TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 721 Date: November 19 

Address: 2612N15St. 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

1^ Video of property (DVD) '_ 

a Executive Summary 

H Signed Access Agreement for subject property 

la Painting Agreement 

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

D Photographs 

[^ Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

of Property information from Douglas County Assessor's Ofifice 

D 

D 

D 

Signature L Date 

40310621 

Superfund 
PROPERTY SUMMARY 

Date: LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: November 

Property Address: 2612 N 15 St. SAD): 721 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Information: None 

Access Date: 09/29/08 

Work Began Date: 09/29/08 

Closeout Date: 10/13/08 

Enclosures; 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOIOCIES. INC. 
TECHNOLOGIES, INC. 

ENVIRONMENTAL & 

CONSTRUCTION 

SERVICES 

Property Status Form 

Address: ^Q>fZ A^ /5 " Sf 

Phone: 

,?^S-/).36^ 

Date: 

BVID: '=pZI 

Item# 

On Map 

O-Si ^ 

Plant & Permanent Landscaping To Remain In Place 

Description and Location 

,fi{J-l-lfi€ , (2rorXM:S OrouyJ ) <^yi^ ' ^ f^u^n JU^ C J ^ 

Pre-Existing Condition of Structures 

Does your Basement have a history of leaking? Yes >— No X 

Item# 

OnM{q> 

Description & Location 

Property Owner 

^^> ^ 

Prudent Employee 

Signature: 

8080 Ward Partway, 8i«a 405 

Kansas CHy. MO 64114 

2808 N. 24* Streat, Suit* 308 

Omaha, Nabraska 68110 

4242 Madloal Drlva, Suite 4260 

San Antonio. TXTflSM 
72f 

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

Enviromnental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a number of properties 

located in Omaha, Nebraska, including tiie property located at ^l^l Z k l l!^3 ^ 

The EPA requests your permission to allow Prudent to perform LBP Stabili2ation at this property. By 

signing this form, the property owner grants permission to Prudent to perfonn activities related to LBP 

Stabilization including scraping paint and painting of the referenced property. Further, the owner/tenant 

verifies that tiiey have received die LBP pamphlet **Renovate Right" 

If you have any questions about the LBP stabilization planned for your property, please contact Prudent's 

Administrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson, 

at (402) 504-1004. 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). 

Pronatv AccegQimledBv: J" S \ C A 0 V\ r^ LL . \ j CJ) \ ^ 

(Please Prim Name) 

.Afl. J Z' / 

Property Owner Sigaature; .ShurJ,././)^'^ Q',Sf-0/ 

(Signature) (Date) 

PROPERTY INFORMATION 

(To be completed by reildcnt and/or propeny owner - please prlnQ 

RESiPaiTMAME: Jhpt C^noy x f . i^ . \J c i ) I <, CT)wner ) Renter 

RESIOBITADDRESS: PL\0 ^ P . I^V K SJ ^ 

IF RENTAL, PROPERTY OUVNEO BY: 

OWNER'S MAIUNO ADDRESS; 

OWNER'S TELEPHONE NUMBER-HOME: I^IJ^ ^ • ^<^6-dSSkta^ i ± 

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

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR S HOURS OR MORE PER WEEK: ^ 

COMMENTS OR SPECUL INSTRUCTIONS: (I.E. DOGS. ENTRY OATES. ETC.) 

Sa Dor.f^ r->^i-(TrAUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS; The activities to be nnplementMl by EPA under tMa agraement are pmuant to Secdon 104 

of CERCLA. 42 U.S.C. 9604. EPA't riglit of access to die property is provided fbr in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entry 

fbr "deteiminisgttie need for lesponse, or choosing ortsldng any response acdon unda this title, or o<herwise en&icing die provisioos of die title." 

80 Ward Parkway. Suite 405 2605 N. 24*^ Street, Suits 308 4242 Medical Driva. Sulta 4260 

insasCHy, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

lono: (816) 383-3703 Phone:(402)504-1004 Phone: (210) 822-9S88 

•: (816) 363-3707 p. v /^no» «n...4A«. 
«r«...i|^aw a ivneiiuvuiion rorm 

Effecthw until April 2010. W 

Confirmation of Receipt of Lead Pamphlet 

6)^1 ham received a copy of the pamptileL/tenov^te/^t-*nportant Leacf Hsza/t:f.-

^ Infonnation fbr Firnilles,Chkl Care Providers and S^ioobMcmlngrnec ^ 

the potential risk of the lead hazard ettposurs from tonovation activity to tie 

perfonned In my dwelling uniL I received this pamphlet before the work began. 

Printed name of recipient ^ - Date 

^ A-?>e^/u, <^^ S/Oi^^ ^ 

Signature of recipient 

Self-Certification Option (for tsnant-occupled dwellings only) — 

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

you may check the appropriate box below. 

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

pamphlet, Rsmt m FSght Important Lead Hazard InfonnaOon fbr FamSies, 

C t M Care Providers and Sdiools. to the rental dwelling unit listed below at the 

date and time indicated and tiiat the occupant refused to sign the confinnation 

d receipL I lurttier certify that I have left a copy of the pam(^let at the unit vvith 

the occupant. 

Q Unavailable fbr Signature---I certify that I have made a good faith effort to 

deBver the pamphlet, Renovate F^ t Important Laad Hazard Infonnation for 

Famlka, C/iM Care provilcters and Sc/wo/s, to tiie rental dwelling unit listed 

below and that the occupant was unavailable to sign tiie confiin»tion of receipt. 

1 furtiier certify ttiat 1 have left a copy of ttie pamphlet at the unit by sliding It 

under ttie door;...—>^ . y 

Printed name of person certifying Attempted delivery 

dateandtime 

'tnri ^ "??--

lead pamphlet delivery 

'^yyut'^ri ^ "tfL^ — 

ire of person certifying lead pamphlet delivery 

^{^/- ^ Al j ^ S-fUnit Address 

Note Regaidlng Mailing Option — As an altemative to delivery in person, you 

may mail ttie lead pamphlet to ttie owner and/br tenant. Pamphlet must be mailed 

at least 7 days before renovation (Document witti a certificate of mailing from ttie 

post office). 
paint match form 

Paint matching form: . 

Property address :c^^/^ ^ ^^ ^^ 

BVID: ^jz j 

Wou ^ ^ — U^/?/^^ 

Area: Color: • ^ /^ , / 

Explanation: 

Area: Color 

Explanati on: 

Area: Color: 

Explanation: 

Area: color: 

Explanation: 

Area: Color: 

Explanation: 

^a^c^^ Page 1 
i4Wi 

S /A/PO/?M/^T/cyYT/?>\CKWO SHEET 

fwiDt %? y Ai>cffEsg, ^^/ ^ ^ y^- s ^ 

MaerOMor* 7\Iuic^f h/^n s 

OmrOiMMHoe Hom« ^^^.<<-/03F ^ v ^ 

M 

iwOBIswBflHiwH 

Wk 
Douglas County Accoimt Inf^aation Page 1 of2 

Douglas County, Nebraska Property Record - R1743960000 

Infonnation is valid as of 2008-9-4 

Owner 

DAVIS BLANCHE E 

2612 N 15 ST 

OMAHA NE 68110-0000 

Property Information 

Key Number: 

Account Type: 

Parcel Number: 

Parcel Address: 

Legal Description: 

Value Information 

; Land 

2008 

2007 

2006 

2005 

2004 

2003 

Land Information 

Acres SF 

, 4396 0000 17 

Residential 

1743960000 

Print Report 

NEW Featur* - Parcel Oimsnsiont available 6 scale 0-50 fl west of SOth St - Vley v Ofl Ma p 

Tigaeuretlslax Report 

New Feature ->-*- • Auto Sales Sejjsh 

,^-°^^ ^ 

2612 N 15 ST 

OMAHA NE 68110-0000 

MILLARD & CALDWELL'S ADD LOT 11 BLOCK 0 N 23.625 E 85 FT LT10 1/2 & S 

10.5 ESS FT 34.125X85 

$800.00 

$800.00 

$800.00 

$800.00 

$800.00 

$800.00 

j Improvement 

$5,600.00 

$4,600.00 

$4,600.00 

$4,600.00 

1 $4,600.00 

: $4,600.00 

Totel 

$6,400.00 

$5,400.00 

$5,400.00 

$5,400.00 

$5,400.00 

$5,400.00 

! Unite \ Depth : Widtii Vacant 

"0.06 2896.0 r 

i 

1.0 85.0 34.0 No 

Improvement Information 

Building 1 

I 

1 

I 
Douglas County Account Inclinatio iQsms n Page 2 of2 

2612N15 

RANCH 

CJjCKIg ENLARQE IMAjpE 

Square Footage: 

Perimeter 

Unit Type: 

Built As: 

HVAC: 

Exterior. 

interior: 

Roof Cover: 

Roof Type: 

Floorcover: 

880.0 

0.6 

Ranch 

Forced Air 

Frame Siding 

Drywall 

Composition Shingle 

Gable 

Allowance 

Percent Complete: ; 100.0% 

Quality: Fair 

Condition: Fair 

Condo Square Footage: 0.0 

Rooms: 4.0 

Units: . 1.0 

Baths: 1.0 

Bedrooms: 2.0 

Stories: '• 1.0 

Foundation: Block 

Sprinl<ler Square Footage: : 0.0 

YearBullt 

1890 

Year 

Remodeled 

Percent 

Remodeled 

6% 

Adjusted Year 

Built 

1890 

Physical Age 

118 

Detail Type 

Appliance 

Basement 

Fixture 

Fixture 

Porch 

Porch 

User 

; Detail Description 

• Allowance 

' Bsmnt Biocl( 8 ft 

: Base Fixtures 

) Bath Full 

; incrsoiid Wall 

^ Enci Solid Wail 

See notes 

Unite 

1.0 

550!6 

10 

1.6 

168.6 

105.0 

1.0 
Pruden t Propert y Close-Ou t Form (Lead-Base d Pain t Stabilization) 

SAID: Vd/ 

Property Address; o^<^/^ XJ- /Jr ^ ^ ' 

Owner's Name; &l<lf)d\ ^ E: • JS^Ulk 

Performanc e Standards/close-Ou t 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 preparattion work completed satisfactorily? 

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

4. y/as tfte paint products utilized equivalent to a 30 year product/quality? 

5. Are ail of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? ^ 

A 

< 

6. Did the contractor collect/vacuum ail failing 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? 2L 

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. K 

,10. Are there any property items that were temporatily re-located by the contractor 

that need to be moved bacic? X 

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

Other Conslderations?property Owner Discussions?Additlonal Work that is Required 

QTXJ^A^/" J^<^,^AAr V^ i^/^f\ //"^- ^ 

Pruden t Reipresentative 

Date 10'/^ ' o f 

^^J/Sjo^