TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 34510 Date: 12/26/2008 s 

Address: 4504 N 21 AV E 

Stabilization Contractor: Prudent Technologies Year: 2008 

PAIN T STABILIZATIO N 

PROPERT Y FIL E FOLDE R DOCUMENT S 

B' Video of property (DVD) 

[?r Executive Summary 

Signed Access Agreement for subject property 

0 Painting Agreement 

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

D Photographs 

Hr Satisfactory restoration signed by Property Owne r 

D Property close-out check list signed by EPA 

IZ Property information from Douglas Cotmty Assessor's OfSce 

D 

D 

D 

•^te 

40310455 

ilHNIMIil 

Superfund 
PROPERTY SUMMARY 

Date: 12/29/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Propertv Address: 4504 N 21 AVE SAID: 34510 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE. 

A.2 Issues Resolved: NONE. 

A.3 Unique Findings: NONE. 

A.4 Otlier Relevant Information: 

Access Date: 10/30/08 

Work Began: 11/03/08 

Closeout Date: 11/07/08 

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 Infonnation Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOLOGIES, INC. 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: ^^'^^ /0-^v:>^^, ^ Date: ^ o/-Jf 

Phone: BVID: 3^S'i ^ 

Plant & Pennanent T.ar>dacapinp, Tn Ramain In Place 

ItSQi# 

Description and Location 

OnM^ 

yVJcn-e. 

Pre-Existing Condition of Structures 

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

Item# Description & Location 

OnM^ 

 C^ AJ^ -yy^

Property Owner Prudent Employee 

Signature: C?4^' \ l^r^^i •.*^^ ^ Signature:y5C/^--^ci—'C^ 

L 

-

X 

»n6 N. 24* Streot, Suite S08 4M2 Medical Drtve, SuMa 4280 8080 Wkid Parkway, Suite 406 

Omaha, Nebraeka 68110 San Antonio, TX 78329 Kansas CHy. MO 64114 lt<n SAJ.4AAJ 
O

^V570 

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

Environmental Protectian Agency (EPA) to stabilize Lead Based PaintjLBP) at a number erfproperties 

located in Omaha, Nebraska, including tiie property located at l4Sf)t-J /[ / ^ ^ nvC * 

The EPA requests your permission 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 scmping paint and painting of the referenced property. Further, the owner/tenait 

verifies Aat &ey have received tiie LBP pamphlet "Renovate Right." 

If youihave any questions abom tiie LBP stabilization plamied for your property, please contact Pruderf s 

^t^miiiistrfltive Clerk for the Lead Based Paint Stabilization, Mra, Deborah Akereie-Johnson, 

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

Publicjlnfonnation Centers at (402) 731-3045 (Soutii Omaha office) or (402) 991-9583 (North Omaha. 

ofScej.. 

(Please Print Name) 

Property Owner SigBituw: -'€^ii'i;^^j( Jjf^Hr^'S^^C^' iZ-7^Z-o 8 

! / (Sigiyrfiue) (Date) 

PROPERTY INFORMATION 

I (To be conpleted bjr reiident ud/o r propert]' owner - please print) 

RESnefTNAME: ^f'^ ^ '^o^^o ^ W Owner 

//^"^^ AJ , P/^ ^ y-^iZ: RESIDENT AD0RE88: 

W RENTAL. PROPBITY OWNED BY: .^^A-frvNtp fi<^r.j^'V(-t 

OWNERfSMAUNOAOORESS; /"^^^ AJ - 5^Al ^ Cr<>g^WOWNERTS TELEPHONE NUMBER • HOME: ( > WORK: J L 

: ^ NUMBE NUMBERROOPOCCUPANT OCCUPANTS 7YEAR YEAR8 0LP AMP OLDER; J 


j 


NUMB» OF OCCUPANTS UNDER 7 YEARS OLD: '=' F S 7 S OLD AND OLDER 

i 
 i 


NUMBBR OPCHILDREN UNDER 7YEARS OLDW HO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: ^ 


j 

OOHMENTSORSPECIALINSTRUCnONS: (LE. DOQS. ENTRY QATES, ETC.) 

AUTHORrrY FOR ENVIRONMBNTAL RBSPONSB ACTIONS; Hie icttvkiei to be impletneiited by EPA under Ms agieement veponaam to SectfHi 104 

efCERCLA,« U&C 9604. EPA'I right of locess lo lhe property isprovided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e). whidi provides eit v 

fbr ""detepdningthe need Ibr response, or chooeing ortaUng any lesponie action under this title, or olherwiie c 
Current Sampl© W©-Ren©vation Form 

Effective until April 2010. 

Confinnation of Receipt of Lead Pamphlet 

^ i haws received a copy of the pamphlet. Ftenovate Pi^ : Important Lead Hazard 

Intommlton far ftrnffies; CNld Care Provklers and Schools infofming me of 

the potantiat risk of the lead hazard e^q^osure firom renovation activity to be 

perfomied In my dwelling unit. I received this pamphlet before the worl< began. 

Printed rame of redpient,>4^ ' Date 

SignatMreof recipient 

Self-CertlflcatiQn Option (Ibr tenant-occupied dwellings only) — 

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

you may check the appropriate box beiow. 

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

pamphlet, /tenovate fljgM; Important Lead Hazard Infonnation tor FamSes, 

Ch%f Care f^oviders and Sc/KX7te, to the rental dweinng unit Ssted b ^ 

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

of receqst. i further certify that i have left a copy of the pamphlet at the unit with 

tiie occupant. 

Q lAiavailabIa fbr signature — I certify that I have made a good faith effort to 

defiver the pamphlet, Aisnovate R^ t Important Laad Hazani Intonnation tor 

FamSea, ChUd Cam provkierB and Schools, to the rental dwelling unit listed 

below and that the occupant was unavailable to sign the confimnation of receipt. 

I further certify that I have left a copy of the pampMet at the unit by sliding it 

underthedoor. 

f-ye'^f^ M ^^IIAVOL-J A 

Printed name of person certifying At^mpted deiivery 

date and time 

Signature of person certifying lead pamphlet delivery 

^^0 4 yu. ^1"" ^ 5 / 

rv^^-^X^. AJ s^ 

UnitAddress 

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

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

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

postoffice). 
paint match form: 

Paint matching form: ^ . ~ 

Property address: H^O4 ^ ^^.^^-yi^^ 

BVID: 54SV0 

^W^^ - ^--^^' ^ .•5.< 

Area: color: ^ .^J, 

Explanation: 

Area: color: 

Explanation: 

Area: Color: 

Explanation: 

Area: color: 

Explanation: 

Area: * color: 

Page 1 
ACCESS INFORMATION TRACKING SHEET 

PROPERTY ,,^,, w ^ U^ . 

BVID: 3^^/ ^ ADDRESS: "^'^'> ^ AJ - ^'^^X^c T 

Property Owned By: /4-i^\c> >/>- c a V '" '^ /o <rj VI < 

fir na u nmmriv nummri - ^ (If new property tmrm) 

iHd-:\ K). sjic^ u Ccee^U ­

(C^^^veJ--«, M«2i C'tsfs-a. 

Owners Phone No's: 

Home:-r5'5 6 5 H H Work: 

Cell: Fax: 

Access Contractor: ASW FDA MES PE U . , W Other. rfUdJA J 

fCfrcteO/w; 

DATE TIME Accessor CONTACT DETAIL 

/-^ ^ Gdi­ (S--<!-.^-^<t==^ Xcee:^-^ /ij ^ j^/o^Y^c ^ 

'U f&oa 6 « CH^i^ei. ^^ V ^.x.^-^ ^ 

Ck^mments: 

Pl^ise write legitOyl 
nctp://aougJasnejnapping-online.com/DougiasCoNe/static/accountinfo. 

Douglas County, Nebrasica Property Record ~ R0202090000 

Print Report i 

NEW Feature - Parcel Dimensions available @ sea e 0-50 ft west of 90th St - Vle W OH IVIap | Infonnation is valid as of 2008-11-5 Treasurer's Tax Report : 

New Feature -*-+- > Auto Sales Search • 

Owner 

PIGNOTTI SR ANTONIO G 

ETAL TR 

1421 N SADDLE CREEK RD 

OMAHA NE 68132-0000 

Property Informatio n 

Key Number: 0209 0000 02 

Account Type: Residential 

Parcel Number. 0202090000 

Parcel Address: 4504 N 21 AV 

OMAHA NE 68110-0000 

Legal Description: LANDS SEC-TWN-RGE 03-15-13 S 42.42 W 107 FT SUB LT 1 TAX LT 18 - 42.42 

X107 

Value Informatio n 

Land Improvement Total 

2008 $2,300.00 $34,200.00 $36,500.00 

2007 $2,300.00 $34,200.00 $36,500.00 

2006 $2,300.00 $34,200.00 $36,500.00 

2005 $2,300.00 $16,500.00 $18,800.00 

2004 $2,300.00 $15,000.00 $17,300.00 

2003 $2,300.00 $15,000.00 $17,300.00 

Sales Informatio n 

Sales Data: 2006-03-08 

Deecf Type: QC Book: 2006 Page: 07164«_2 J 

Price: $0.00 

Grantor: Pignotti Antonio G Sr 

Grantee: Pignotti Antonio G Sr etal 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Land Informatio n 

Acres SF Units Depth Widtii Vacant 1 

0.1 ^ 4494.0 1.0 107.0 42.0 No 

1 Improvemen t Informatio n 

1 Building 1 

l o f 3 12/23/2008 1:19 PM 
nnp://aouglasne.mapping-online.coni/DouglasCoNe/static/accountinfo... 

CLICK CLICK TO ENLARGE IMAGE TO ENLARGE IMAGE 

2 of: 12/23/2008 1:19 PM 
,iaav..oiNe/static/accountinfo.. 

Square Footage: 1028.0 

Perimeter 0.0 

Unit Type: 

Built As: 1 1/2 Story Unfin 

HVAC: Central Air to Air 

Exterior: Frame Siding 

Interior: Drywall 

Roof Cover: Composition Shingle 

Roof Type: Gable 

Floorcover: Allowance 

YearBuilt Year 

Remodeled .._^__ 

Percent 

Remodeled 

1925 0% 

Detail Type Detail Description 

Add On Fence Chain Link 

Appliance Allowance 

Basement Bsmnt Block 8 ft 

Fixture Base Fixtures 

Fixture Bath Full 

Garage Detached 

Porch End Screen 

! User Attic Full Finish 

Percent Complete: '•• 100.0% 

Quality: ' Low 

Condition: ] Fair 

Condo Square Footage: ; 0.0 

Rooms: 5.0 

Units: 1.0 

_ Baths: ; 1.0 

Bedrooms: ; 2.0 

Stories: 1.5 

Foundation: , Block 

Sprinkler Square Footage: i 0.0 

Adjusted Year Physical Age Built 

1925 ; 81 

Unita 

1.0 

1.0 

728.0 

_1.0_ 

I.o' 

224.0 

133.0 ; 

280.0 . 

12/23/2008 1:19 PM 

of: 
Prudent Property Close-Out Form (Lead-Based Paint Stabiiization) 

SAID: 3^-^/Z > 

Property Address: HSO" ^ A?- ^1'' ^ A^ ^ 

Ownerfs Name: -Ar-^^g>>%. t o r* \ c M ^ "<^ '^ 

Performance Standards/close-Out Criteria 

YES NO 

1. Was the entire structure{s) painted with the exception of the stated, excluded areas? This would 

include painting of other associated features including fascia, eaves, siding, all trim, porches, box 

bea'ms, columns, rails, and exterior surfaces of garages^ ^ 

2. Was all scraping and other preparattion work completed satisfactorily? < 

3. Were all required areas of the structure(s) primed as needed and painted with two top coats? xr 

4. WaS;the paint products utilized equivalent to a 30 year product/quality? •<r 

5. Are jail of the areas where contaminated materials' have been spilled 

thonoughly vacuumed/ cleaned? < ' 

6. Did the contractor collect/vacuum all falling and scraped paint chips on the entire property, 

roadways, alleyways, public access areas and also reniove any other generated debris? ^ 

7. Is thje grass area that surrounds the structure(s) in reasonably good condition? < 

8. Are all items such as polyethylene sheeting, ladders, paint brushes,'cones, barrier tape etc. 

prop|erly removed? r < 

9.

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

needs to be completed prior to the EPA Close-Out. 

y 

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

thatlneed to be moved back? X

11. Are there any (known) lingering issues with the property owner(s) that have been left unresoived? 

/C Other Considerations?property Owner Discussion5?AddltiQnal Work that is Required 

Prudeht Representative Signature-.^y^c.^.^ 

Date !' V^'-A'tr .

 .A/&S^/^ /^ ^ Properjty Owner Signature 

Date: i/z-Z2-<^S^