# TRANSMITTA Lof OMAHA LEAD SIT E PAIN T STABILIZATIO NFIL EFOLDE R
SAID : 310 4 Date : 12/26/200 8 Address : 244 7 CROW NPOIN T Remediatio nContractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 0 Vide o o f

propert y (DVD ) E TExecutiv e Summar y [? r Signe dAcces s Agreemen t fo r subjec t propert y iz f Paintin g Agreemen t I D Settlemen t

document s (i.e. , fo r

damag e o r

t o replac e plants , etc. ) D Photograph s H ^ Satisfactor y restoratio nsigne db y Propert y Owne r D Propert y close-ou t chec k Us t signe db y EP A 0 ^ Propert y informatio nfromDougla s Coimt y Assessor' s OfBc e D D D 

## Signatur

e / Dat ( to 9 at e

4030984 2 

# 1 1 ill Superfun d

## PROPERT Y SUMMAR Y Date : 12/23/0 8 LB PSTABILIZATIO NEPA CONTRAT EP-R7-08-0 7 Monthof : Decembe r r 

## Propert y Address : 244 7 CROWNPOIN T SAID : 310 4 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : NONE . A. 2 Issue s Resolved : NONE . A. 3 Uniqu e Findings : NONE . A. 4 Othe r

Relevan t Information : NONE . Acces s Date : 09/29/0 8 Work Began : 10/14/0 8 Closeout Date : 10/16/0 8 Enclosures ; 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreement 5 . Pre-Renovatio nForm 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio nPag e 9 . EP A Propert y Closeout for m 10 . Propert y Completio nAgreemen t

TECHNOLOGIES , INC .

## TECHNOLOGIES , INC . ENVIRONMENTA LA CONSTRUCTION SERVICE S 

# Propert y Statu s For m Address : ^Q^- j (TrovA/oT^om f /^ate : Phone : BVID : 3/O M
Item # O nMa p Plan

t & Pennanen

t L-flndscapinp

r T o Remai nI nPlac e Descriptio nan dLocatio n 

# "-yUP' ^

Pre-Existin g Conditio no f Structure s Does you r Basemen t hav e ahistor y o f leaking ? Yes -i ^ N o Item # OnM ^ Descriptio

n& Locatio

n

Propert y Owne r Signajim r ^JJST.JJM ^ 

# Pruden t Employe e Signature : \lLYvmM^.^ic ^ i 808 0 Vtard Paricway , Suit e 40 5 Kansa s City . M O 6411 4 Plione : (816 ) 363-3703 Fax : (816 ) 363-3707 2505 N . 24* ^ Street . Suit e 308 Omaha , Nebraslc

a 6811 0 Phone : (402)504-100 4 Pa yi»tn \

RnA.inn c 424 2 Medl(» l Drive , Suit e 426 0 Sa n Antonio , T

X 7822 9 Phone : (210)822-958 8

# 3lo M

Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t (Contract #EP-R7-08-07 ) wit

hth e U . S . Environmenta

l Protectio nAgency (EPA) to stabiliz e Lea dBasedPaint

(LBP) a t anumbe r ofpropertie s locatedi nOmaha , Nebraska , including the propert y locate da

t ^^^ ^ ^rAJj\y nfn]nrt ' /?-<•/€- . Th e EP A request s you

r permissio nto allo w Pruden t to perfor mLB PStabilizatio na

t thi s property . B y signing thi s form , tiie propert y owne r grant s permissio nto Prudent t o perfor mactivitie s relate dto LB P Stabilizationincluding scraping paint andpaintin g ofth e referencedproperty . Further , th e owner/tenan t verifie s tha

t they hav e receive dth e LB Ppamphlet "Renovat e Right " If you hav e an

y question s abou

t th e LB Pstabilizatio nplannedfo r you r property , pleas e contac t

Prudent' s Administrative Cler

k fo r th e Lea dBasedPaint

Stabilization , Mrs . DeborahAkerele^ohngon . a t (402 ) 504-1004 . Genera

l question s about

th e OmahaLea

dSit e cleanu p ca nb e directe dt o th e EP

A Publi c InformationCenter s a t (402 ) 731-304 5 (Sout

hOmahaoffice) or

(402 ) 991-958 3 (Nort

hOmaha ofifice) . Propert y Acces s Grante dB y ^ OPIease Prin t Name ) Propeit y Owne r

Signature :

RESIDEN TNAME : 

# r /hyc^yu ^ (Signature ) (Date )

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

- pleas e print ) 

# - D 

# f-^ F

Owne r Rente r RESIDEN TADDRESS: . I F RENTAL , PROPERT YOWNE D BY : OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBE R . HOM E NUMBER O F OCCUPANT S UNDE R 7 YEAR S OL D



# : 

# d{CS , I f 5 ^ > WORK : 

### J L

. NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : NUMBER O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e iinplemente db y EP Aunde r thi s agreemen t

ar e pursuan t

t o Sectio n10 4 o f CERCLA , 4 2 U.S.C . 9604 . EPA' s ri ^ o f acces s t o flie propert y isprovide dfor i i Sectio n104(e ) o f

CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entr y for "determinin g th e nee dfor

response , o r

choosin g ortaldn g an y respons e actio nunde r thi s title , o r

oflierwis e enforcin g flie provisicn s o f tli e title. "

108 0 War d Paricway , Suit e 40 5 iansa s Clly , M O 6411 4 'hone : (816 ) 363-370 3 ax : (816 ) 363-370 7 250 5 N . 24* " Street , Suit e 30 8 Omaha , Nebrask a 6811 0 Phone : (402)504-100 4 424 2 Medica l Drive , Suit e 425 0 Sa n Antonio , T X 7822 9 Phone : (210)822-958 8 r.» . t*tM

m

### . « . 

# Curren t Sampl e Pre-Renovatio n For m EfTectlv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t l3| [ i hav e receive d a cc^ yo f th e pamphlet . Renovat e flight : Importan t Lea d Hazan j ' m/bmiatfo n fb rFamilies , Chil d Car e Provider s an d Schoof e IrTfonnln g m e o f th a potentia l risl < o f th e lea d hazar d exposur e fro m renovatio n activit yt o b e performe d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e worl < began . 

# C/^/Pf ^ Kl^^c L ^O^r^f ^ PrintecLnameo f reclplertt ; Dat e 

# ^^:;2z Slgnatur e o f recipien t Self-Certificatio n Optio n (fo rtenant-occupie d dweiling s onl ^ — I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ms ychecl < th e appropriat e bo xbelow . Q Refusa l t o sig n —I certifytha t I hav e mad e a goo d M h effort t o delive rth e pamphlet , RsncmH e FSght : importan t Lea d Hazar d Irrfbrmatk m fo rFamilies , Chil d Car e Providers an d Schools , t o th e renta l dwellin g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t tiie occupan t refuse d t o sig n th e confinnatio n o f receipt . I fiirtiie rcertif ytiia t I hav e left a cop yo f tiie pamphle t a t th e uni t witi i th e occupant . Q Unavailabl e fo rsignatur e —I certifytha t I hav e mad e a goo d fait h effor t t o delive rttie pamphlet , Fienovat e FVgh t Importan t Lea d Hazar d infonnatio n fo r Families , ChU d Car e provider s an d School , t o tiie renta l dwellin g uni t liste d belo wan d tiiat th e occupan t wa s unavailabl e t o sig n tiie confirmatio n o f receipt . I furtiie rcertifytiiat I hav e left a cop yo fth e pamphle t a t tiie uni t b yslidin g i t unde rtiie door . / Printe d nam e of perso n certifyin g Attempte d deliver y 

# <2 . dat e an d tim e lea d pamphle t deliver

y Sl^tur e o f perso n certifyin g lea d pamphle t deliver y 

### (- / 

# .^^^ ^ /^yn^ ^

/^/^ ^

n^/ ^ Uni t Addres s Not e Regardin g IMailin g Optio n —A s a n attemativ e t o deliver yi n person , yo u maymai l tiie lea d pamphle t t o ttie owne rand/o rtenant . I=>amphle t mus t b e maile d a t leas t 7 day s befor e renovatio n (Documen t witi i a certificat e o f mailin g fro m tiie pos t office) .

# pain t matc h fonrr ^ Pain t matchin g form : —/^$ ^ Propert yaddress : L^ - j a ovTn * i / I 

# BVID : Area : color : Explanation :
Area : color : Explanat i on :
Area : Color : Explanation : Area : color : Explanat i on : Area : Color : Explanation : Page 1 

# ^7 /

# [ -^i m



# ACCES S Wf^ORM^rioNTfKAOKIH Q SHEE T 

# 1

Prtf t S/O V 

# PRopcer v 

# cPW / rlr^... ^ Lni ^ Ain

P

OMwOoiMNO E Horna ; WDfi (

0611 : \ 

## AODMOOIM K 

# on e I tw e I toosor 

# cocrwroETAn . 

# K V o ^ 

# \ y ^ 

# i P Punrya^ i ^?fci ^



# U^au^oi^sqJic [

••••••••• H 

# OfflMte .

## Dougla s County Accoun t InfoMatio n :ama a Pag e 1 of 2 Dougla s County , Nebrask a Properl YRecor d - R161372000 0 Informatio n i s vali d a s o f 2008-9- 4 Prin t Repor t NE W FMtui e - Parce l Dimension s avaHabl e @ scal e 0-5 0 f t wes t o f90t h S t - VieVt fO n Ma p 

### Treasurer' s Ta xRepor t Ne wFeatur e -•.-•' * Aut o Sale s Searc h 

## Owne r KNOWLE S ADRIA N ETA L 244 7 CROW N POIN TAV E OIVIAHAN E 68111-000 0 

## T ? ^py O 

## ^ 

# ;v>c > 

# ^ r ^ Propert yInformatio n Ke yNumber : 

## 137 2 000

0 1 6 Accoun t Type : Residentia l Parce l Number : 161372000 0 Parce l Address : 244 7 CROW N POIN TA V

OMAHAN E 68111-000 0 Lega l Description : IJ^URELTO N AD D LO T1 3 BLOC K3 4 5 X 12 0 

### Valu e Informatio n

Lan d Improvemen t Tota l 200 8 $2,500.0 0 $35,400.0 0 

## $37,900.00 200 7 $2,500.0 0 $37,300.0 0 $39,800.0 0 200 6 $2,500.0 0 $37,300.0 0 

## $39,800.00 200 5 $2,500.0 0 $37,300.0 0 $39,800.0 0 200 4 $2,500.0 0 $23,500.0 0 $26,000.0 0 200 3 $2,500.0 0 $23,500.0 0 $26,000.0 0 Lan d Informatio n Acre s S F Unit a Dept h 

## Widti i Vacan t 0.1 2 5400. 0 1. 0 120. 0 45. 0 N o Improvemen t Informatio n Buildin g 1

http://douglasne.maDDine-online.com/DouelasCoNe/static/accoi)ntiTif n isTi9nrrT.iintnn= P i n anAnnn s

## Dougla s Count

y Accoun t In&|matio n n&cm a Pag e 2 of 2

CUC KT O ENLARG E IMAG E JUTCROWMPCXHrAV . HI T a a « n . RmFta r
4 0 O

f ?»( r

I«< r 11/ 2 STOfi YFINISHE D

CLIC KTO ENLARG E IMAG E 

### Squar e Footage : Perimete r Uni t Type : Buil t As : HVAC : Exterior : Interior : Roo f Cover : Roo f Type : Floorcover : YearBuil t 191 5 1406. 0

0. 0 1 1/ 2 Stor yFi n Force d Ai r Fram e Sidin g Drywal l Compositio n Sliingl e Gabl e Allowanc e yea r Remodele d 0 Detai l Typ e Applianc e Basemen t Fixtur e Fixtur e Garag e Porci i Porc h Use r Percen t Complete : Quality : Condition : Cond o Squar e Footage :

Rooms : Units : Baths : Bedrooms : Stories : Foundation : Sprinkle rSquar e Footage : Percen t Remodele d 0 % Adjuste d Yea r

Buil t 191 5 100.0 % Fai r Fai r 0. 0 7. 0 1. 0 1. 0 4. 0 1. 5 Bloc k 0. 0 Physica l Ag e 9 4 Detai l Descriptio n Allowanc e Bsmn t Bloc k

8 f t Bas e Fixture s Batl i Ful l Detaclie d En d Scree n Sla b Roo f Cei l Atti cFul l Finisi i Unit a 1. 0 960. 0 1. 0 1. 0 528. 0 192. 0 50. 0 384. 0



## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.isT)?ar,nniintnr.= p i AO/O/

Innr\o

## Pruden t Propert yClose-Ou t For m ( Lead-Base d Pain t Stabilization ) 

# SAID : 3iby

_ Propert yAddress : XQ^f l Kr^Mn J pJUtT t Ui/ i Owner' s Name ; <„^Yv/yyc ^ fy/Yvr^j4sy > ^ 

## Performanc e Standards/close-Ou t Criteri a YE S N O 1 . Wa s tii e entir e structure(s ) painte d wit h tii e exceptio n o f th e stated , exclude d areas ? Thi s woul d inciud e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al i trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 2 . Wa s al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 . Wer e al l require d area s ofth e structure(5 ) prime d a s neede d 3n d painte d wit h tw o to p coats ? 4 . Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 5 . Ar e al i o f th e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? 

# X 

# E 

# i X 1 5 . Di d th e contracto rcollect/vacuu m ai ! falli.n g an d scrape d pain t chip s o n th e entir e property , roacways , alleyways , publi cacces s area s an d als o remov e an yothe rgenerate d debris ? I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 8 . Ar e al l item s suc h as polyethylen e sheeting , ladders , pain t brushes , cones , bar.ne rtap e etc . properl yremoved ? 

# J d 

# I X 9 . I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s to.b e complete d prio rt o th e EP AClose-Out . 10 . Ar e ther e an ypropert yitem s tha t wer e temporatil yre-locate d b yth e contracto r tha t nee d t o b e move d back ? 

# p r 11 , Ar e ther e an y(known ) lingerin g issue s wit h th e propert yownsr(s ) tha t hav e bee n lef t unresolved ? Othe rConsiderations?propert YOwne rDiscussions?Additiona l Wor k tha t i s Require d 

## Pruden t Representativ e Signature://^^^^,^^^^^^^^^ ^ Propert yOwne rSignature : ^^>yO^<n ^ h^^^ a 

# Date : (7-17-^ ^ ) ^