 

8080 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 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577 
PRE-RENOVATION FORM - OWNER 

This form is to be used by thefirms contracted by the Environmental Protection Agency-Region 7 to perform Lead-Based 

Paint stabilization activities at the Omaha Lead Site, Omaha, Nebraska. 

Owner Confirmation 

Pamphlet Receipt 

p I have received a copy ofthe lead hazard information pamphlet, Renovate Right: Importand Lead Hazard Information for 

Families, Child Care Providers and Schools, informing me ofthe potential risk ofthe lead hazard exposure from renovation 

activity to be performed in/on my dwelling unit. I received this pamphlet before the work began. 

Owner Acknowledgment 

0(A) I confirm that I own and live in this property, that no child under the age of 6 resides here, that no pregnant woman 

resides here, and that this property is not a child-occupied facility. 

Note: A child resides in the primary residence of his/her custodial parents, legal guardians, foster parents, or 

informal caretaker if the child lives and sleeps most of time at the caretaker's residence. 

Note: A child-occupied facility is a pre-1978 building visited regularly by the same child, under 6 years of age, on at 

least two different days within any week, for at least 3 hours each day, provided that the visits total at least 60 hours 

annually. 

D (B) I understand that the renovation fum, contracted by the Environmental Protection Agency (EPA), will be using leadsafe work practices required by EPA's Renovation, Repair and Painting Rule. 

^^^ i g ^ \/cA^yy, y\. 

Printed Name of Owner-Occupant 

^- /^ - 2^/ ^ 

Signature of Owner-Occupant Date 
PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: lll O ^V.i.v>r^€ . ^ T 

BVID: 

The following notes are for the benefit of paint crew only. 

Paint Yes Paint No Location Paint Description 

Siding Vi<vY L^ 

l 

Soffit U J 0 e (^ 

Fascia 

\A> o ^d 

Comer Trim vy><^^_^ 

Window Trims K.)^ fi A j ^ 

Door Trims 

^^o^ ^ j:^:r ^ 

Front Porch Ceiling o o ik y 

Front Porch Ceiling Beams X.SJ 0 ^ A. l ^ 

Front Porch Floor 

LA/ 0 * A l^ 

Front Porch Railings UN/- » © 

Front Porch Steps » ^ e> » c( 

Siding Baseboards vJ\ V 

Foundation C<./VU<^A-J|— 

Garage/Shed Oltv- L^ ^^t^-ti<i.ys wCftdo*^'^ V(5<K: 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature; Date: 

8080 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 

Fax:(816)363-3707 Fax: (402) 504-1005 Fax:(210)579-6577 
pRlJDEra 

TECHNOU}GISS,INC 

ACCESS ASSESSMENT FORM: /-^/ 6

House siding (circle all applicable) 

*Transite is same as asbestos 

**Also called aluminum siding 

***Aiso called roof shingles 

If the siding is aluminum (metal), Is it original 

factory finish or painted over? Circle one. 

If the siding is Wood/Asphalt/Roof shingles, is it 

painted? Circle one. 

Does this property require lots of scrapping? 

Does this property require a lift or scaffolding to 

reach upper levels? 

Does this property have lots of plants/ivy or items 

in the areas where painting is required? If yes 

explain. 

Does this property have any significant structural 

damage? If yes. EXPLAIN? 

Does this property have a: Garage / Shed 

Garage: Yes / No 

Shed: Yes / No 

If yes, describe the location & siding material of 

garage / shed. 

Is this property vacant or occupied - circle one 

Are there any pets at this property? If yes explain. 

Are there any low hanging power lines? 

Do we need neighbor's access? If yes please 

explain and get neighbor's property address and 

owner information. 

 d>fa7 n^.'f- ^ 

Wood / Transite*(^yiny>/ Pre-finished Metal** / 

Brick / Concrete / Concrete blocks / wood 

Shingles / Asphalt shingles*** / Stucco / 

Original Factory Finish, 

Pairrted Over 

Shingles painted 

Shingles not painted"^ 

Yes(/ Noj 

Yes (R> 

Yes % 

Yes /'|Ko I ) 

Garage: Attached / Detached 

Garage siding: Wood / Transite* / Vinyl / Prefinished Metal** / Brick / Concrete / Concrete 

blocks / wood shingles / Asphalt shingles*** / 

Stucco / 

Shed: 

Occupl^ / Vacant 

Yes i m 

Yds/No 

Yes/ gj 

8080 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 

Fax:(816)363-3707 Fax; (402)504-1005 Fax:(210)579-6577 
(effective April 2010) 

RENOVATION RECORDKEEPING CHECKLIST 

Name of Firm: -^fvuAi^J^-

Date and Location of Renovation: Start Date: £ ^)lo End Date: G 2.^|lo Location: \2J0 BVxifAa ^|^ 

Brief Description of Renovation: •^^^^t>^ii^.\" 

Name of Assigned Renovator: ^<jtmp ' (^O^Mie.1 ^('^eJ l ''TiJCLirs. 

Name(s) of Trained Workers: T5<^«»^<'<?^ 

Name of Dust Sampling Technician, Inspector, and/or Risk Assessor, if used: 

Copies of renovator and dust sampling technician qualifications (training certificates, certifications) on file. 

Certified renovator provided training to workers on (check all that apply): 

'^ Posting warning signs Setting up plastic containment barriers 

Maintaining containment ^""^ Avoiding spread of dust to adjacent areas 

'-"-'Waste handling '—"Post-renovation cleaning 

Test kits used by certified renovator to determine whether lead was present on components affected by 

renovation (identify kits used and describe sampling locations and results: 

,.^'Warning signs posted at entrance to work area. 

/"Work area contained to prevent spread of dust and debris. 

(^Windows in and within 20 feet ofthe work area are closed 

^Door s in and within 20 feet ofthe work areas are closed and sealed 

/^ Doors that must be used in the work area are covered to allow passage but prevent spread of dust. 

^ Ground covered by plastic sheeting extending 10 feet from work area - plastic anchored to the 

Suilding and weighted down by heavy objects! 

If necessary, vertical contaimnent installed to prevent migration of dust and debris to adjacent 

property. 

Waste contained on-site and while being transported off-site. 

Renovation Recordkeeping Checklist Omaha Lead Site 
(effective April 2010) 

Work site properly cleaned after renovation. 

"^All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for 

removal. 

Work area HEPA vacuumed to get paint chips from ground surface, if necessary. 

Certified renovator performed post-renovation cleaning verification (describe results): 

1 certify under penalty of law that the above information is tme and complete. 

Name and Title Date 

Renovation Recordkeeping Checklist Omaha Lead Site 
ENVIRONMENTAL & CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

OMAHA LEAD BASED PAINT REMEDIATION 

Property Owner Close-Out Form 2010 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-07) 

SAID: jy^cjr^ ^ 

Property Address: -y ^/^ n ^Z^^^> ^ c^'T' 

Owner's Name: Ay/f^TC^y^ L^^//^y ^ y^^^i/ ^/9^/^yi O 

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 preparation work completed satisfactorily? 

3. Were all required areas ofthe structure(s) primed as needed and painted with two top coats? 

4. Was the paint products utilized equivalent to a 25 year product/quality? 

5. Are all ofthe areas where contaminated materials have been spilled 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? 

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

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 you satisfied with the work performed? 

11. Are there any property items that were temporarily re-located by the contractor that need 

to be moved back? 

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

unresolved? 

Other Considerations/Property Owner Discussions/Additional Work that is Required: 

^ 

Property Owner Signature Date 

\g.forcLo 

Pruden ii t Technologies, Inc. Signature Date 

8080 Ward Parkway, Suite 405 2505 N. 24'" street. Suite 218 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 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
t Q\ttJ ^ 

Checklist for the Worksite Hazard Analysis 

Address 

Crew: Date: to- y fi 

Item Hazard , i Corrective Action i L 

Overhead Lines ci ^ ^ z ) CHi: 

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 i^ LL/M^Q'SL 0-^ ^ k^^/A^ 

Neighbor Access Required L>l^-0 

High Traffic Area 

Garage 

Structures ico^^OciiU l LOaxlZ^^^Zj^ rcL - hojo 

l^a-M'i-fe^^ l 

Foundation <Ux^, ui-*/-A>~ 

Retaining Walls tLwAjg<^ 

Fences 

^"^^^ffH 

Trees U/(\ •haiJk: Foliage 

General Condition of i^t^-U.gri.^^yg^ i\jtuJk ^*- ^ Damaged Areas: sink -Ouu^oy ^^T ' 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditiitiimi s 

Unsafe driving conditions 

Unsafe neighborhood uli^AJ^ f *M\/es.e»ej\rm. MA\9%j\» ^ f. t

Crew Foreman Safetv^Officer coar< ojyea^ 

_\gjro<r cie) dreor (X^CUT 

oOSC 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 

Pdx: :816j 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
Checklist for the 

MtHiMiiliiAMiil 



Douglas County Account Infijcmatio ^jm a n Page 1 of3 n 

Douglas County, Nebraska Property Record - R1937230000 

Print Reoort 

View Interactive GIS Mao Information is valid as of 2010-5-28 Treasurer's Tax Reoort 

New Feature ^ - f r^ Subdivision Sales Search 

Owner 

VALENTIN-CALIXTO MARIA 1 

ETAL 

1210 BLAINE ST 

OMAHA NE 68107-0000 

Property Informatio n 

Key Number 3723 0000 19 

Account Type: Residential 

Parcel Number 1937230000 

Parcel Address: 1210 BLAINE ST 

OMAHA NE 68107-0000 

Legal Description: PARK FOREST LOT 9 BLOCK 10 N 1/2 LT 8 & S 1/2 50 X 120 

Value Informatio n 

Land Improvement Total 

2010 $4,800.00 $57,800.00 $62,600.00 

2009 $4,800.00 $57,800.00 $62,600.00 

2008 $4,800.00 $35,200.00 $40,000.00 

2007 $4,800.00 $35,200.00 $40,000.00 

2006 $4,800.00 $35,200.00 $40,000.00 

2005 $4,800.00 $35,200.00 $40,000.00 

Sales Informatio n 

Sales Date: 2008-12-05 View Document 

Deed Type: WD Book: 2008 Page: 119369 

Price: $65,000.00 

Grantor SEMIN JOSEPH G ETAL 

Grantee: VALENTIN-CALIXTO MARIA 1 ETAL 

Vaiid/lnvalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.13 6000.0 1.0 120.0 50.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountao=R193... 6/3/2010 
Douglas County Account Information tMjma Page 2 of3 

Building 1 

1 1/2 Stwy Unfin 1210 BJErine St 

s r 

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CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 836.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Good 

Built As : 1 1/2 Story Unfin Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Vinyl Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1906 0 0% 1906 103 

Detail Type Detail Description Units 

Add On Unfinished Attic W/floor 836.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 836.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Porch Slab Roof Ceiling 120.0 

Porch Slab Roof Ceiling 100.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R193... 6/3/2010 
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