## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID# : Zl^iy ^ Date : 7^^/^ ^ Address : &2S ^ S 3 ^ Sf " Remediatio n Contractor : PROFESSIONA LENVIRONMENTA LENGINEER S Year : 20a 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S [

/ 0 M y D M u y y Vide o o f propert y (DVD ) Executiv e Suimnary

Signe dAcces s Agreemen t for subjec t propert y Paintin g Agreemen t Settlemen t document s (i.e. , fo r damag e o r t o replac e planfe , etc. ) Photograph s . _ Satisfactory restoratio n signe db y Propert y Owne r Propert y close-ou t chec k lis t signe db y EP A Propert y informatio n fromDougla s Coimty Assessor' s Offic e 

# s / .\AC . Pnin'tinj ^ Li e VA^V . dnea r

Signatur e ^ / Dat e

## PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC
. ''°'"^ol'h t NE?8 m "Providin g cost-effectiv e environmenta l solutions " ^ ll^^c^ltoo ^ ^Fa x (402 ) 504-328 1 Consultin g • Engineerin g Desig n • Remediatio n • Abatemeii t • Emergenc yRespons e



### Lea dBas e Stabilizatio n Omaha , N e Clos e Ou t Repor t SAID #2196 9 82 5 S 3 6 S t

•Date s worke d09/1 8 t o 09/1 9 200 8 •Prio r hous e pain t wa s i n poo r conditio n withflakin g an dpeelin g paint , pain t chip s i n yard
• Inspecte d11/1 2 Retume dt o re-scrap e pain t o n porc han dunde r windo w trim s an dt o vacuu mpain t chips . 11/1 7 N o issue s

## PROFESSIONA L 250 5 Nort h 24' ^ Suit e 21 9 

## ENVIRONMENTA L ENGINEERS , INC
. Omaha , NE6811 0 (402 ) 504-468 8 

### "Providin g cost-effectiv e environmenta l solutions " Fa x (402 ) 504-328 1 Consultin g • Engineerin g Desig n • Remediatio n • Abatemen t • Emergenc yRespons e 

### Propert y Owne r Close-Ou t For m (Lead-Base dPain t Stabilizatio n EP A Contrac t EP-R7-08-06 ) 

### SAID : X.I 9 C 9 Property Address : S-^ ^ S i C s i Owner' s Name : Co->^ctic< ^ ShccL l ^ 

### Performanc e Standards/Close-Ou t Criteri a YE S 1 . Wa s th e entir e structure(s ) painte dwithth e exceptio n ofth e stated , exclude d areas ? Thi s woul dinclud e paintin g o f othe r associate dfeature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an dexterio r surface s o f garages . 2 . Wa s al l scrapin g an dothe r preparatio n wor k

complete dsatisfactorily ? 3 . Were al l require darea s ofth e structure(s ) prime da s neede dan dpainte dwith tw o to p coats ? 4 . Wa s th e pain t product s utilize dequivalen t t o a3 0 year product/quality ? 5 . Ar e al l ofth e area s wher e contaminate dmaterial s hav e bee n spille dthoroughl y vacuumed / cleaned ? 6 . Di dth e contracto r collect/vacuu mal l fallin g an dscrape dpain t chip s o n th e entir e property , roadways , alleyways , publi c acces s area s an dals o remov e an y othe r generate ddebris ? 7 . I s th e gras s are athat surround s th e structure(s ) i n reasonabl y goo dcondition ? / 

### 8 . Are al l item s suc ha s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r tape , etc . properl y removed ? 9 . I s ther e an y evidenc e ofpropert y damag e that wa s don e b y th e contractor ? Any property damag e need s t o b e complete dprio r t o th e EP A Close-Out . 10 . Are ther e an y property item s that wer e temporaril y re-locate db y th e contracto r that nee dt o b e move dback ? 11 . Are ther e any (known ) lingerin g issue s withth e property owner(s ) that hav e bee n lef t unresolved ? Comments :

Property Owne r Si^amr e Dat e 

## //-^H'^ S 

# M^f ^ ivm o Professional Eryimronmenta l Engineer s Representativ e Dat e

## PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC
. "Providin g cost-effectiv e environmenta l solutions " Consultin g • Engineerin g Desig n • Remediatio n • Abatemen t • Emergenc yRespons e 

### EP A Close-Ou t For m (Lead-Base dPain t Stabilizatio n EP A Contrac t EP-R7-08-06 ) SAID : ^ ) 9^ 9 Property Address : S'^ S S 3 ^ ^ ^ Owner' s Name : Coyy^x^c

- ShockU ^ Performanc e Standards/Close-Ou t Criteri a 250 5 Nort h 24 ^ Suit e 21 9 Omaha , N E 6811 0 (402 ) 504-468 8 Fa

x(402 ) 504-328 1



### YE S N O 1 . Wa s th e entir e structure(s ) painte dwithth e exceptio n ofth e stated , exclude d areas ? Thi s woul dinclud e paintin g o f othe r associate dfeature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an dexterio r surface s o f garages . - j y 

### 2 . Wa s al l scrapin g an dothe r preparatio n wor k

complete dsatisfactorily ? 3 . Were al l require darea s ofth e structure(s ) prime da s neede dan dpainte dwith 

### y tw o to p coats ? 4 . Wa s th e pain t product s utilize dequivalen t t o a3 0 year product/quality ? y 

### 5 . Are al l ofth e area s wher e contaminate dmaterial s hav e bee n spille dthoroughl y vacuumed / cleaned ? 

# y 6 . Di dth e contracto r collect/vacuu mal l fallin g an dscrape dpain t chip s o n th e y 

### entir e property , roadways , alleyways , publi c acces s area s an dals o remov e any othe r generate ddebris ? 7 . I s th e gras s are atha t surround s th e structure(s ) i n reasonabl y goo dcondition ? 8 . Are al l item s suc ha s polyethylen e sheeting , ladders , pain t brushes , cones , 

### y barrie r tape , etc . properl y removed ? 9 . I s ther e any evidenc e ofpropert y damag e that was don e b y th e contractor ? An y property damag e need s t o b e complete dprio r t o th e EP A Close-Out . y 

### 10 . Ar e ther e an y property item s that wer e temporaril y re-locate db y th e contracto r that nee dt o b e move dback ? 11 . Ar e ther e any (known ) lingerin g issue s withth e property owner(s ) that hav e bee n lef t unresolved ? Othe r Considerations/Property Owne r Discussions/Additiona l Wor k

tha t i s Required :



## ' ivitcLu f JDCKCI ^ . I I D 

# L 4 L^y^^^'i^ ^ 'S-Siie ^ ri^/}l u 

# '^yryyj^^u-. ^ JW/ ~ llMIOf y PA CO RSignature

# CONSEN T OF RACCES S T O PROPERT Y OMAHA LEA D SIT E REMEDIA LACTIO N - LEAD-BASED PAIN T STABILIZATIO N PROPERT Y ID : r Q |Q(z3 ^ 

### PROPERT Y ADDRESS : ^^5 ' LJ ^ J?< ^ L5~/ ^ OWNE RNAME : ^ 

### DAYTIM E PHONE : 

# 9yf?y^/ o CELLPHONE : 

### E-MAIL : OWNER' S ADDRES S I FDIFFERENT : TENANT' S NAM E I FAPPLICABLE : 

### DAYTIM E PHONE : CELLPHONE : E-MAIL : Professiona l Environmental Engineers , Inc . (PE ) i s unde r contrac t (#EP-R7-08-06 ) wit hth e U.S . Environmenta l Protectio n Agency (EPA ) t o stabiliz e leadbase dpain t (LBP ) on residential structure s a t anumbe r of propertie s locate din Omaha , Nebraska . Th e pain t stabilizatio n work i s bein g don e t o protec t th e soi l cleanup s tha t were performe dby EP A contractors . Pain t stabilizatio n activitie s wil l include : scrapin g o f cracke do r flakin g LB P fromstructures , applicatio n of aprim e coat an d tw o (2 ) coat s of pain t Moving part s of window s an ddoor s ar e no t include dan dwill no t b e addressed . You r cooperatio n i s requeste di n givin g permissio n t o thi s EPA contracto r (PE ) t o ente r an dhav e acces s t o thi s propert y fo r th e purpos e o f stabilizin g lead-base dpain t a s outline do n th e propert y identifie dabove . B y signin g thi s document I agre e t o allo w a n EPA contracto r t o conduc t asoi l cleanu p a t m y propert y following completio n o f lead-base dpain t stabilization . I understan dtha t th e stabilizatio n contracto r can no t provid e assurance s tha t th e soi l cleanu p contracto r will b e boun dto . I furthe r understan dtha t th e soi l cleanu p contracto r will make al l reasonabl e effort s t o addres s concern s tha t I , a s th e propert y owner , ma y hav e regardin g soil cleanu p a t m y property . I full y understan dtha t b y signin g thi s Consen t for Access , (1 ) thi s acces s will remai n i n effect unt U th e work ha s been satisfactoril y completed , (2 ) tha t th e Propert y Owne r o r Tenant , if applicable , wil l b e given th e Housm g an dUrba n Development (HUD ) an dEPA pamphlet , "Renovat e Right , Importan t Lea dHazar dinformatio n for Families , Da y Car e Providers , an dSchools" , (3 ) th e Propert y Owne r o r tenan t wil l remov e al l obstruction s fromsurface s t o b e painted , (4 ) will abid e b y healt han dsafet y guidanc e provide db y EPA , (5 ) will allo w photograph y ofpropert y before an dafte r th e pain t stabilizatio n work , (6 ) will b e contacte dby aP Erepresentativ e approximatel y 4 8 hour s i n advanc e of startin g work , (7 ) agre e no t t o obstmc t o r tampe r wit han y ofth e LB P stabilizatio n actions , an d(8 ) will participat e i n final propert y inspectio n an d sign th e Completio n Agreement an dPropert y Owne r Satisfactio n Survey . Shoul dyou hav e any question s abou t th e plane dLeadBased-Pain t stabilizatio n activitie s for you r property , pleas e contac t Professiona l Environmental Engineers , Inc . Projec t Manager , Willi e Clay At 402-504-4688 . Genera l question s abou t th e Omah aLeadSit e cleanup can b e directe dt o Paulett aFrance-Isetts , EPA Remedial Projec t Manage r 402-731-2454 , o r th e EP A PubU c Informatio n Center s a t 402-991-958 3 (Nort hOmah aoffice) o r 402-731-304 5 (Sout hOmab aoffice) . ^ ^ Yes , I gran t acces s t o m ypropert yan d wa s give n th e pamphle t D No , I d o no t gran t acces s t o m ypropert yan d I vwa s /"RSnovat e Right , Importan t Le M InformatkHiib rFanrilies , Chi M give n th e pamphl ^ "Renovat e Right , Importan t Lea d ' Caie)Providers,\and^hoois.'' \ biformatkH i forFamilies , Chikl e Cap p Providers , an d Schoois. " 

# y7

- 

# y-oS ' Dat e SPECIA L INSTRUCTION S AN D CONSIDERATION S

# Confirmatio n O f Receip t O f Lea d Pamphle t BVI D y)n(o ^ 

# ^ f J^^^ V ^ ZI P COD E ^fy^
. PROPERT YADDRES S O F OWNE R I F DIFFEREN TTHA N PROPERT Y BEIN G PAINTED : PROPERT YADDRES S ^ZI P COD E i hav e receive d a cop yo f th e pamphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n Fo rFamilies , Chil d Car e Provide rAn d School s infonnin g m e o f th e potentia l ris k o f th e lea d hazar d exposur e fro m renovatio n activit yt o b e perfonne d o n dwellin g unit
. I receive d thi s pamphle t befor e th e wor k began
. 

# (^yu i y^^ocykij yy ^ PRINTE D NAM E O F RECIPIEN T I A I \ ' DAT E



# - W 

# 'BAgni l g/M: i SIGNATUR E OF RECIPIEN T Self-Certificatio n Optio n (Fo rTenant-Occupie d Dweliing s Only ) I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e appropriat e bo x below : I J Refusa l T o Sig n - 1 certif ytha t I hav e mad e a goo d fait h effort t o delive rth e pamphlet , renovate right: importan t lea d hazar d infonnatio n fo rfamilies , chil d car e provider s an d schools ; t o th e renta l dwellin g uni t liste d abov e a t th e dat e an d tim e indicate d an d tha t th e occupan t refuse d t o sig n th e confinnatio n o f receip t I furthe rcertif ytha t I hav e lef t a cop yofth e pamphle t a t th e uni t wit h occupant . 

# n Unavailabl e Fo rSignatur e - 1 certif ytha t I hav e mad e a goo d fait h effort t o delive rth e pamphlet , renovat e right; importan t lea d hazar d infonnation fo rfamilies , chil d car e provider s an d schools , t o th e rental 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 confinnatio n o f receipt. I furthe rcertif ytha t I hav e lef t a cop yo f th e pamphle t a t th e uni t b yslidin g i t unde rth e doo ro rsomewher e o n th e premises
. 

# y^T::^^ ^ yyS^^^ ^ yy-y^ o ^ PRINTE D NAM E OF PERSO N CERTIFYIN G AHEMPTE D DELIVER Y DAT E AN D TIM E LEA D PAMPHLE T DELIVER Y 

# -y^.^.,^yyf^ - SIGNATUR E O F PERSO N CERTIFYIN G LEAD PAMPHLE TDELIVERY:
Not e Regardin g Mailin g Optio n - a s a n alternative t o deliver yi n person , yo u ma ymai l th e lea d pamphlet t o th e owne r and/o rtenan t Pamphlet must 1) 6 maile d at least 7 days before renovation
. (Document wit h a certificat e o f mailin g fro m th e pos t office)
. CONFIRMATIO N O F RECEIP T O F LEA D PAMPHLE T 08/0 8

# i PAIN TSTABILIZATIO N PRE-PROPERT Y PAIN TMATC H ASSESSMEN T
PROPERT YADDRESS : ^^ ^

U O ^ S^ ^



### _DAT E 

# / ^ y-^ ^ BVI D — AREA(S ) T O B E PAINTED : HOUS E PROPER : \)dKy COLO R 

# J £i l

HOUS E TRI M 

# A COLO R 

# ^r

^ 

# 7W ^

GARAG E 

# AU L COLO R


### GARAG E TRI M COLOR . 

# 4 ^
PORC H COLOR
. 

# \X^\\ ^ r:^y/^^r j •kA= ^

PORC H TRI M COLO R 

# Wlk- y \A\\y ^ (COMPLET E AL L SECTION , YES , NO , O R NON-APPLICABLE ) 

# I AGRE E T O TH E COLOR S LISTE D ABOVE . ONC E PAINTIN G BEGINS , I UNDERSTAN D I CA NNO T CHANG E TH E ABOV E SELECTE D COLORS : PROPERTYOWNE R SIGNATURE : P E ACCESSO R SIGNATURE : 

# LiM^JjU i ^ ^ 

# V ^ i ^ 

# 'y^<o< ^ \ k W^^ b oi c O^V^\AV ^



# \)^\yt^xy \ \yto^-t^ii PA.NTMATbHFORM08/08,0> ^

VO l ^'A6\0lAi ^ tU D " 0 A \ 1 lOl ^

W W^/ H ^ ^

# PAIN TSTABILIZATIO N PRE-PROPERT YASSESSMEN T

PROPERTYADDRES S 

# •• j3?,< r.ry< ^ s ^ DAT E yyy ~ (^j r BVI D 

### PLAN T& PERMANEN TLANDSCAPIN G TO BE REMOVE ? NO YE S IF , YE S WHERE : ^



### PRE-EXISmi G CONDIUQ N OF FOUNDATION/STRUCTURE , i.e
. BASEMEN TLEAiQNG ? NO y ^ YE S ' ' IF , YE S WHERE :

EXISTIN G PAIN T ON WINDOWS , DOORS , FOUNDATION , SIDEWALK, ( I.E.) ? N0|— | YE S I ^ IF , YE S WHERE : 7 ­ 

### y^^* ^ '^y»^~y_5yOy^^^/ ^ ^g ^ Jg»^/ ^ ^y:,y^^yy^^y ^ yyyy^^cJ. ^ ytyt ^ c:Py ry^^yyr yyi ^ ^^^/ ^

, 

## .7^7-^—^-^ y y^'^ y .r3>^^7^ ^ . ^yy> ^ <^ru y /^^^ ^ yyr// ^ ypy^.r - y^ -^^yy^^y ^

. VISUA L DESCRIPTIO N OF PROPERTY/STRUCTURE/GARAGE , (I.E.) : (US E BAC KSID E IF NECE^ARY ) 

# K LL

PROPERTYOWNE R SIGNATUR E re m I vmnc n aniraM i uni ^ <-\

### ^ Dougla s County Accoun t Informatio n Pag e 1 of 3 Dougla s County , Nebrask a Propert yRecor d - R103832000 Q Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 ft wes t o f 90t h S t - VieW

_ O n JUla p Informatio n i s vali d a s o f 2008-9- 4 Treasurer' s Ta xRepor t Ne wFeatur e -»-*- • Aut o Sale s Searc h Owne r SHOCKLE YCANDIC E D 82 5 S 3 6 S T OMAH AN E 68105-000 0 

# Sy-9^ c Propert yInformatio n Ke yNumber : 383 2 000 0 1 0 Accoun t Type : Residentia l Parce l Number : 103832000 0 Parce l Address : 82 5 S 3 6 S T OMAH AN E 68105-000 0 Lega l Description : FEARO N PLAC E LOT2 5 BLOC K0 32 X 12 5 Valu e Informatio n Lan d Improvemen t Tota l 200 8 $ 5,300.0 0 $ 56,900.0 0 $ 62,200.0 0 200 7 $ 5,300.0 0 $ 56,900.0 0 $ 62,200.0 0 200 6 $5,300.0 0 $38,600.0 0 $ 43,900.0 0 200 5 $ 5,300.0 0 $ 38,600.0 0 $ 43,900.0 0 200 4 $ 5,300.0 0 $ 38,600.0 0 $ 43,900.0 0 200 3 $5,300.0 0 $ 38,600.0 0 $ 43,900.0 0 Sale s Informatio n Sale s Date : 2005-12-0 9 Dee d Type : W D Book : 200 5 Page : 1571I 6 Price : $ 45,000.0 0 Grantor : Visio n 55 , LL C Grantee : Candic e D Shockle y Valid/Invalid : Vali d Exclusio n Reason : Sale s Date : 2002-12-2 0 

# y Dee d Type : W D Book : 223 1 Page : 43 4 Price : $ 45,000.0 0 Grantor : 

### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rl. . . 10/20/200 8

### JDougla s County Accoun t Infomiatio n Pag e 2 o f 3
Grantee : Valid/Invalid : Exclusio n Reason : Vali d Sale s Date : Dee d Type : Price : Grantor : I 1994-07-2 0 I D $25,500.0 0 Book : 198 5 Page : 30 6

Grantee : Valid/Invalid : Exclusio n Reason : Vali d
Lan d Informatio n Acre s 0.0 9 S F 4000. 0 Unit s 1. 0 Dept h 125. 0 Widt h 32. 0 Vacan t N o Improvemen t Buildin g 1 Informatio n

M



# RANC H CLIC KTO ENLARG E IMAG E Squar e Footage : 752. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Averag e

Buil t As : Ranc h Cond o Squar e Footage : 0. 0

HVAC : Centra l Ai rt o Ai r Rooms : 3. 0 Exterior : Fram e Sidin g Units : 1. 0 Interior : i Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 1. 0

Roo f Type : Gabl e Stories : 1. 0 Floorcover : Allowanc e Foundation : Bloc k 

# /^ i 

# y ^ http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.js p ?accountno=Rl.. . 10/20/200 8

### J& C Paintin g LL C Propert yAddress & A S S - 3( b ^" ^

Dat e j )- • nCo " CP , Star t Dat e 11 ~ OCQ- Q 

### 9 ^

Complet e Dat e Amoun t O f Prim e An d Pain t Use d Prim e (Gallons )

Pol y(Boxes ) Pain t (Color ) \JjeAiO ^

Amoun t (Gallons ) / 0 Pain t (Color ) ^hif- cpf.^^/ i Amoun t (Gallons ) / Pain t (Color ) Amoun t (Gallons ) Pain t (Color ) Amoun t (Gallons ) Pain t (Color ) Amoun t (Gallons )