TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 34563 Date: 01/15/2009 

Address: 4514 N 41 ST 

Stabilization Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of property (DVD) 

Bi Executive Summary 

IZT Signed Access Agreement for subject property 

J Painting Agreement 

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

D Photographs 

0 Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

\3 Property information from Douglas County Assessor's Office 

D 

D 

D 

Signaturo/ Date 

40307790 iliil 

Superfund 
PROPERTY SUMMARY 

Date: 01/15/2009 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: JANUARY+ 

Property Address: 4514 N 41 ST SAID: 34563 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: 

A.2 Issues Resolved: 

A.3 Unique Findings: NONE. 

A.4 Otiier Relevant Information: 

Access Date: 10/08/08 

Work Began: 10/10/08 

Closeout Date: 10/10/08 

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 

TECHNOLOCIES, INC. 
ENVIRONMENTAL & 

CONSTRUCTION TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: ^^ V M QlST ^^^e: jD "1-7)1 

Phone: ^^- ^ mAi/^IJ^02lO ^"^ ^ ^'0^ 3 

Plant & Pennanent Landscaping To Remain In Place 

Item# 

Description and Location 

On Map 

ueA - I' ll 

61)717 - » " 

Ivoidii -" '' 

d/AAA. ^ " " 

Pre-Existing Condition of Structures 

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

Item# Description & Location 

On Map 

i/ue^t-- ^^ 

Property Owner 

llfff^ bjdo^ (im/^if l e 

ll 

ll 

II 

)i 

Prudent Emp^yee 

Sigaa^:^C^ : Signature: 

8080 Ward Parinvay, Suite 405 A 2505 N. 24** Street, Suite 308 4242 Medical Drive, Suite 4250 

Omaha, Nebra6ka 68110 San Antonio, TX 78229 Kansas City. MO 64114 

Phone: (402)504-1004 Phone: (210)822-9588 Phone: (816) 363^703 Fax: (402) S04.iftn'i: Fax: (816) 363-3707 
3Q^'(^3 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. 

Environmental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a number ofproperties 

located in Omaha, Nebraska, including the property located at H'A'lU AJ Ql^it 

The EPA requests your permission to allow Prudent to perfonn LBP Stabilization at this property. By 

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

Stabilization including scraping paint and painting of the 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 plaimed for your property, please contact Prudent's 

Administrative 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 Infonnation Centers at (402) 731-3045 (South Omaha office) or (402) 991-9583 (North Omaha 

Property Access Granted By: 

(Please Print Name) 

Propeity Owner Signature: (o-7ry. (Date) 

PROPERTY INFORMATION 

/-) .^ (To l)e completed by resident and/or proper^ owner — please print) 

RESIOENT NAME : L>^ LA\ ) \\E.A77C( A/Cj /^wneT ^ Renter 

RESIDENT ADDRESS 
 HSiXLXldsXAA. 

IF RENTAL. PROPERTY OWNED BY: seiq 

OWNER'S MAILING ADDRESS; XSHLAAiAbl 

OWNER'S TEL£PH0NE NUMBER-HOME: f \ -^23 ^ ^ 7 \. WORK ^ : J 1 3'\oy32.& xy^/ 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.A: l 

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

AXOi^E 

AUTHORrrY FOR ENVIRONMENTAL RESPONSE ACTIONS; The activities to be in^lementedby EPA under this agreement are pursuant to Section 104 

of CERCLA, 42 U.S.C. 9604. EPA'sright of access toflic property isprovided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e). which provides entry 

for "determining the need for response, or choosing ortaking any response action under this title, or otherwise enfiarcing «ie provisions ofthe titte." 

2505 N. 24* Street, Suite 308 4242 Medical Drive, Suite 4250 '080 Ward Paricway, Suite 405 

Omaha, Nebraska 6B110 San Antonio, TX 78229 '.ansas City, MO 64114 

Phone: (402)504-1004 Phone: (210)822-9568 •tione: (816) 363-3703 

Fax: (402)504-1005 Fax: (210) 579-6577 8x: (816) 363-3707 
wviifc^iiL ociiiipit; j^e-nenovation horm 

Effeciive until April 2010. 

Confinmation of Receipt of Lead Pamphlet 

OJ 1 have received a copy C3f the pamphlet, ftenoi/ate ftig/>t/mportanf Z.eatf Haza^ .: " . 

/ \ Irriormation for Families, Child Care Providers 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 before the work began. 

fxry j Ae^lfo/A lOzA-^Q 

Printed nanp^ of recipiept' / ^ 'Otste 

SignaturS of recipient 7 7 

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

If the lead pamphlet was delivered but a tenant signature was not obtainable, 

you may check the appropriate box below, 

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

pamphlet, flenowate Right: Important Lead Hazard Infonnation for Families, 

Child Care Providers and Schools, to the rental dweiiing unit listed below at the 

date and time indicated and that the occupant refused to sign the confimiation 

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

the occupant. 

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

deliver the pamphlet, Renovate Rght: Important Lead Hazard Information for 

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

below and that the occupant v/as unavailable to sign the confirmation of receipt. 

I furttier certify ttiat I have left a copy of the pamphlet at tfie unit by sliding it 

m r tne aofx. , Ii 

fill CM//A /AHLAXAp^' 

3d name of person catifyjng Attempted delivery date and time 

lead pamphlet delivery 

Signature of persotusertifying lead pamphlet delivery 

-T^/V A jA ' 

UnitAddress 

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

may mail the lead pamphlet to the ovmer and/or tenant. Pamphlet must be mailed 

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

post office). 
,..^.no.^i>m^foctxyysy,^i^ {7, 

paint match form ' 4 ^ 

paint matching form: ^ <AM A /T'T^&fiPl^i 

property address: ^^/^ //. V/^^ D^''"^ ^^"^^^ » 

BVID: 5*/^<^^ 

Area: 


Explanation: 


Area: 


Explanati on: 


Area: 


Explanati on: 


Area: 


Explanation: 


X (rXJy^' 

color 

color: 

color: 

color: 

page 1 
•jSaSa 

ACCESS MFOi^HATioiiTtiACmiG SHEET 

looaMBi 

pfiopcerV 

«a 3^^n 7S^ ^ Vr/V /V- ^/ <r 

AAA> .1^/,/^/W 

OmrOoiMlte Home: ^T? - f P^ ^ Wht Jf^ - A?.? ? ^ "/^ l 

31k ^ 

MBMOOMK 'I7(>1/JT 

7lK7t7hj4' SAm 

^ 

CcUTKTDEmL 

W-^\1'M 71 X^i^Ad k V/^/^f-^ 

^MXnAj /Jc7 /Sjl } 7^6 AJ4J6S-

BBH 
j-/uugia i ^uum y /T.ucuuil^UlIUIiIiailUIl Fage 1 ot 2 

Douglas County, Nebraska Property Reci 3rd - R2329830000 

1 Print Report re - Parcel Dimensions available @ scale 0-50 ft \ vest of 90th St - View On Map Information is valid as of 2008-9-4 1 '*^^ ''^^*" Treasurer's Tax Report 

New Feature -* -* -> Auto SaLes Search 

Owner 

JENKINS BRIAN D 

4514 N 41 ST 

OMAHA NE 68111-000 

. •^ r 

Property Inform at 

Key Number: 

Account Type: 

Parcel Number: 

Parcel Address: 

Legal Description: 

Value

2008 

2007 

2006

2005

2004 

2003 

Sales

 Information 

i Land 

i 

j 

 Information 

Sales Date: 

Deed Type: 

Price: 

Grantor: 

Grantee: 

Valid/Invalid: 

Exclusion Reason: 

Land Information 

Acres SF 

0.12 

ion 

2983 OOOO 23 

Residential 

2329830000 

4514 N 41 ST 

OMAHA NE 68111-0000 

TUTTLES SUB DIV LOT 9 BLOCK 0 N 42 S 194 W 133,5 E 163.5 FT-42X133.5 

; Impro 

$4,500.00 

$4,500.00 1 

$4,500.00 i 

$4,500.00 1 

$4,500.00 

$4,500.00 

2006-03-14 

WD 

$50,000,00 

: Sally M Burkhiser, TR 

: Brian Jenkins 

1 Vaiid 

1 Units 

5586.0 1.0 

vement

$31,500.00

$31,500.00

$31,500,00

$14,900.00

$13,500.00 

$13,500.00 

i 

 Total 

 $36,000.00 

 $36,000.00 

 $36,000.00 

$19,400.00 

$18,000.00 

$18,000.00 

Book: 2006 Page: 029875 

j Deptfi Width Vacant 

133.0 1 42.0 No 

Improvement Informatio n 

http://douglasne.mapping-online.coiii/DouglasCoNe/static/accountinfo.jsp?accountno=R23. 9/24/200R 
Page 2 of2 

Building 1 

S54 i•.^ ft, ;; 

I l.'l-FiM 

HIMIl.-li«.J.I.I.g.l.ilM»..M.|.lli!i.'J?a:?3:!?rT; ' " ' l 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Percent Complete: 100.0% 

Quality; ; Fair 

Condition: Average 

Condo Square Footage: 0.0 

Rooms: 6,0 

Units: 1.0 

Baths: 1.0 

Bedrooms: 3,0 

Stories: 1.5 

Foundation: Block 

Sprinkler Square Footage: 0.0 

Adjusted Year Physical Age Built r....: 

1924 84 

Units 

^ 1.0 

832.0 

1.0 

1.0 

1,0 

240.0 

128.0 

Square Footage: 

Perimeter 

Unit Type: 

Built As: 

„HVAC: 

Exterior: 

Interior: 

Roof Cover: 

Roof Type: 

Floorcover:

Year Built 

1924 

Detail Type 

Appliance 

Basement 

Basement 

Fixture 

Fixture 

Garage 

Porch 

1272.0 

0.0 

1 1/2 Story Fin 

Forced Air 

Frame Siding 

Drywall 

Composition Siiingle 

Gable 

 Allowance 

Year Percent 

Remodeled Remodeled i

0 0% 

Detail Description 

Allowance 

Bsmnt Block 8 ft 

Outside Entrance 

Base Fixtures 

Batii Full 

Detached 

End Solid Wall 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.isp?accountno=R23,,, 9/24/2008 
Prudent Propertv diss-Out ?o?m {Lsad-Bsssd Pairst StsfeMisatlonl 

leJD: 

Dv.-sr=3 Name: Bf^^Ai} D-.TeriMKTS 

Fsrformance Standarps/doss-Out Criteria 

;YES INO 

1. Was the entire structure(s^lps!nted wrt!^, the exception of the statad, exciudsd sraas? Tnis would s 

Include painting cf other associated features including fascie, eaves, siding, all tri?n, porches, box ^y beams, coiun^ns, rails, and ^epior surfaces of gareges. 

2. Was all, scraping and other greparattion work compieted satisfactorily? TTT 

3. Ware ail required areas of tqe structure(s) primed as needed and pai.nted with two top coats? y r 

j4. Was the paint products utiiiqed squh/aient to a 30 year product/quality? y r 

is. Are ail ofthe areas where cdntaminated matsriais have bean spliisd 

thoroughly vacuunf^ed/ dearilpd? \y\ 

|£. Did the contractor coliect/vsicuum aii fa'iing and scraped paint chips en ths entire property, 

! roadways, aiieyways, public apcess areas and also remove any other generated debris? A 

tl . 

is the grass area that surrourifis the stpjctureis) in reasonably good condition yi 

is. Are ail items such as polyethy|ene sheeting, ladders, paint brushes, cones, barrier taps etc. 

•, properly removed? ;1 \y 

iS. is there any evidence of property damage that was dons by ths contractor? ,Any proper^/ damage 

needs to be compieted pric- t|p the SPA Close-Out 

K 

ilC. .Are there any property items tt'.at were te.mporatily .re-iocated by ths contractor 

\ that need to be moved bacic?; 1 \x .• I . 111.

 Are there any (known) 'ingerina issues svith the property owner(s) that have bssn ieft unresolved? 

;/ Othe? Consideratigp.s?property'|Owner Di5Cussions?.&ddition8i Woric that is Recui.'ed 

llbi'-l JA^AJLMA.^ CICAULA '^J-s'tW^sk. X. Jl /y i 

Fruc4nt Rep/esentatlve 

"7^ 

Dats 

X