## TRANSMITTA Lo f OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID# : 72 1 Date : Novembe r 1 9 Address : 2612N15St . Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S 1 ^ Vide o o f

propert y (DVD ) ' _ aExecutiv e Summary H Signe dAcces s Agreemen t for subjec t property l aPaintin g Agreemen t D Settlemen t

docimient s (i.e. , for

damag e o r

t o replac e plants , etc. ) D Photograph s [ ^ Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A o f Property informatio n fromDougla s County Assessor' s Ofific e D D D 

### Signatur e LDat e

4031062 1 Superfun d

### PROPERT Y SUMMAR Y Date : LB P STABILIZATIO N EPA CONTRAT EP-R7-08-0 7 Mont h of : November Propert y Address : 261 2 N 1 5 St . SAD) : 72 1 A . EXECUTIVE SUMMAR Y A. 1 Issue s Encountered : None A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r

Relevan t Information : None Acces s Date : 09/29/0 8 Work Bega n Date : 09/29/0 8 Closeout Date : 10/13/0 8 Enclosures ; 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . SignedAcces s Agreemen t 5 . Pre-Renovatio n For m 6 . Pain t Matc h For m 7 . Trackin g Form 8 . Dougla s Count

y Assessor

Propert y Informatio n Pag e 9 . EPA Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOIOCIES . INC .

### TECHNOLOGIES , INC . ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Propert y Statu s For m Address : ^Q>f Z A

^ /5 " S f Phone : 

# ,?^S-/).36 ^ Date : BVID : '=pZ I

Item # O n Map O-Si ^ 

### Plan t & Permanen t

Landscapin g T o Remai n I n Plac e Descriptio n an dLocatio n ,fi{J-l-lfi€ , (2rorXM: S OrouyJ ) <^yi ^ 

# ' ^ f^u^ n

# JU ^ C J ^



### Pre-Existin g Conditio n o f Structure s Doe s you r

Basemen t

hav e ahistor y o f

leaking ? Ye s >

—N o X Item # OnM{q > Descriptio n & Locatio n

Propert y Owne r ^^> ^ 

### Pruden t Employe e Signature : 808 0 Ward Partway , 8i« a 40 5 Kansa s CHy . MO 6411 4 280 8 N . 24 * Streat , Suit * 30 8 Omaha , Nabrask

a 6811 0 4242 Madloa l Drlva , Suit e 426 0 Sa n Antonio . TXTflS M

# 72 f Pruden t Technologies , Inc . (Prudent) i s under contract (Contract #EP-R7-08-07 ) wit

hth e U . S . Enviromnenta

l Protectio n Agenc y (EPA ) t o stabiliz e Lea dBase dPaint

(LBP ) at anumbe r o f propertie s locatedi n Omaha, Nebraska , includin g tiie propert y locateda

t ^l^l Z k l l!^3 ^ Th e EP A request s your

permissio n t o allo w Pruden t t o perfor mLB P Stabili2atio n a

t thi s property . B y signing thi s form, th e propert y owner grant s permission t o Pruden t t o perfon n activitie s relatedto LB P Stabilization including scrapin g paint an dpaintin g o f

th e referencedproperty . Further , th e owner/tenan t verifie s tha

t tiiey hav e receive ddi e LB P pamphlet **Renovat e Right " I f you have an

y question s abou t

th e LB P stabilizatio n plannedfo r your property , pleas e contact

Prudent' s Administrative Cler

k fo r th e Lea dBase dPaint

Stabilization , Mrs . Debora hAkerele-Johnson , at (402) 504-1004 . Genera

l question s about

the OmahaLea

dSit e cleanup can b e directe dt o the EP A Publi c Informatio

n Center s at

(402 ) 731-304 5 (Sout

hOmahaoffice) or

(402 ) 991-958 3 (Nort

hOmaha office) . Pronat vAccegQimledBv : J" S \ C A 0 V \

r ^ L L . \ j CJ ) \

^ (Pleas e Pri mName ) 

# .Afl . J Z ' / Propert y Owne r

Sigaature ; 

# .ShurJ,././)^' ^

Q',Sf-0/ (Signature ) (Date )

PROPERT Y INFORMATIO N (T o b e complete db y reildcn t and/o r propen y owne r

- pleas e prln Q RESiPaiTMAME : Jhp t C^noy xf . i^ . \J c i ) I < , CT)wne r) Rente r 

### RESIOBITADDRESS

: PL\0 ^ P . I^V KSJ ^ I F RENTAL , PROPERT

YOUVNE O BY : OWNER' S MAIUN O ADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : I^IJ^ ^ • ^<^6-dSSkta^ i ± NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R S HOUR S O R MOR E PE R WEEK : ^ COMMENT S O R SPECU L INSTRUCTIONS : (I.E . DOGS . ENTR YOATES . ETC. ) S a 

# Dor.f ^ r->^i-(TrAUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS ; Th e activitie s t o b e nnplementM l b y EP A unde r tM aagraemen t

ar e pmuan t

t o Secdo n 10 4 o f CERCLA . 4 2 U.S.C . 9604 . EPA' t riglit o f acces s t o di e propert y i s provide dfb r in Sectio n 104(e ) o f

CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entr y fb r "deteiminisgtti e nee dfor

lesponse , o r

choosin g ortsldn g an y respons e acdo n und athi s title , o r o<herwis e en&icin g di e provisioo s o f di e title. "

8 0 War d Parkway . Suit e 40 5 260 5 N . 24* ^ Street , Suit s 30 8 424 2 Medica l Driva . Sult a 426 0 insasCHy , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 lono : (816 ) 383-370 3 Phone:(402)504-100 4 Phone : (210 ) 822-9S8 8 • : (816 ) 363-370 7 p. v/^no » «n...4A« .

# «r«...i|^a

wa ivneiiuvuiio n ror m Effecth wunti l Apri l 2010 . W Confirmatio n o f Receip t o f Lea d Pamphle t 6)^ 1 ha m receive d a cop yo f th e pamptileL/tenov^te/^t-*nportan t Leacf Hsza/t:f. - ^ Infonnatio n fb rFirnilles,Chk l Car e Provider s an d S^ioobMcmlngrnec ^ th e potentia l risk

o f th e lea d hazar d ettposur s fro m tonovatio n activit yt o ti e perfonne d I n m ydwellin g uni L I receive d thi s pamphle t befor e th e wor k began . Printe d nam e o f recipien t ^ - Dat e 

## ^ A-?>e^/u , <^

^ S/Oi^^ ^ Signatur e o f recipien t Self-Certificatio n Optio n (fo rtsnant-occuple d dwelling s only ) — I f th e lea d pamphle t wa s delivera d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k

th e appropriat e bo xbelow . Q Refusa l t o sig n —I certif ytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Rsmt m FSgh t Importan t Lea d Hazar d InfonnaOo n fb rFamSies , C t M Car e Provider s an d Sdiools . t o th e renta l dwellin g uni t liste d belo wa t th e dat e an d time indicate d an d tiiat th e occupan t refuse d t o sig n th e confinnatio n d receip L I lurttie rcertif ytha t I hav e lef t a cop yo f th e pam(^le t a t th e uni t vvit h th e occupant . Q Unavailabl e fb rSignature--- I certif ytha t I hav e mad e a goo d fait h effor t t o deBve rth e pamphlet , Renovat e F^ t Importan t Laa d Hazar d Infonnatio n fo r Famlka , C/i M Car e provilcters an d Sc/wo/s , t o tiie renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n tiie confiin»tio n o f receipt . 1 furtiie rcertif yttiat 1 hav e lef t a cop yo f ttie pamphle t a t th e uni t b yslidin g I t unde rttie door;...—>

^ . y Printe d nam e o f perso n certifyin g Attempte d delivery dateandtim e 

## 'tnri ^ "??-
- lea d pamphle t delivery '^yyut'^ri ^

"tfL^ — ire o f perso n certifyin g lea d pamphle t deliver y 

## ^{^/- ^ A l j ^

S-f Uni t Addres s Not e Regaidln g Mailin g Optio n —A s a n altemativ e t o deliveryi n person , yo u ma ymai l ttie lea d pamphle t t o ttie owne rand/b rtenant . Pamphle t mus t b e maile d a t leas t 7 day s befor e renovatio n (Documen t witt i a certificat e o f mailin g fro m ttie pos t office) .

# pain t matc h for m Pain t matchin g form : . Propert yaddres s :c^^/ ^ ^ ^ ^ ^ ^ 

# BVID : ^jz j 

# Wou ^ ^ —U^/?/^ ^ Area : Color : • ^ / ^ , / 

# Explanation : Area : Colo r Explanat i on : Area : Color : Explanation : Area : color : Explanation : Area : Color : Explanation : ^a^c^

^ Pag e 1i4W i 

# S /A/PO/?M/^T/cyYT/?>\CKW O SHEE T fwiD t %? y Ai>cffEsg , ^^/ ^ ^ y^ - s ^ 

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

OmrOiMMHo e Hom « ^^^.<<-/03F ^ v ^ M
iwOBIswBflHiw H

W k

### Douglas Count

y Accoim t Inf^aatio n Page 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R174396000 0 Infonnatio n i s vali d a

s o f 2008-9- 4 Owne r DAVI S BLANCH E E 261 2 N 1 5 S

T OMAH AN E 68110-0000 Propert yInformatio n KeyNumber : Accoun t Type : Parce l Number : Parce l Address : Lega l Description : Valu e Informatio n

; Lan d 200 8 200 7 2006 200 5 200 4 200 3 Lan d Informatio n Acre s S F , 439 6 000 0 1 7

Residentia l 174396000 0 Prin t Repor t NE W Featur * - Parce l Oimsnsion t availabl e 6 scal e 0-5 0 f l wes t o f SOt h S t - Vley vOf l Ma p Tigaeuretlsla xRepor

t Ne wFeature ->-*- • Aut o Sale s Sejjs h 

# ,^-°^^ ^

261 2 N 1 5 S

T OMAHA N E 68110-000 0 MILLAR D & CALDWELL' S AD D LO T 1 1 BLOC K0 N 23.62 5 E 8 5 F T LT1 0 1/ 2 & S 10. 5 ES S F

T 34.125X8 5 $800.0 0 $800.0 0 $800.0 0 $800.0 0 $800.0 0 $800.0 0 j Improvemen t $5,600.00 $4,600.00 $4,600.00 $4,600.00 1 $4,600.00 : $4,600.00 Tote l $6,400.0 0 $5,400.0 0 $5,400.00 $5,400.0 0 $5,400.0 0 $5,400.0 0 ! Unit e \

Dept h : Widti i Vacan t "0.0 6 2896. 0 r i 1.0 85. 0 34. 0 N o Improvemen t Informatio n Buildin g 1

I

1 IDougla s Count y Accoun t Inclinatio n iQsm s Pag e 2 of 2

2612N1 5

RANC H

CJjCKI g ENLARQ E IMAjp E Squar e Footage : Perimete r Uni t Type : Buil t As : HVAC : Exterior . interior : Roo f Cover : Roo f Type : Floorcover : 880. 0

0. 6 Ranc h Force d Ai r Fram e Sidin g Drywal l Compositio n Shingl e Gabl e Allowanc e Percen t Complete : ; 100.0 % Quality : Fai r Condition : Fai r Cond o Squar e Footage : 0. 0

Rooms : 4. 0 Units : . 1. 0 Baths : 1. 0 Bedrooms : 2. 0 Stories : '

• 1. 0 Foundation : Bloc k Sprinl<le rSquar e Footage : : 0. 0 YearBull t 189 0 Yea r

Remodele d Percen t

Remodele d 

## 6 % Adjuste d Yea r

Buil t 189 0 Physica l Ag e 11 8 Detai l Typ e Applianc e Basemen t Fixtur e Fixtur e Porc h Porc h Use r ; Detai l Descriptio n • Allowanc e ' Bsmn t Biocl ( 8 f t : Bas e Fixture s ) Bat h Ful l ; incrsoii d Wal l ^ Enc i Soli d Wai l Se e note s Unit e 1. 0 550! 6 1 0 

### 1. 6 168. 6 105. 0 1. 0

## Pruden t

Propert y Close-Ou t

For m(Lead-Base dPain t

Stabilization ) SAID : Vd / Propert y Address ; o^<^/ ^ XJ - /Jr ^ ^ ' 

### Owner' s Name ; &l<lf)d\ ^ E: • JS^Ul k 

## Performanc e Standards/close-Ou t Criteri a YE S N O 1 . Wa s th e entire structure(s ) painte dwit hth e exception o

f th e stated , excludedareas ? Thi s would Includ e painting o

f othe r associate dfeature s includin g fascia , eaves , siding , al

l trim , porches , box beams , columns , rails , an dexterio r surface s o f garages . 2 . Wa s al l scraping an dothe r

preparattio n wor

k complete dsatisfactorily ? 3 . Wer e al l require darea s o

f th e structure(s ) primeda s neede dan dpainte dwit

htw o to p coats ? 4 . y/a s tfte paint

product s utilize dequivalent t o a3 0 yea

r product/quality ? 5 . Ar e ai l o f th e area s wher e contaminate dmaterial s hav e bee n spilled thoroughl y vacuumed

/ cleaned ? ^ 

# A
< 6 . Di dth e contracto r

collect/vacuu mail failin

g andscrape dpaint

chip s on 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 atha t

surround s th e structure{s ) i n reasonably goodcondition ? 

# 2 L 8 . Ar e al l item s sucha s polyethylen e sheeting , ladders , pain t brushes , cones , barrier

tap e etc . properl y removed ? > ^ 9 . I s ther e an y evidenc e o

f property damag e tha t

wa s 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 AClose-Out . 

# K ,10 . Ar e ther e an y property item s tha t

wer e temporatil y re-locate db y th e contracto r tha t nee dt o b e move

dbacic ? 

# X 11 . Ar e ther e an y (known) lingering issue s wit hth e propert

y owner(s ) tha t

hav e bee n lef

t unresolved ? Othe r Conslderations?propert

y Owne r Discussions?Additlona

l Wor k tha t i s Required

QTXJ^A^/ " 

## J^<^,^AA r V^ i^/^f

\ //"^- ^ 

## Pruden t Reipresentativ e 

# Dat e 10'/^ ' o f 

# ^^J/Sjo ^