TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: _3i^3M_7 _ Date: 

Address: 3 <^ 1 % ^ 1> S SV ' 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

A Executive Summary 

A Signed Access Agreement Form 

A Advance Notice Form 

A Pre-Stabilization Video Agreement Form 

A Access Tracking Form 

A Property Access Assessment Form 

A Neighbor Access Agreement Form 

A Paint Match Form 

y Pre-Stabilization Property Safety Assessment Form 

A Work-Site Hazards Analysis Checklist 

y Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

y Douglas County Assessor Property information 

y Property Completion Agreement Form Signed by Property Owner 

Property Close-Out Check List Signed By EPA 

y^A^y^^^^ ^^_ Prudent Technologies, Inc. Signature Date 

EPA Signature Date" 

30055323 i 

Superfund 
.INC. 

Property Summary 

Date: 12/-/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Dec 

Property Address: 3923 N 25 St. SAID #: 33347 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 10/13/2009 

ii. Work Began: 10/30/2009 

iii. Close-Out Date: 11/07/2009 

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 
TBOINaLOCIBS, IN C 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. Environmental Protection 

Agency (EPA) to stabjlize Lead Based Paint (LBP),ate number of properties located in Omaha, Nebraska, including the 

propertv located at y 7^, ^ N^f ^ <" > T ' 

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 akeady been performed. I understand that the stabilization contractor 

cannot provide assurances of which contractor will be bound to the soil cleanup. I fiirtfaer 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. 

[ {y^s, Ihav haveereareadd anandd understanunderstandd ththee paragrapparagraphh above i .

Signature ofTroperty Owner r- ^ 

^0-/3- 09 

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, 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 ofRce). 

Property Access Granted By; toperty Access urantea uy: » t 

(Please Print Name) 

Property Owner Signature: ' •/Q^ttrlat^lr<. ^ '(Signature) 

//-:>- / s d)? 

(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 
• TBCHNOLOGIBS, INC;~ 

PROPERTY INFORMATION 

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

RESIOENTNAME: iV)iCHt.Ll c )4" ft. L L wner / Renter 

RESIDENT ADDRESS: ^1^.^ ^ m %-i ­

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: ( U/f^^ ^OS- * I ^ZQoRK: (^<CL 9 IA' ^ t i i J i f 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: ^L^ 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: 

A. 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: Tlie activities to be implemented by EPA under this agreement are 

pursuant to Section 104 ofCERCLA, 42 U.S.C. 9604. EPA's right of access to the property is provided for in Section 104(e) ofCERCLA, 

42 U.S. C 9605(e), which provides entry for "determining the need for response, or choosing or taking any response action under this title, or 

otherwise enforcing the provisions ofthe title." 

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 
TECHNOLOGIES, INC. 

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? |V ^ 

Notice needed : A-n/ ; ^» 'IVl c 

Number to call to give notice: S'O A ^ I o e>c O 

Whom we are giving notice to: (^ r ^ IV I ^ y ' ^ ^ 

Home Owner's Signature 

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 
TECHNOLOGIES.] 

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. 

Je.SS>€. WQ OWNERS NAME: 

PROPERTY ADDRESS: 3><^22> ^^ '2. 6 ^ 

333M1- BVID/SAID :

HOMEOWNERS SIGNATURE •.^-^4t^4j^ h'i y 

PRUDENT REPRESENTATIVE SIGNATURE: 

cyHr 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (I.E. PETS, NOTICE NEEDED): 

•/jt^^h^^ 

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 
TECHNOLOGIES,] 

ACCESS INFORMATION TRACKING SHEET 

BVID : ^^3^7 PROPERTY ADDRESS : 3q2S ^ 2^-^-^ 

Property Owned By: 

(If new property owner) 

Owners Phone No's: Home: Work: 

Cell: ~ Fax: ~ 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

fe>lf%)/^ ///h iU^iM^ aA.a4^%4''<^ ' 

/ ' f ' I I ' 

/ r ^ 

(A 

Comments: 

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 
TECHNOLOGIES. INC. 

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? 

If yes, is any ofthe stucco or asbestos damaged or cracked? 

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

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

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 or items in areas where painting is 

required? A- ^ 

Does this property have any significant structural damage? 

If yes, EXPLAIN? 

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 
TECHNOLOGIES, INC. 

Does this property have a garage? 

If yes, describe location of garage. 

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)? 

If yes, EXPLAIN? 

Is this property vacant of occupied? 

Are there any pets at this property? 

/-\A ^ 

Are there any low hanging power lines? 

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 
OOLOGIES. INC. 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: gt^^ b <^ O^S S f 

BVID: 2>2)^M > 

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

Paint Yes Paint No Location Paint Description 

Siding / 

Soffit A? 

Fascia CK 1 Comer Trim 

^ ^ 

Window Trims 

Door Trims 

/ 

Front Porch Ceiling ^^S' / 

Front Porch Ceiling Beams 1J Front Porch Floor 

Front Porch Railings 

\ ^ 

Front Porch Steps 1 

^ 

Siding Baseboards 

Foundation 

1 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature; •.^MiJeuU k ^ D..e:/^-;.3-df 

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 
TECHNOLOGIES, INC 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

tsjO 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

1^0 

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 
TECHNOLOGIES,] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 3 ^ 2 ?> f^ 2- S S T* 

BVID/SAID: Q>3>S^ ^ 

PRUDENT ASSESSMENT REPERSENTATIVE: 

l^a^J 4^f^ -

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

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

8080 Ward Parkway, Suite 405 2505 N. 24*" Street, Suite 308 4242 Medical Drive, Suits 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 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

ar 1 have receiveci a copy of the pamphlet. Renovate Right: Important Lead Hazard 

Information for Families, Child Care Providers and Schools informing me of 

the potential risk of the lead hazard exposure from renovation activity to be 

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

^.Vh-elU jQ i^ y /o-j>-c>l 

Printed name of recipient ^ ^ 0 / Date 

Signature of recipient 

Self-Certification Option (for tenant-occupied dwellings only) — 

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

you may check the appropriate box below. 

• Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, Renovate Right: Important Lead Hazard Information for Families, 

Child Care Providers and Schools, to the rental dwelling unit listed below at the 

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

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

the occupant. 

QKfnavallable for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Renovate Right: Important Lead Hazard Information for 

Families, Child Care providers and Schools, to the rental dwelling unit listed 

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

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

under the door. // /> i 

Printed name of person certifyingf ^ Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person certifying lead pamphlet delivery 

Unit Address 

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

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

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

post office). 
--- 

Checklist for the Worksite Hazard Analysis 


a59% 

Address: 

Crew: Date: 

Levels around high wires - -- I Vehicle Clearance around 1 

.General Condition 6. J,,u 

, ,, Damaged Areas: sink 


holestrotted wood 


Insects P 

nditions 


ing conditions -
 a .. 

Crew Fnremanl Sub- 

, Site Safety Officer 

180%ard Parkway. 

ansas City. MO 64'~,.+ 

Fax: (402) 504-1005 
- w • 

lilt 
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-^^H ^ ^ R Li;.

; •' -^>:.i^:::H: ^ V - = <•-• 

f - •*-.-^" '

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Douglas County Account Information http://douglasne.niaRBJng-online.com/DouglasCoNe/static/accountinfo.. laDDin , 

Douglas County, Nebraska ProperlY Record - R1840440000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VlCW On Ma p Information is valid as of 2009-9-29 Treasurer's Tax Report 

New Feature •* r¥ ^ Auto Sales Search 

Owner 

HALL JESSIE R 

ETAL 

3923 N 25 ST 

OMAHA NE 68111-0000 

333^7 

Propert y Informatio n 

Key Numtier 

Account Type: 

Parcel Numtier 

4044 0000 18 

Residential 

1840440000 

Parcel Address: 3923 N 25 ST 

OMAHA NE 68111-0000 

Legal Description: NO RRI S SUB DIV LOT 6 BLOCK 0 42 X 100 

Value Informatio n 

2009 

Land 

$2,200.00 

Improvement 

$15,500.00 

Total 

$17,700.00 

2008 

2007 

2006 

2005 

2004 

$2,200.00 

$2,200.00 

$2,200.00 

$2,200.00 

$2,200.00 

$15,500.00 

$15,500.00 

$15,500.00 

$6,800.00 

$6,200.00 

$17,700.00 

$17,700.00 

$17,700.00 

$9,000.00 

$8,400.00 

Land Informatio n 

Acres 

0.09 

SF 

4200.0 

Units 

1.0 

Depth 

100.0 

Width 

42.0 

Vacant 

No 

Improvemen t Informatio n 

Building 1 

lof 2 10/9/2009 9:29 AM 
Douglas County Account Infonnation 

http://douglasne.maDDing-online.coin/DouglasCoNe/static/accountinfo.. laoDin 

3a23ND 2MSI. 

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11/2 9lgry 

CLICK CLICK TO ENLARGE IMAGE TO ENLARGE IMAGE 

Square Footage: 1248.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Poor 

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

HVAC: Forced Air Rooms: 7.0 

Exterior: Frame Siding Units: 1.0 

Interior: Plaster Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Buiit 

Physical Age Remodeled Remodeled Buiit 

1910 0 0% 1910 99 

Deta/7 Type Defa/7 Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 856.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Porch Cvrd Wood Deck 153.0 

User Attic Full Finish 392.0 

User Source # 2.0 

2 of 2 

10/9/2009 9:29 AM 
VXLOCJBS.JNC. 

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

SAID: s2>2?'b'yj — /k — ^ " I 

Property Address: 3^^ ^ ^ «^ ^ -^ ' 

Owner's Name: M/'CW^'e ^ l-f^tl l 

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

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, ali trim, porches, box 

beams, columns, rails, and exterior surfaces of garages. 

Was all scraping and other preparation work completed 

satisfactorily? 

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

painted with two top coats? y Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

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? 

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

condition? 

Wa

product/quality

s the paint product

? 

s utilized equivalent to a 30 year 

V

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

cones, barrier tape etc properiy removed? 

V 

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? y 12 

other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Prudent Representative Signature 

Date:\\0-'C^ 

Property Owner Signature: 

Date: \y n ^ 

8080 Ward Parkway, Suite 405 2505 N. n r 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