4 - 1 

TRANSMITTA L of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID. 9 W^ ^ Date: Co\9'=\\\\ 

Address: \^\ 9 K> P"? ^ f ^ 

Stabilization Contractor: Professional Environmental Engineers Year: ^ZOl | 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

Video of property (DVD) 

Executive Summary 

Signed Access Agreement for subject property 

Pre-Renovation FoiTii signed by Property Owner 

Pre-Renovation Fonn for Occupant/Tenant, if applicable 

Painting Agreement 

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

Renovation Recordkeeping Checklist signed by Certified Renovator 

Photographs 

Satisfactory close-oui check list signed by Property Owner 

Property close-out check list signed by EPA 

Property information from Douglas County Assessor's Office 

D Hazard analysis, if prepared 

D Safety Audit 

D Other (describe); 

Prot^ionalEnwonmSTtai^ngineers Signature 4^ ...... ^v^.. ^mnatuK 

(after file folder review) 

40377562 

} Date 

Superfund 
PROFESSIONAL 

ENVIRONMENTAL ENGINEERS, INC. 

"Providing cost-effective environmental solutions" 

Consulting • Engineering Design • Remediation • Abatement • Emergency Response 

2505 North 24^ Suite 219 

Omaha, NE 68110 

(402) 504-4688 

Fax (402) 504-3281 

Lead Base Stabilization Omaha, Ne 

Close Out Report 

2011 

SAID# 26443 

1712 N 28 St 

• Dates worked: 6/8 to 6/11 2011 

• Pre property condition: House has painted wood siding with painted wood trims, 

porch and foundation areas. Paint was flaking off in areas. 

• Problems encountered: None. 

• Owner request/concerns: N/A 

• Inspection/closeout dates. Owner 6/14/11 
liBi^ PROFESSIONAL 

500 S. Ewing, Suite E ENVIRONMENTAL ENGINEERS, INC. St. Louis, MO 63103 

(314)531-0060 "t-'lUVidhi g UUir:i-.:ii!ri( •*/' t^ c^r ivifi>iilliciitH l S.Illliii^i: , Fax (314) 531-0068 

r;'.>iisMl;ii.', • t;i.(:::u-L-'.'i.;! ! >i-'s!ti'.l • l'l :..; '.'J.'^-^'i A'"'."! -.ri. r.iV •.lij.'.i.j.. . : .:-..K' 

2011 

Property Owner Close-Out Form 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-06) 

SAID: MB 

Property Address: \- \ \1 . V j Q ft 1 ^ 

Owner's Name: 

Performance Standards/Close-Out Criteria YES NO 

1. Was the entire structure(s) painted with the exception ofthe 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. / 

A2. Was all scraping and other preparation work completed satisfactorily? 

3. Were all required areas ofthe structure(s) primed as needed and painted with two top 

coats? 

4. Was the paint products utilized equivalent to a 25 year product/quality? 

5. Are all ofthe areas where contaminated materials have been spilled thoroughly 

vacuumed/ cleaned? 

6. 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? 

7. Is the grass area that surrounds the structure(s) in reasonably good condition? 7 ^ 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, 

etc. properly removed? 

9. Is there any evidence ofproperty damage that was done by the contractor? Any property 

damage needs to be completed prior to the EPA Close-Out. 

10. Are you satisfied with the work performed? 

11. Are there any property items that were temporarily re-located by the contractor that 

need to be moved back? 

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

unresolved? 

Other Considerations/Property Owner Discussions/Additional Work that is Required: 

\.o- \H - W 

Property Owner Signature Date 

•>!S^C3^V5^ ro-H-\' 

Professional EnVirommBhtal Engineers Signature Date 
Professional Environmental Engineers: EPA Paint Stabilization 2011 

SAID, g(JW> 

Property Address | I I Z N Jj ) Ot " 

Stories/ Siding type | / ^ Transite Wood Vinyl Metal Stucco 

Garage? Yes No Painted? Yes No 

Date access signed 

Pre-video 

6/s^ /( 

Where? Siding 

Trim 

Post video 

Contractor Assigned 

Date started 

^ Oe V \ Os:>r\\ 

^Em Date ended V\i-\\ 

weather Conditions ^^„\^^.^l> ^ / ^0\ ^ }S^ 

Paint used 

Prime used Tm\. 

U6i4 , 

Poly used 

Problems/Issues 
(effective April 2010) 

RENOVATION RECORDKEEPIN G CHECKLIST 

Name of Firm: 

^ A . Date and Location of Renovation: l o Q \ \ 0 " \i " VJ \ ^ \ /:A '^ ^ Q.r ) 

Brief Description of Renovation: 

Name of Assigned Renovator: QT) ^ X S YCXV^VA J \ A Q 

Name(s) of Trained Workers: 

Name of Dust Sampling Technician, Inspector, and/or Risk Assessor, if used: 

D Copies of renovator and dust sampling technician qualifications (training certificates, certifications) on file. 

D Certified renovator provided training to workers on (check all that apply): 

D Posting warning signs D Setting up plastic containment barriers 

D Maintaining containment D Avoiding spread of dust to adjacent areas 

D Waste handling D Post-renovation cleaning 

U Test kits used by certified renovator to determine whether lead was present on components affected by 

renovation (identify kits used and describe sampling locations and results: 

'S^Waming signs posted at entrance to work area. 

D Work area contained to prevent spread of dust and debris. 

D Windows in and within 20 feet ofthe work area are closed 

D Doors in and within 20 feet ofthe work areas are closed and sealed 

D Doors that must be used in the work area are covered to allow passage but prevent spread of dust. 

D Ground covered by plastic sheeting extending 10 feet from work area - plastic anchored to the 

building and weighted down by heavy objects. 

D Ifnecessary, vertical containment installed to prevent migration of dust and debris to adjacent 

property. 

D Waste contained on-site and while being transported off-site. 

Renovation Recordkeeping Checklist Omaha Lead Site 
(effective April 2010) m CI 

D Work site properly cleaned after renovation. 

D All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for 

removal. 

D Work area HEPA vacuumed to get paint chips from ground surface, ifnecessary. 

D Certified renovator performed post-renovation cleaning verification (describe results): 

U I certity under penalty of law that the above information is true and complete. 

hML 

Date 

Renovation Recordkeeping Checklist Omaha Lead Site 
5/26/2011 ^)ouqlas County Account Information ^2M ^ 

Douglas County, Nebraska Pro Record - R2212680000 

Print Report 

View Interactive GIS Map Infomiation is valid as of 2011-5-16 Treasurer's Tax Report 

New Feature Subdivision Sales Search 

Owner 

GAINES CERITA L 

1712 N 28 ST 

OMAHA NE 68111-0000 

Property Information 

Key Number: 1268 0000 22 

Account Type: Residential 

Parcel Number: 2212680000 

Parcel Address: 1712 N 28 ST 

OMAHA NE 68111-0000 

Legal Description: SHINNS 2ND ADD LOT 12 BLOCK S N 60 FT 60 X 60 

Value Information 

2011 

2010 

2009 

2008 

2007 

2006 

Land 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

$500.00 

Improvement 

$13,900.00 

$13,900.00 

$13,900.00 

$13,900.00 

$13,900.00 

$13,900.00 

Total 

$14,400.00 

$14,400.00 

$14,400.00 

$14,400.00 

$14,400.00 

$14,400.00 

Sales Information 

Sales Date: 1996-03-01 

Deed Type: 

Price: 

Grantor: 

$3,000.00 

Book: 2026 Page: 553 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Valid 

Land Information 

Acres 

0.08 

SF 

3600.0 

Units 

1.0 

Deptii 

60.0 

Widtii 

60.0 

Vacant 

No 

Improvement Information 

.mapping-online.com/.../acoountinft).j., 1/3 
...mapping-online.com/.../accountinfo.j... 2/3 
CONSENT FOR ACCESS TO PROPERTY 

OMAHA LEAD SITE REMEDIAL ACTION - LEAD-BASED PAINT STABILIZATI 

PROPERTY ID FROPERTY ADDRESS: 
~rn^ 'Wl /

DAYTIME PHONE 

OW : 4fe?- m-T'p^^ 

CELLPHONE: ^-^/3T^7 ^ E-MAIL: 

OWNER'S ADDRESS IF DIFFERENT: 

TENANT'S NAME IF APPLICABLE: 

DAYTIME PHONE: 

CELLPHONE: E-MAIL: 

Professional Environmental Engineers, Inc. (PE) is under contract (#EP-R7-08-06) with the U.S. Environmental Protection 

Agency (EPA) to stabilize lead based paint (LBP) on residential structures at a number of properties located in Omaha, 

Nebraska. The paint stabilization work is being done to protect the soil cleanups that are being performed by EPA contractors. 

Paint stabilization activities will include: scraping ofcracked or flaking LBP from structures, application of a prime coat and two 

(2) coats of paint. Moving parts of windows and doors are not included and will not be addressed. 

Your cooperation is requested in giving permission to this EPA contractor (PE) to enter and have access to this property for the 

purpose of stabilizing lead -based paint as outlined on the property identified above. 

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 

can not provide assurances that the soil cleanup contractor will be bound to. I further understand that the soil cleanup 

contractor will make all reasonable efforts to address concerns that I, as the property owner, may have regarding soil cleanup at 

my property. 

D Yes, I h/ve 

Signature of Property Owner Date 

I fully understand that by signing this Consent for Access, (I) this access will remain in effect until the work has been 

satisfactorily completed, (2) that the Property Owner or Tenant, if applicable, will be given the Housing and Urban Development 

(HUD) and EPA pamphlet, "Renovate Right, Important Lead Hazard information for Families, Day Care Providers, and 

Schools", (3) the Property Owner or tenant will remove all obstructions from surfaces to be painted, (4) will abide by health and 

safety guidance provided by EPA, (5) will allow photography ofproperty before and after the paint stabilization work, (6) will be 

contacted by a PE representative approximately 48 hours in advance of starting work, (7) agree not to obstruct or tamper with 

any ofthe LBP stabilization actions, and (8) will participate in Tmal property inspection and sign the Completion Agreement and 

Property Owner Satisfaction Survey. 

Should you have any questions about the planed Lead Based-Paint stabilization activities for your property, please contact 

Professional Environmental Engineers, Inc. Project Manager, Willie Clay or Kelley Sanders At 402-504-4688. General questions 

about the Omaha Lead Site cleanup can be directed to Pauietta France-Isetts, EPA Remedial Project Manager 402-731-2454, or 

the EPA Public Information Centers at 402-991-9583 (North Omaha office) or 402-731-3045 (South Omaha office). 

D No, 1 do not grant access to my property and I was 

] A Yes, I grant access to my property and was given the pamphlet 

given the pamphlet "Renovate Right, Important Lead 

/"Renovate Right, Important Lead Information for Families, Child 

Information for Families, Childe Care Providers, and Schools." 

/ Capfe Providers, and^hools." 

signature Date Signature Date 

SPECIAL INSTRUCTIONS AND CONSIDERATIONS 

V 
PRE-RENOVATION FORM -- OWNER 

This form is to be used by the firms contracted by the Environmental Protection Agency-Region 7 to perform Lead-Based 

Paint stabilization activities at the Omaha Lead Site, Omaha, Nebraska. 

Owner Confirmation 

Pamphlet Receipt 

^ I have received a copy ofthe lead hazard information pamphlet. Renovate Right: Important Lead Hazard Information for 

Families, Child Care Providers and Schools, informing me ofthe potential risk ofthe lead hazard exposure from renovation 

activity to be perfonned in/on my dwelling unit. I received this pamphlet before the work began. 

Owner Acknowledgment 

^QYA) I confirm that I own and live in this property, that no child under the age of 6 resides here, that no pregnant woman 

/resides here, and that this property is not a child-occupied facilit)'. 

Note: A child resides in the primary residence of his/her custodial parents, legal guardians, foster parents, or 

informal caretaker if the child lives and sleeps most of time at the caretaker's residence. 

Note: A child-occupied facility is a pre-1978 building visited regularly by the same child, under 6 years of age, on at 

least two different days within any week, for at least 3 hours each day, provided that the visits total at least 60 hours 

annually. 

A(B) I understand that the renovation firm, contracted by the Environmental Protection Agency (EPA), will be using leadsate work practices required by EPA's Renovation, Repair and Painting Rule. 

^-/m 

Printed Name of Owner-Occupant 

> r r ?/-/, 

Signature of Owner-Occupant Date 
?<VC) ^ -v)' 

^^f

\ 

PAINT STABILIZATION PRE-PROPERTY 

PAINT MATCH ASSESSMENT 

PROPERTY ADDRESS: ^1^/ lvVP) ^\- DATE:

BVID: j^^^ . I iv ^ 

AREA(S) TO BE PAINTED: 

HOUSE PROPER: M ] [ ^N f COLOR: 

HOUSE TRIM: H yf COLOR: i 

GARAGE: COLOR: 

GARAGE TRIM: COLOR: 

PORCH: M lj. -.Cv- COLOR: 

PORCH TRIM: COLOR: 

Hr^/ ^ i (COMPLETE ALL'SECTION . YES, NO, OF R NON-APPLICABLE)

I AGREE TO THE COLORS LISTED ABOVE. ONCE THE PAINTING 

BEGINS, I UNDERSTAND I CAN NOT CHANGE THE ABOVE SELECTED COLORS: 

PROPERTY OWNER SIGNATU PE ACCESOR SIGNATURE 

n