TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 5201 Date: 12/08/2008 

Address: 1542N17St 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

B^ Video of property (DVD) 

H^ Executive Summary 

B^ Signed Access Agreement for subject property 

[5 Painting Agreement 

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

D Photographs 

n Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

0^ Property information from Douglas County Assessor's OfRce 

D 

D 

D 

2/3S/0 f9 9

Date" 

40309901

ill 

Superfund 
PROPERTY SUMMARY 

Date: 12/08/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address: 1542 N 17 St SAID : 5201 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Infomiation: None 

Access Date: 10/14/08 

Work Began Date: 11/04/08 

Closeout Date: 11/19/08 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHN0i6GltS. iNC. 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

/ry^ Property Status Form 

Address: IS^ ^ KI• i l Sh . Date: /A^/z/oj^ 

Phone: ^{ ^ ^~ ^ " C>^ I ^ BVID: 5 ^ O | 

Plant & Permanent Landscaping To Remain In Place 

Itein# 

Description and Location 

On Map 

7 

Pre-Existing Condition of Structures 

Does your Basement have a history of leaking? Yes — No ^ 

Item# Description & Location 

OnM^ 

Property Owiwr Prudent Empl 

Signature: QJ2^^*^ 

8080 Ward Parkway, Suite 406 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suits 4250 

Kansas City, MO 64114 Omaha, Nebraslca 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-8588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
•yao' 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R)^8-07 ) with the U. S. 

Environmental Protection Agency (EPA) to stabilize Lead Based Paint (LBPXat a number ofwoperties 

located in Omaha, Nebraska, including the property located at ..-f^flil.'i ^ ^ /"7 ^^-^ 

The EPA requests your pennission to allow Prudent to perform LBP Stabilization at this property. By 

signing this form, the property owner grants permission to Prudent to perform activities related to LBP 

Stabilization including scraping paint and painting ofthe referenced property. Further, the owner/tenant 

verifies that they have received the LBP pamphlet "Renovate Right." 

If you have any questions about the LBP stabilization planned for your property, please contact Prudent's 

AHTnini.«rtrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (402) 504-1004. General questions about the Omaha Lead Site cleanup can be directed to the EPA 

Public Information Centers at (402) 731-3045 (South Omaha ofifice) or (402) 991-9583 (North Omaha 

ofifice). 

Property Access Granted By: ^ 

1 Tr y tCPleSe Prin Printt Name Na ) .

Property Owner Signature: 

(Pate) 

PROPERTY INFORMATION 

pleted by resident and/or property owner - pleate print) 

RESiDENT NAME: fcff[fi'a/\ Renter 

RESIDENT ADDRESS:. /rv^ /^. 17 ^

IF RENTAL, PROPERTY OWNED BY: 

OWNER' St^ ^ S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER-HOME: J L .WORK: J L 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: C ^ NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: / 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 


COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 


AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS; Tlie activities t» be implemented by EPA under this agreement are pursuant to Section 104 

OfCERCLA, 42 U.S.C. 9604. EPA'srigiitofaccess to Hie property isprovidedforin Section 104(e) ofCERCLA, 42 U.S. C 9605(e), which provides entry 

for "determiningthe needforresponse, or choosing ortaldng any response action under tbis title, or oflierwise enforcingflieprovisicns ofthe title." 

1080 Ward Parinvay, Suite 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

lansas City, MO 64114 Omaha, Nebraslca 68110 San Antonio, TX 78229 

'hone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

ax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
Current Sample PrA^enovation Form 

Effective until April 2010. 

Confimiation of Receipt of Lead Pamphlet 

5/h1 hav i e received a copy of the pamphlet, Ftenovate FUght: Important Lead Hazard 

infonnation for Families, Chiki Care Pn)vkiers and Schools informing me of 

the potential risk of the lead hazard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet befbre the work began. 

Self-CeAiflcation Option (for tenant-occupied dwellings only) — 

If the Ieadoamphlet was delivered but a tenant signature was not obtainable, 

you may check the appropriate box below. 

Q Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, Flenavata FVght: important Lead Hazard Infonnation fbr Families, 

CNId Care Provkiers and Schools, to the rental dwelling unit listed below at the 

date and time Indicated and that the occupant refused to sign the confirmation 

of receipt. I further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

Q Unavaiiable for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Fienovate FVght: important Lead Haard Information fbr 

Families, Child Cam providers and Schools, to the rental dwelling unit listed 

below and ttiat the occupant was unavailable to sign the confirmation of receipt. 

I further certily that I have left a copy of the pamphlet at the unit by sliding it 

under the d( 

' ^ v7^ ^e^tAS­ / ^ -//" d^ 

Printed name of person certifying 

yCJit/l^^'V^^ 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of persorroertifyin 

/ /— ^ l^ f A 

irsorroertifying lead pamphlet delivery 

CMaAay /0£' 

Unit Address 

Note Regarding Mailing Option — As an altemative to delivery in person, you 

may maii the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

at least 7 days befors renovation (Document with a certificate of mailing from the 

post office). 
-j^ paint match *^ " A l 

color: 

Area-, 

explanation: 

CO^or: GT 

Area-. 

Exp-\anation-. 

color: 

Area: 

Explanation: 

color: 

Area ^.f ^ : ^.'Vfe^^^^/ * Explanation: 

^^.H^P 

color: 

Area: 

Explanation. 

page 
•Su 

ACCESS MPORHfinrioNTfKAOKlHQ SHEET 

BMDt S^^o/ 

<JZA€^/1 P , ff^cd^ts^ 

OmCoMHlK Home; ^^-:?i>^ - 031 ^ VferK 

AooBiiOadMto fMctl^ ' n 

MIE I IMB I taessor cotiTMn'DerMi 

W^F-^At f^ I fk^i o^Mtce^ cU- pToiAed^. 

^^^;?a%/c^ ^ ^ 

,"/ / Q J T wpoj^M^ KM^ 1? ^ --ivir) da^^dip^ '-FJLJJ i W 

aiwfev 

u 

aBHBBBBI 
jjougias county Account inlMmatio [^jma n Page 1 of2 

Douglas County, Nebraska Property Record - R0214720002 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of SOth St - VJe w o n Ma p Infonnation is valid as of 2008-9-4 Treasurer's fax Report 

New Feature ->->• * Auto Sales Search 

Owner 

MATTES JR STEPHEN D 

1542 N 17 ST 

OMAHANE 68110-0000 

Property Informatio n 

Key Number: 1472 0002 02 

Account Type: Residential 

Parcel Number: 0214720002 

Parcel Address: 1542 N 17 ST 

OMAHANE 68110-0000 

Legal Description: LANDS SEC-TWN-RGE 15-15-13 N 25.5 E 140 FT TX LT 24 & S 1/2 E 140 FT TX 

LT 25 61X140 

Value Informatio n 

Land Improvement Total 

2008 

2007 

2006 

2005 

2004 

2003 

$3,000.00 

$3,000.00 

$3,000.00 

$3,000.00 

$3,000.00 

$3,000.00 

$23,100.00 

$9,900.00 

$9,900.00 

$6,700.00 

$6,700.00 

$6,700.00 

$26,100.00 

$12,900.00 

$12,900.00 

$9,700.00 

$9,700.00 

$9,700.00 

Land Informatio n 

Acres SF Unita Depth Width Vacant 

0.19 8540.0 1.0 140.0 61.0 No 

Improvemen t Inf ormatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R02... 9/24/2008 
uougias uounty Account Intonnatio r^jmat 

n Page 2 of2 

UK 

Firrtftaw aw.O 34. It. 

)0 RAISED RAr«:H UI 

SsEnitt EEtodc 6 8 

9S3.Q »» tt. 

igj_,,.. . 

CLICK TO ENLARGE IMAGE 

CUCK TO ENLARGE IMAGE 

Square Footage: 840.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

Built As: Raised Ranch Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Hip/Gable Stories: 1.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year YearBuilt 

Physical Age Remodeled Remodeled Built 

1900 0% 1900 108 

Detail Type Detail Description 

Unita 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 952.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Basement Single 1.0 

Porch End Solid Wall 112.0 

Porch Slab Roof Ceil 42.0 

http://douglasne.mapping-online.coin/DouglasCoNe/static/accountinfo.jsp?accountno=R02... 9/24/2008 
Prudent Property Clc|se-Out Form (Lead-Based Paint Stabilization} 

SAID: ^<^ 6 ( 

Property Address: \>S'^|' l /\^» / W S 4 

Owner's Wame: ^Cjrv.>fluL HfV\a^ ' 

Performance Standar^s/close-Out Criteria YES NO 

Was the entire structureis) painted with the exception of the stated, excluded areas? This would 

inciude painting of other associated features including fascia, eaves, siding, ali trim, porches, box 

beams, columns, rails, and fxterior surfeces of garBges. X

2. Was all scraping and other preparattion worl< completed satisfactoriiy? 

Were ail required areas of tqe structure{s) primed as needed and painted with two top coats? 

Wasthe paint products utilised equivalent to a 30 year product/quality? 

Are al! ofthe areas where contaminated materials have been spilled •^ ^ 

thoroughly vacuumed/cleaned? X 

5. Did the contractor collect/vslcuum al! failing and scraped paint chips on the entire property, 

roadways, alleyways, public Recess areas and also remove any other generated debris? 

k 

Is the grass area that surrour^ds the structure(s} In reasonably good condition? 

Are ai! items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. 

properiy removed? 

X 

9. 

Is there any evidence of property damage that was done by the contractor? Any property damage 

needs to be compteted prior \o the EPA Close-Out. 

X 

10. Are there any property items that were temporatiiy re-located by the contractor 

that need to be moved back?! 

X 

il . Ars there any (known) lingeririg issues with the property owner(s) that have been ieft unresolved? 

Other Consideratlons?propert7 Owner p!scussions?Addition8l Work that is Required X 

).. h 

Pruden entatlve \/ir f t Representative \/] ­ -4 ^ ^ ^ ^^^ 

Date//-/^^0 ? ' ^