TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: fiO\ Date: R^u[^nQ«^ 

Address: ^f^t^\ . ^ I S S T 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

 Executive Summary 

 Signed Access Agreement Form 

 Advance Notice Form 

 Pre-Stabilization Video Agreement Form 

 Access Tracking Form 

 Property Access Assessment Form 

 Neighbor Access Agreement Form 

 Paint Match Form 

 Pre-Stabilization Property Safety Assessment Form 

 Work-Site Hazards Analysis Checklist 

 Photographs: Pre-Stabilization Property Hazard Assessment Photographs 

 Douglas County Assessor Property information 

 Property Completion Agreement Form Signed by Property Owner 

 Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature Date 

EPA Signature DatT 

30054686 ilil 

Superfund 
TECHNOLOGIBSi, INC 

Property Summary 

Date; 8/^^/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of; Aug. 

Property Adtlress; 2501 S 12 St SAID #; 601 

A. Executive Summary; 

a. Issues Encountered: NONE 

b. Issues Resolved; NONE 

c. Unique Findings; NONE 

d. Other Relevant Information: 

i. Access Date: 7/13/2009 

ii. Work Began: 7/22/2009 

iii. Close-Out Date; 7/24/2009 

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 
lS»~:'.\,;i.....":;:i-'-i.--!Tf"'..:j.'ii«.«I=r.:j r-r:rr.yn7rrr^.'" 

TECHNOLOGIES. UMC. 

Prudent Teciinologies, 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 JL^O l ^ )'^ g, b 

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 understand 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. 

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

Signature of Prop© 

Date 

If you 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). 

Property Access t

inted By: 

Please Print Name) 

Property Owner Signature: 

l-<]y H 

(Date) 

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

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

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

Fax: (816) 363-3707 Pax: (402)504-1005 Fax:(210)579-6577 
TECHNOLOCnSS. INC 

PROPERTY INFORMATION 

(T e and/or property owner — please print)

y ^ (Ipp bbe complete completedd bbyy residen resident

t ai 

RESIDENT NAME: Owner ^ Renter 

RESIDENT ADDRESS:

r-<^. x:^ cSv 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: 7~fO\\ ^tt^V^^ViOR^ : ( ^M T I/1~SI~7 T 

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

.3-

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

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 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9588 

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? If you 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? fOQ 

Notice needed: 5' 3 A^nATS 

Number to call to give notice: ^/"] - ^li ' 

Whom we are giving notice to: (^_jXQ) 'V^ 

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, 1 

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 NAME: yf\ 

PROPERTYADDRESS: ^S5 1 ^ ' 1 ^ ^ 

BVID/SAID: 6^ 1 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVE SIGNATURE: 

[}/7il^H 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): A p^ 

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 
STto sr4; V> 

^ 

TECHNOLOGIES, INC .&( pno1 ^ 

ACCESS INFORMATION TRACKING SHEET 

: 601 . 2 5oa ^ ^^ sl 

BVID 

PROPERTY ADDRESS: ^ 

Property Owned By: 

(If new property owner) 

Owners Phone No's: 

Home: ------i ----' Work: 

Cell: Fax: 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

7H /.prv, k*aoi<u t ^ri^c c\\^y ^ 

I 

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 
TECHNOLOGIESi 1 

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. 

NO 

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? 

y' 

Does this property have any significant structural damage? 

(A) 

If yes, EXPLAIN? 

NlO 

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. 

1)A4O 

Does this property have aluminum siding? 

^J0 

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 or occupied? 

)iU! ^ 

W) i.- ^ C«v(U/ ^ ^ ^c-VA^es^, 

Are there any pets at this property? So^i^"\ ­ (5^ (fr»v^^ "u, \=.Yr^Q^_ 

} ^ §r»vti* |VtAi9-» jy? ^/,C4.^< : s-- ^ 

^ ^ yt:^1py^ _cr^ 5/^ « 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 
TECHNOLOGIES, INC. 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

WO 

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

^tyO 

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 

PAINT MATCHING FORM: 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTYADDRESS; J^bO l 5 II. S t 

BVID; (^C>1 

1 UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signaturi 

uOill CA1\ aJfV to^ jy ^ ^ ^'' ^ 

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 : :x9o\ ^ ^a ^+ 

BVID/SAID: (o d 

PRUDENT ASSESSMENT REPERSENTATIVE: 

i^oyi ^^^ ­

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

KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A CREW/SUB. 

REPERSENTATIVE REMARKS/FINDINGS; 

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

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

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON; 

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 
TBCHNOLOCIBS. INC 

Checklist for the Worksite Hazard Analysis 

Adtiress: ^<S^ [ Q i ^ Q T 

Crew: Date: 

Item OK? 1 Hazard Corrective Action 

Overhead Lines SaiTM ^ iXe ^ li^yr^^y^—' 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance aroand 

hi^h wires when working 

Phone lines . 

Cable lines 

Gas Line . -

Water Line ^__^.^ 

Sewer Line 

Septic Tank ^..­

Propane/Butane 

Access to/on Property n o pdLYKiVA­ iCfsf^L-t- Neighbor Access Required .jl/T\ .SfHil Wi SrXn^OfLMtk^ 

High Traffic Area r T^^ 

Garage Kr.cL/u )rtO(dl' ' 

Structures (2/2Sb^?Vcf * 1 a Driveway KAz>k«^ )t^K(AU...^ . Sidewalk Q}t.u}^ ^ - U^Oy>&<\^A^ 6 I i^ ^ I Foundation Ppj^X^ft ^ Z VC8JU OXJ.^OJLACU^ 3wu ^ 5^y<\M.\^&y6f'^^Lwid>i^\ 

Retaining WaUs 

Fences 1 • 1 A A 1

Trees S t^uQ^/i^i ty^--- ^ uJ.cuA^iy^Jl. h-o Foliage / 

General Condition of yard 

e>C 

Damaged Areas: sink 

holes/rotted ^ wood -(Wh^Q ^ 

Sprinkler System v . ^ ^ Pets PAT- Insects 

Weather Conditions - ^ 

Unsafe driving conditions .— 

Unsafe neighborhood 

Forenmn^ Sub-Contractor 

1080 Ward Mrkway, Suite 405 2505 N. 24*" street, Suite 308 irive, Suite 4250 

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

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

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


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11 

Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

& I have received 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 v\/ork began. 

^-^-rff 

Signature of recipifent 

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. 

•• Unavailable 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 

'^ari\^\ f^\t'^A 'It-^C^^O^ 

Printe^a name of person certifying Attempted delivery 

date and time 

yl^^K 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). 
Douglas County Account In£anation Page 1 of2 

Douglas County, Nebraska Property Record - R0704230000 

Print Report 

,_r_ 4„ _ •„ ,„I: J t nr\f\n e ^ e NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - Vie W OH Ma p 

information is valid as of 2009-6-16 Treasurer's Tax RepoS 

New Feature ->-»-> Auto Sales Search 

Owner 

SMITH JASON A \ y \ \ 

P^ Go\ 2501 8 12 ST Y\0 ^ \ W 

OMAHA NE 68108-0000 \ V ^ \ ^ 

Property Informatio n 

Key Number 0423 0000 07 

Account Type: Residential 

Parcel Number 0704230000 

Parcel Address: 2501 8 12 ST 

OMAHA NE 68108-0000 

Legal Description: BOWERY HILL LOT 7 BLOCK 8 LTS 6 & 7 132 X 138 

Value Informatio n 

Land Improvement Total 

2009 $11,400.00 $92,600.00 $104,000.00 

2008 $11,400.00 $92,600.00 $104,000.00 

2007 $11,400.00 $92,600.00 $104,000.00 

2006 $11,400.00 $77,200.00 $88,600.00 

2005 $11,400.00 $77,200.00 $88,600.00 

2004 $11,400.00 $77,200.00 $88,600.00 

Sales Informatio n 

Sales Date: 2004-01-20 

Deed Type: WD Book: 2004 Page: 036072 

Price: $97,500.00 

Grantor David J Zenchuk 

Grantee: jason A 8mith etal 

Valid/Invalid: valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Deptfi Width Vacant 

0.41 18216.0 1.0 138.0 132.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R070... 7/7/2009 
^-' *.Ij/.^CO'S' .WW""l^''^^•'''.t'^'f'^'^^A-M.jf^v.'fU^.tyf • !..^!,f• •'V.ti.yy '?r'•"-•T;'rt'••"•;•.^ 

Douglas County Account In£|^ation Page 2 of2 

Building 1 

:'Mi sn^'ot I'Li^STO^YUNFIN 

. : E*-,.-- 0 !• ••i•' ^ 0 :-n 

CLICK TO ENLARGE IMAGE 

Square Footage: 1738.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Fair 

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

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Hip Stories: 2.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1895 0% 1895 114 

Deta/7 Type Detail Description Units 

Add On Unfinished Attic W/floor 864.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 864.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 360.0 

Porch End Screen 160.0 

Porch Open Slab 112.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R070... 7/7/2009 
t 

TECHNOLOGIBS. INC 

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

SAID: M. Property Address: 2-7701 ^ ' J< ^ S ^ 

Owner's Name: d^Ol J j Ufi^dlu7\) C/HlH f 

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 

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

2 Was all scraping and other preparation worl( completed 

satisfactorily? 

3 

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

painted with two top coats? 

4 Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

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? 

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 bacWf 

11 Are there any (Itnown) lingering issues with the property owner(s) 

that have been left unresolved? 

12 Other Considerations? Property Owner Discussions? Additional 

Worl( that is Required 

Prudent Represenftative Signature: 

Date: 7/W ^ 

Property Owfier Signature^ 

Date: 2^7/4" 

8080 Ward Parkway, Suit 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 
TECHNOLOGIBS, INC 

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

BVID: AC>\ 

Property Address: D^O ] S / 2 - S l 

Owner's Name: Ct^ Cr>L^ 3"*^'^' ' ^ 

S.NO 

Performance Standards/close-Out Criteria 

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 of the structure(8) primed as needed and 

painted with two top coats? 

4 Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

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? 

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 

Work that is Required 

EPA COR/ Representative ^'^yy/oM^-^-^^^*^^'^^ 

Date ^lAoi 

Yes 

y 

y 

y 

. y 

y 

y 

y 

y 

NO 

y 

y 

y 

y