# 4 - 1



### TRANSMITTA L o f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R 

# SAID . 9 W^ ^ Date : Co\9'=\\\ \ Address : \^\ 9 K > P"? ^ f ^ Stabilizatio n Contractor : Professiona l Environmenta l Engineer s Year : ^ZO l | PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S Vide o o f propert y (DVD ) Executiv e Summar y Signe dAcces s Agreemen t fo r subjec t property Pre-Renovatio n FoiTi i signe db y Property Owner Pre-Renovatio n Fon n fo r Occupant/Tenant , if applicabl e Paintin g Agreemen t Settlemen t document s (i.e. , fo r damag e o r t

o replac e plants , etc. ) Renovatio n Recordkeepin g Checklis t signe db y Certifie dRenovato r Photograph s Satisfactor y close-ou i chec k lis t signe dby Propert y Owne r Propert y close-ou t chec k lis t signe db y EP A Propert y informatio n fromDougla s Count y Assessor' s Offic e D 

### Hazardanalysis , i f prepare d D 

### Safet y Audi t D 

### Othe r (describe) ; 

# 4 ^ Prot^ionalEnwonmSTtai^ngineer s Signatur e

..... . ^v^. . ^mnatu K (after file folde r review ) 4037756 2 

### } Dat e

Superfun d

# 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 y Respons e 250 5 Nort h 24 ^ Suit e 21 9 Omaha , N E 6811 0 (402 ) 504-468 8 Fa x (402 ) 504-328 1



### LeadBas e Stabilizatio n Omaha , N e Clos e Ou t Repor t 201 1 SAID#2644 3 171 2 N 2 8 S t

•Date s worked : 6/ 8 to 6/1 1 201 1 •Pr e propert y condition : Hous e ha s painte dwoo dsidin g wit h painte dwoo dtrims , porc h an dfoundatio n areas . Pain t wa s flakin g of f

in areas . •Problem s encountered : None . •Owne r request/concerns : N/ A •Inspection/closeou t dates . Owne r 6/14/1 1

## liBi ^ PROFESSIONA L 50 0 S . Ewing , Suit e E



## ENVIRONMENTA L ENGINEERS , INC . St . Louis , M O 6310 3 (314)531-006 0 "t-'lUVidhi g UUir:i-.:ii!ri ( •*/ ' t ^ c^ rivifi>iilliciitH l S.Illliii^i: , Fa x (314 ) 531-006 8 r;'.>iisMl;ii.' , • t;i.(:::u-L-'.'i.; ! ! >i-'s!ti'. l • l'l :.. ; '.'J.'^-^'i A'"'." ! -.ri . r.i V •.lij.'.i.j. . . : .:-..K ' 

## 201 1 Property Owne r Close-Ou t Form (Lead-Base dPain t Stabilizatio n EPA Contrac t EP-R7-08-06 ) SAID : 

# M B Propert y Address : \- \\1 . V j Q ft 1 ^ Owner' s Name : Performanc e Standards/Close-Ou t Criteri a YE S N O 1 . Wa s th e entir e structure(s ) painte dwit h th e exceptio n ofth e stated , exclude dareas ? 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 . / A



### 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 dwit h tw o to p coats ? 4 . Wa s th e pain t product s utilize dequivalen t t o a2 5 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 contractor 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 d debris ? 7 . I s th e grass are athat surround s th e structure(s ) i n reasonabl y goo dcondition ? 7 ^ 8 . Are al l item s suc h a 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 ? An y property damag e need s t o b e complete dprio r t o th e EPA Close-Out . 10 . Ar e yo u satisfie dwith th e wor k

performed ? 11 . Are ther e any property item s tha t were temporaril y re-locate dby th e contracto r tha t nee dt o b e move dback ? 12 . Ar e ther e any (known ) lingerin g issue s wit h th e property owner(s ) that hav e bee n lef t unresolved ? Other Considerations/Propert y Owne r Discussions/Additiona l Wor k

that i s Required : 

# \.o - \H - 

# W Propert y Owne r Signatur e Date



## • >!S^C3^V5 ^ 

# ro-H-\ ' Professional EnVirommBhta l Engineer s Signatur e Dat eProfessiona l Environmenta l Engineers : EP A Pain t Stabilizatio n 201 1 

# SAID , g(JW > Propert y Addres s | I I Z N Jj ) Ot " Stories/ Sidin g typ e | / ^ Transit e Woo d Viny l Meta l Stucc o Garage ? Ye s N o Painted ? Ye s N o Dat e acces s signe d Pre-vide o 

# 6/s ^ 

# / ( Where ? Sidin g Tri m

Pos t vide o Contracto rAssigne d Dat e starte d 

### ^ Oe V \Os:>r\\ 

# ^E m Dat e ende d 

# V\i-\ \ weathe rCondition s ^^„\^^.^l> ^

/ ^0\ ^

}S ^
Pain t use d Prim e use d 

# Tm\ . U6i 4 ,

Pol y use d Problems/Issue s(effectiv e Apri l 2010 )


### RENOVATIO N RECORDKEEPIN G CHECKLIS T
Name o f Firm : ^ A . Dat e an dLocatio n o f Renovation : l o Q \ \0 " \i " V J \ ^ \/: A '^ ^ Q.r ) Brie f Descriptio n o f Renovation : Name o f Assigne dRenovator : QT) ^ 

### X S YCXV^VA J 

### \A Q Name(s ) o f Traine dWorkers : Nam e o f Dus t Samplin g Technician , Inspector , and/o r Ris k Assessor , i f used : D Copie s o f renovato r an ddus t samplin g technician qualification s (trainin g certificates , certifications ) on file. D Certifie drenovato r provide dtrainin g to worker s o n (chec k all tha t apply) : D Postin g warnin g sign s D Settin g u p plasti c containmen t barrier s D Maintainin g containmen t D Avoidin g sprea do f dus t t o adjacent area s D Wast e handlin g D Post-renovatio n cleanin g U Tes t kit s use db y certifie drenovato r t o determin e whether lea dwa s presen t on component s affecte db y renovatio n (identif y kit s use dan ddescrib e samplin g location s andresults :

'S^Wamin g sign s poste da t entranc e t o wor k

area . D Wor k

are acontaine dto preven t sprea do f dus t anddebris . D Window s in an dwithi n 2 0 fee t ofth e wor k

are aar e close d D Door s i n an dwithi n 2 0 fee t ofth e wor k

area s ar e close dan dseale d D Door s tha t mus t b e use di n th e wor k

are aare covere dt o allo w passag e but preven t sprea do f dust . D Groun dcovere dby plasti c sheetin g extendin g 1 0 fee t fro mwor k

are a- plasti c anchore dt o th e buildin g an dweighte ddow n b y heav y objects . D Ifnecessary , vertical containmen t installe dt o preven t migratio n o f dus t an ddebri s to adjacent property . D Waste containe don-sit e andwhil e bein g transporte doff-site .

Renovatio n Recordkeepin g Checklis t Omah a Lea d Sit e(effectiv e Apri l 2010 ) 

# m C I

D Wor k

sit e properl y cleane dafter renovation . D Al l chip s an ddebri s picke dup , protectiv e sheetin g misted , folde ddirty sid e inward , an dtape dfo r removal . D Wor k

are aHEP A vacuume dt o get pain t chip s fro mgroun dsurface , ifnecessary . D Certifie drenovato r performe dpost-renovatio n cleanin g verificatio n (describ e results) :

U I certit y unde r penalt y of la w tha t the above informatio n i s tru e an dcomplete . 

# hM L Dat e

Renovatio n Recordkeepin g Checklist Omah a Lea d Sit e5/26/201 1 ^)ouqla s Count y Accoun t Informatio n 

# ^2M ^ Dougla s County , Nebrask a Pr o Recor d - R221268000 0 Prin t Repor t Vie w Interactiv e GI S Ma p Infomiatio n i s vali d a s o f 2011-5-1 6 Treasurer' s Ta x Repor t Ne w Featur e Subdivisio n Sale s Searc h Owne r GAINE S CERIT A L 171 2 N 2 8 S T OMAH A N E 68111-000 0 Propert y Informatio n Ke y Number : 126 8 000 0 2 2 Accoun t Type : Residentia l Parce l Number : 221268000 0 Parce l Address : 171 2 N 2 8 S T OMAH A N E 68111-000 0 Lega l Description : SHINN S 2N D AD D LO T 1 2 BLOC KS N 6 0 F T 6 0 X 6 0 Valu e Informatio n 201 1 201 0 200 9 200 8 200 7 200 6 Lan d $500.0 0 $500.0 0 $500.0 0 $500.0 0 $500.0 0 $500.0 0 Improvemen t $13,900.0 0 $13,900.0 0 $13,900.0 0 $13,900.0 0 $13,900.0 0 $13,900.0 0 Tota l $14,400.0 0 $14,400.0 0 $14,400.0 0 $14,400.0 0 $14,400.0 0 $14,400.0 0 Sale s Informatio n Sale s Date : 1996-03-0 1 Dee d Type : Price : Grantor : $3,000.0 0 Book : 202 6 Page : 55 3

Grantee : Valid/Invalid : Exclusio n Reason : Vali d Lan d Informatio n Acre s 0.0 8 S F 3600. 0 Unit s 1. 0 Depti i 60. 0 Widti i 60. 0 Vacan t No Improvemen t Informatio n .mapping-online.com/.../acoountinft).j. , 1/ 3... mapping-online.com/.../accountinfo.j.. . 2/ 3

## CONSEN T FO RACCES S T O PROPERT Y OMAH A LEA D SIT E REMEDIA L ACTIO N - LEAD-BASE D PAIN T STABILIZAT I PROPERT Y I D FROPERT Y ADDRESS : / 

# ~rn ^ 'W l

DAYTIM E PHON E 

### O W 

# : 4fe?

- m-T'p^ ^ CELLPHONE : 

# ^-^/3T^7 ^ E-MAIL : OWNER' S ADDRES S I F DIFFERENT : TENANT' S NAM E I F APPLICABLE : DAYTIM E PHONE : CELLPHONE : E-MAIL : Professiona l Environmenta l Engineers , Inc . (PE ) i s unde r contrac t (#EP-R7-08-06 ) wit h th e U.S . Environmenta l Protectio n Agenc y (EPA ) t o stabiliz e lea dbase dpain t (LBP ) o n residentia l structure s a t anumbe r o f propertie s locate din Omaha , Nebraska . Th e pain t stabilizatio n wor k i s bein g don e t o protec t th e soi l cleanup s tha t ar e bein g performe db y EPA contractors . Pain t stabilizatio n activitie s wil l include : scrapin g ofcracke do r flakin g LB P fro mstructures , applicatio n o f aprim e coa t an dtw o (2 ) coat s o f paint . Movin g part s o f window s an ddoor s ar e no t include dan dwil l no t b e addressed . You r cooperatio n i s requeste din givin g permissio n t o thi s EP A contracto r (PE ) t o ente r an dhav e acces s t o thi s propert y for th e purpos e o f stabilizin g lead-base dpain t a s outline don th e propert y identifie dabove . B

y signin g thi s documen t I agre e t o allo w a n EP A contracto r t o conduc t asoi l cleanu p a t m y propert y followin g completio n o f lead-base dpain t stabilization , i f th e soi l cleanu p ha s no t alread y bee n performed . 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 wil l b e boun dto . I furthe r understan dtha t th e soi l cleanu p contracto r wil l mak e al l reasonabl e effort s to addres s concern s tha t I , a s th e propert y owner , ma y hav e regardin g soi l cleanu p a t m

y property . D Yes , I h/v e Signatur e of Propert y Owne r Dat e I full y understan dtha t b y signin g thi s Consen t fo r Access , (I ) thi s acces s will remai n i n effec t unti l th e wor k ha s bee n satisfactoril y completed , (2 ) tha t th e Propert y Owne r o r Tenant , i f applicable , will b e give n th e Housin g an dUrba n Developmen t (HUD ) an dEP A pamphlet , "Renovat e Right , Importan t Lea dHazar dinformatio n fo r Families , Da y Car e Providers , an d Schools" , (3 ) th e Propert y Owne r o r tenan t wil l remov e al l obstruction s fro msurface s t o b e painted , (4 ) wil l abid e b y healt h an d safet y guidanc e provide db y EPA , (5 ) wil l allo w photograph y ofpropert y befor e an dafte r th e pain t stabilizatio n work , (6 ) wil l b e contacte db y aP E representativ e approximatel y 4 8 hour s in advanc e of startin g work , (7 ) agre e no t t o obstruc t o r tampe r wit h an y ofth e LB P stabilizatio n actions , an d(8 ) wil l participat e in Tma l propert y inspectio n an dsig n th e Completio n Agreemen t an d Propert y Owne r Satisfactio n Survey . Shoul dyo u hav e an y question s abou t th e plane dLea dBased-Pain t stabilizatio n activitie s fo r you r property , pleas e contac t Professiona l Environmenta l Engineers , Inc . Projec t Manager , Willi e Cla y o r Kelle y Sander s At 402-504-4688 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca n b e directe dt o Pauiett aFrance-Isetts , EPA Remedia l Projec t Manage r 402-731-2454 , o r th e EP A Publi c Informatio n Center s a t 402-991-958 3 (Nort h Omah aoffice ) o r 402-731-304 5 (Sout h Omah aoffice) . D No , 1 d o no t gran t acces s t o m y propert y an d I wa s ] A Yes , I gran t acces s t o m y propert y an d wa s give n th e pamphle t give n th e pamphle t "Renovat e Right , Importan t Lea d /"Renovat e Right , Importan t Lea d Informatio n fo rFamilies , Chil d Informatio n fo rFamilies , Child e Car e Providers , an d Schools. " / Capf e Providers , and^hools. " signatur e Dat e Signatur e Date SPECIA L INSTRUCTION S AN D CONSIDERATION S 

# V

## PRE-RENOVATIO N FOR M - - OWNE R Thi s for mi s t o b e use dby th e firms contracte db y th e Environmental Protectio n Agency-Regio n 7 t o perfor mLead-Base d Pain t stabilizatio n activitie s a t th e Omah aLea dSite , Omaha , Nebraska . Owne r Confirmatio n Pamphle t Receip t ^ I hav e receive dacop y ofth e leadhazardinformatio n pamphlet . Renovate Right : Importan t Lea dHazar dInformatio n fo r Families , Chil dCar e Provider s an dSchools , informin g m e ofth e potential ris k ofth e lea dhazar dexposur e fro mrenovatio n activit y t o b e perfonne din/o n m y dwellin g unit . I receive dthi s pamphle t befor e th e wor k

began . Owne r Acknowledgmen t ^QYA ) I confir mtha t I ow n an dliv e i n thi s property , tha t no chil dunder th e ag e o f 6 reside s here , tha t no pregnan t woma n /reside s here , an dthat thi s property i s no t achild-occupie dfacilit)' . Note : A chil dreside s i n th e primar y residenc e o f his/her custodia l parents , lega l guardians , foste r parents , o r informa l caretake r i

f th e chil dlive s andsleep s mos t o f tim e a t th e caretaker' s residence . Note : A child-occupie dfacility i s apre-197 8 buildin g visite dregularl y by th e sam e child , under 6 year s o f age , on a t leas t tw o different day s withi n any week , fo r a

t leas t 3 hour s eac h day , provide dtha t th e visit s tota l a t leas t 6 0 hour s annually . 

# A (B ) I understan dtha t th e renovatio n firm , contracte db y the Environmental Protectio n Agenc y (EPA) , wil l b e usin g lead

sate wor k

practice s require db y EPA' s Renovation , Repai r andPaintin g Rule . 

# ^-/ m Printe dNam e o f Owner-Occupan t 

# > rr 

# ?/-/ , Signatur e o f Owner-Occupan t Dat e?<VC) ^ -v) ' 

# ^^ f \ 

## PAIN T STABILIZATIO N PRE-PROPERT Y PAIN T MATC H ASSESSMEN T PROPERT Y ADDRESS : DATE : 

# ^1^ / lv 

# VP ) ^\

- BVID : j^^^ . I iv ^

AREA(S ) TO BE PAINTED : HOUS E PROPER : 

## M ] [ ^N f COLOR :

HOUS E TRIM : 

## H yf COLOR : i

GARAGE : COLOR :
GARAG E TRIM : COLOR : 

# M lj . 

# -.Cv - PORCH : COLOR :
PORC H TRIM : COLOR :

Hr^/ ^ i (COMPLET E ALL'SECTION . YES , NO , O R NON-APPLICABLE ) F



### I AGRE E TO TH E COLOR S LISTE D ABOVE . ONC E TH E PAINTING BEGINS , I UNDERSTAN D I CA N NO T CHANG E TH E ABOV E SELECTE D COLORS : PROPERT Y OWNE R SIGNAT U PE ACCESO R SIGNATUR E 

# n