## TRANSMITTA L of OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID# : 520 1 Date : 12/08/200 8 Address : 1542N17S t Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S B^ Vide oof propert y (DVD ) H^ Executiv e Summary B^ Signe dAcces s Agreemen t for subjec t property [5 Paintin g Agreemen t D Settlemen t document s (i.e. , for damag eor to replac e plants , etc. ) D Photograph s n Satisfactory restoratio n signe dby Property Owne r D Property close-ou t chec k lis t signe dby EP A 0^ Property informatio n fro mDougla s County Assessor' s OfRc e D D D

2/3S/0 f 9 9 

### Date "

4030990 1 

# il l Superfun d

### PROPERT Y SUMMAR Y Date : 12/08/0 8 LB PSTABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address : 154 2 N 1 7 S t SAI D : 520 1 

### A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : Non e A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Infomiation : None Acces s Date : 10/14/0 8 Wor k Bega n Date : 11/04/0 8 Closeou t Date : 11/19/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . SignedAcces s Agreemen t 5 . Pre-Renovatio n Form 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EPA Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHN0i6GltS . iNC .ENVIRONMENTA L & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# /ry ^ Propert y Statu s For m Address : IS^ ^ KI • i l Sh . Date : /A^/z/oj ^ Phone : ^{ ^ ^~ ^ " C> ^ I ^ BVID : 5 ^ O | Plan t & Permanen t Landscapin g T o Remai n I n Place Itein # Descriptio n an dLocatio n O

n Ma p 

# 7

Pre-Existin g Conditio n o f

Structure s Does you r

Basemen t hav e ahistor y o f

leaking ? Yes — N o ^ 

## Item # Descriptio n & Locatio n OnM ^

Propert y Owiw r Pruden t Empl Signature : QJ2^^* ^
808 0 War d Parkway , Suit e 40 6 250 5 N . 24* ^ Street , Suit e 30 8 424 2 Medica l Drive , Suit s 425 0 Kansa s City , M O 6411 4 Omaha , Nebraslc a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-858 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

# • yao '

Pruden t Technologies , Inc . (Prudent) is unde r

contrac t (Contract #EP-R)^8-07 ) 

## wit hth e U. S. Environmenta l Protectio n Agency (EPA) to stabiliz e Lea dBasedPaint (LBPXa t anumbe r

ofwopertie s located in Omaha , Nebraska , includin g th e propert y locate d at ..-f^flil.' i ^ ^ /" 7 ^^- ^ The EP A request s you r

pennissio nto allo w Pruden t to perfor mLB PStabilizatio n atthi s property . By signing thi s form , th e propert y owne r

grant s permissio n to Pruden t to perfor mactivitie s relate dto LB P Stabilizatio n including 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 about th e LB Pstabilizatio n planne dfo r

you r

property , pleas e contac t Prudent' s AHTnini.«rtrativ e Cler k

fo r

th e Lea dBase dPaint Stabilization , Mrs . DeborahAkerele-Johnson . at

(402 ) 504-1004 . Genera l question s abou t th e Omah aLea dSit e cleanu p ca nbe directe d to th e EP A Publi c Information Center sat (402 ) 731-304 5 (Sout hOmahaofifice ) or (402 ) 991-958 3 (Nort hOmaha ofifice) . Propert y Acces s Grante dBy : ^ 1 Tr y tCPleS e t Na . Prin Prin t Name ) Propert y Owne r Signature : (Pate ) PROPERTY INFORMATIO N plete d by residen t and/o r property owner - pleat e print ) RESiDEN T NAME : 

## fcff[fi'a/ \ Rente r 

# /rv ^ /^ . 17 ^ RESIDEN TADDRESS: . IF RENTAL , PROPERT YOWNE D BY : 

# St^ ^ OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : J L .WORK : J L NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : C ^ NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDER : / NUMBE R OF CHILDREN UNDE R 7 YEAR S OL D WH O PLA Y IN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS E ACTIONS ; Tlie activitie s t» be implemente d

by EP A unde r thi s agreemen t ar

e pursuan t to Sectio n 10 4 OfCERCLA, 42 U.S.C . 9604 . EPA' s rigiit of acces s to Hi e propert y isprovide d for in Sectio n 104(e ) ofCERCLA , 42 U.S . C 9605(e) , whichprovide s entr y for "determining the need forresponse , or choosing ortaldng an y respons e actio n unde r tbi s title , or oflierwise enforcin g flie provisicn sof the title. "

108 0 War dParinvay , Suit e 40 5 250 5 N. 24* ^

Street , Suit e 30 8 4242 Medica l Drive , Suit e 425 0 lansa s City , MO 6411 4 Omaha , Nebraslc a 6811 0 Sa n Antonio , TX 7822 9 'hone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 ax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

# Curren t Sampl e PrA^enovatio n For m Effectiv e unti l Apri l 2010 . Confimiatio n of Receip t of Lea d Pamphle t 5/h i 1 hav e received a copy of th e pamphlet , Ftenovat e FUght : Importan t Lea d Hazar d infonnatio n fo rFamilies , Chik i Car e Pn)vkier s an d School s informin g me of th e potentia l ris k of th e lead hazar d exposur e fro m renovatio n activit y

to be performe d in mydwellin g unit . I receive d thi s pamphlet befbr e th e wor k began .

Self-CeAiflcatio n Optio n (fo rtenant-occupie d dwelling s only) — If th e Ieadoamphlet was delivere d bu t a tenan t signatur e was not obtainable , yo u ma ychec k th e appropriate bo xbelow . Q Refusa l to sig n —I certif ythat I hav e mad e a goo d fait h effor t to delive rth e pamphlet , Flenavat a FVght: importan t Lea d Hazar d Infonnatio n fb rFamilies , CNI d Car e Provkier s an d Schools , to th e renta l dwellin g uni t liste d belo w

at th e dat e an d tim e Indicate d an d that th e occupan t refuse d to sig n th e confirmatio n of receipt . I furthe rcertif ytha t I hav e lef t a copy of th e pamphle t at th e uni t wit h th e occupant . Q Unavaiiabl e fo rsignatur e — I certif ythat I hav e mad e a goo d fait h effor tto delive rth e pamphlet , Fienovat e FVght: importan t Lea d Haar d Informatio n fb r Families , Chil d Ca m provider s an d Schools , to th e renta l dwellin g uni t liste d belo wan d ttia t th e occupan t was unavailabl e to sig n th e confirmatio nof receipt . I furthe rcertil ytha t I hav e lef t a cop y of th e pamphle t at th e uni t byslidin g it unde rth e d( 

# ' ^ v7^ ^e^tAS
­ / ^ -// " d^ Printe d nam e o f perso n certifyin g 

### yCJit/l^^'V^ ^ Attempte d deliver y dat e an d tim e lead pamphle t deliver y Signatur e

of persorroertifyin / /— ^ l^f A irsorroertifyin g lead pamphlet deliv er

y 

# CMaAay/0£ ' Uni t Address Not e Regardin g Mailin g Optio n — Asan altemativ e to deliver y

in person , yo u ma ymai i th e lea d pamphle tto th e owne rand/o rtenant . Pamphle t mus t be mailed at leas t 7 day s befor s renovatio n (Document wit h a certificate of mailin g fro m th e post office) .

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aBHBBBB Ijjougia s count y Accoun t inlMmatio n Pag e 1 of 2 [^jma Dougla s County , Nebrask a Propert yRecor d - R021472000 2 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t o f SOt h S t - VJewo n Ma p Infonnatio n i s vali d a s o f 2008-9- 4 Treasurer' s fa xRepor t Ne wFeatur e ->->• * Aut o Sale s Searc h Owne r MATTE S J R STEPHE N D 154 2 N 1 7 S T OMAHAN E 68110-000 0 Propert yInformatio n Ke yNumber : 147 2 000 2 0 2 Accoun t Type : Residentia l Parce l Number : 021472000 2 Parce l Address : 154 2 N 1 7 S T OMAHAN E 68110-000 0 Lega l Description : LAND S SEC-TWN-RG E 15-15-1 3 N 25. 5 E 14 0 F TTX LT2 4 & S 1/ 2 E 14 0 F TTX L

T 2 5 61X14 0 Valu e Informatio n Lan d Improvemen t Tota l 200 8 200 7 200 6 200 5 200 4 200 3 $3,000.0 0 $3,000.0 0 $3,000.0 0 $3,000.0 0 $3,000.0 0 $3,000.0 0 $23,100.0 0 $9,900.0 0 $9,900.0 0 $6,700.0 0 $6,700.0 0 $6,700.0 0 $26,100.0 0 $12,900.0 0 $12,900.0 0 $9,700.0 0 $9,700.0 0 $9,700.0 0 Lan d Informatio n Acre s S F U nit a Dept h Widt h Vacan t 0.1 9 8540. 0 1. 0 140. 0 61. 0 N o Improvemen t Inf ormatio n Buildin g 1

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R02. . . 9/24/200 8

## uougia s uount y Accoun t Intonnatio n r^jma t 

## Pag e 2 of 2

U K Firrtfta w aw. O 34 . It .
) 0 RAISE D RAr«: H U I SsEnitt EEtod c6 8 9S3. Q » » tt. igj_,,.. .

CLIC KTO ENLARG E IMAG E CUC KTO ENLARG E IMAG E Squar e Footage : 840. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Fai r

Buil t As : Raise d Ranc h Cond o Squar e Footage : 0. 0

HVAC : Force d Ai r Rooms : 5. 0 Exterior : Fram e Sidin g Units : 1. 0 Interior : Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 2. 0

Roo f Type : Hip/Gabl e Stories : 

### 1. 0 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea r Percen t Adjuste d Yea r YearBuil t Physica l Ag e Remodele d Remodele d Buil t 

### 190 0 0 % 190 0 

### 10 8 Detai l Typ e Detai l Descriptio n Unit a Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 ft 952. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Garag e Basemen t Singl e 1. 0 Porc h En d Soli d Wal l 

### 112. 0 Porc h Sla b Roof Cei l 42. 0



## http://douglasne.mapping-online.coin/DouglasCoNe/static/accountinfo.jsp?accountno=R02.. . 9/24/200 8

## Pruden t Propert yClc|se-Ou t For m (Lead-Base d Pain t Stabilization } SAID : ^<^ 6 ( Propert yAddress : \>S'^|' l /\^ » / W S 4 Owner' s Wame : ^Cjrv.>flu L HfV\a^ ' 

## Performanc e Standar^s/close-Ou t Criteri a YE S N O Wa s th e entir e structureis ) painte d wit h th 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 , box 

# X beams , columns , rails , an d fxterio rsurfece s o f garBges . 2 .

Wa s al l scrapin g an d othe rpreparattio n worl < complete d satisfactoriiy ? Were ai l require d area s o f tq e structure{s ) prime d a s neede d an d painte d wit h tw o to p coats ? Wasth e pain t product s utilise d equivalen t t o a 3 0 yea rproduct/quality ? Ar

e al ! ofth e area s wher e contaminate d material s hav e bee n spille d •^ ^ thoroughl yvacuumed/cleaned ? 

# X 5 .Di d th e contracto rcollect/vslcuu m al ! failin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cReces s areas an d also remove an yothe rgenerate d debris ? 

# k I s th e gras s are a tha t surrour^d s th e structure(s } I n reasonabl ygoo d condition ? Are ai ! item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properi yremoved ? 

# X 9 . I s ther e an yevidence o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e comptete d prio r\ o th e EP AClose-Out . 

# X 10 . Are ther e an ypropert yitem s tha t wer e temporatii yre-locate d b yth e contracto r tha t nee d t o b e move d back? ! 

# X il . Ars ther e an y(known ) lingeriri g issues wit h th e propertyowner(s ) tha t hav e bee n ief t unresolved ? Othe rConsideratlons?propert 7 Owne rp!scussions?Addition8 l Wor k tha t i s Require d 

# X ). . 

# h entatlv e \/irf Pruden t Representativ e \/ ] ­ -4 ^

^ ^ ^^ ^ Date//-/^^0 ? ' ^