TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 35093 Date: 12/26/2008 

Address: 4728 N. 38 ST. 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

gf Video of property (DVD) 

H ' Executive Summary 

[3 Signed Access Agreement for subject property 

^ 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 

0^ Property information from Douglas County Assessor's Ofifice 

D 

D 

D 

Signature i T)ate 

40309824 

•1 1 

Superfund 
PROPERTY SUMMARY 

Date: 12/23/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Propertv Address: 4728 N. 38 ST. SAID: 35093 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE. 

A.2 Issues Resolved: NONE. 

A.3 Unique Findings: None 

A.4 Other Relevant Infomiation: None 

Access Date: 10/16/08 

Work Began: 11/04/08 

Closeout Date: 11/05/08 

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 

TECHNOIOCIES, INC. 
ENVIRONMENTAL A 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

i Address: q7^ & M - 3 8 5t . ^^'' ^^MA^ 

Phone:. i^D S^S'I/^^"^^' ^ ®^- 3509 3 

Plant & Permanent Landscaping To Remain In Place 

Iteai# 

Desoiption and Location 

On Map 

J<U^ei^ 

- /^f/J ^ (ys m'jc h CISyrpoaan M<^^" ^^^"^^ "^ ^'^ 

Item# 

OnM^ 

Pre-Eyisting ([Condition of Structures 

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

v/' 

Description & Location , . ,y 

, s,^/r.. J^^fe', /^^^^ ^^^^' ^'^'^' ^"^'^^' r^^e-^y 

'>arct 

^ 

UJmok>uJ JcL^ci^ci ^uo^s^y 

Property Owne LTwncr Prudent Empl r 

Signature Signature: lOM ^ ' 

v m Wud ParkiiMyi Si't* 405 250S N. 24* StTMl. Suits 308 4242 NMIcal Drive. Sulta 4260 w—i — MU-. U A •J4 4 J Omaha. NabrMka 68110 San Antonio, TX 78229 
^ ^5o?3 

Pruddit 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 of properties 

locate^ in Omaha, Nebraska, includingtiie property located at ^^7^^ ^ A> 3 ^ ^Ir -

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

signii%tills form,tiie property owner grants permission to Prudent to perform activities related to LBP 

Stabilization including scraping paint and painting of the referenced property. Furtiier, the owner/tenant 

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

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

ive Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (40ji) 504-1004. General questions about the Omaha Lead Site cleanup can be directed to the EPA 

Publi<f Infomiation Centers at (402) 731-3045 (Soutii Omaha office) or (402) 991-9583 (North Omaha 

office). r\ j 

PiopeilyiAeoeis Otanted By: / - ^ (L\ \ ^^^^jj^^'^y ^ 

Piopeit]^ Owner Signature: 

PROPERTY INFORMATION 

(Fo be eoniplctcd by midcat and/or property onmer - pleaic print) 

J_ RESIDENT NAME: *'- Ovmer Renter 

RE8l0^AO0RE88:. 

IF RENTAL. PROPERTY OWNED BY: . ,Cw ^rif> FiySoJA 

OWNEivSMAIUNGADORESS; f O Bo / ^^O^il , D/jJ^fl^., >t> ^ C?^/^^ J 

OWNER'S TELEPHONE NUMBER -iolj^£ii^i HOME: {i^r^\^^ o r ^^ ' WORK: J L 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER:. i 

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

COMMENTS OR SPECIAL INSTRUCTIONS: (LE DOOS, ENTRY GATES, ETC.) / 

AUTHORTTY FOR ENVIRONMENTAL RESPONSE ACTIONSi The aetivkiei to be hnplemented by BPA under tUf igreeiMnt an punuant to Section 104 

of CERCLA. 42 U.S.C. 9604. EPA'I right of acccu to (he property if providedfor in Section 104(e) of CERCLA. 42 US. C 9605(e), which providei ertiy 

Ibr "degermlningthe need fbr response, or dioosins ortaking any response action under Ihis titie. or otherwise enfbrcing (he provisicns ofthe title." 

1080 Ward Partway. Suite 405 2S05 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4200 

lantaa CHy, MO 64114 Omaha. Nebraska 68110 San Antonio, TX 78229 
Curreht Sample Pre-Renovatio rCTRi n Forni 

Effective until April 2010. I 

j 

Copllmiatioin of Receipt of Lead Pamphlet 

I have rBpeived a copy of the pamphlet, ftenovate Right: Important Lead Hazard 

Information for Families, Child Care Providers and Schools infonning me of 

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

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

Signature of recipient 

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

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

you may cneck the appropriate box bekm. 

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

pamphlet, Fienovate Right: Important Lead Hazard Information for FamSes, 

Child Care Pmviders 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 tBcelpit. 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, Fienovate Right: Important Lead Hazard Information for 

FamlSes', ChUd Care pmviders and Schools, to the rental dwelling unit listed 

below aiyj that the occupant was unavailable to sign the confirmation of receipt. 

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

under the 

f&'^r^ S^i^^n^ /^/r(^oj' 

Printed naiine of person certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person i»rtifying lead pamphlet delivery 

Oucf^lf^.^. (IJ/^ f- Unit Address 

I 

Note ReQEUdIng Mailing Option — As an aitemative to del/very in person, you 

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

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

post offic^). 
ACCESS IMFO/^M/^-ioNTRACKniQSHEET 

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Douglas County Account In4|h; ation Page 1 of2 

Douglas County, Nebraska Property Record - R1602910000 

1 Print Report 

NEW FMture - Pancal Oimen«ion< availaUa A scale O^O ft wait of 90th St - Vie w On IMap Information is valid as of 2008-9-4 Treasurer's Tax Report 

New Feature ••••- • Auto Sales Search 

Owner 

PUSCH JAN ERIC 

P 0 BOX 540432 

OMAHAN E 68154-0000 

Property Informatio n 

Key Number: 0291 0000 16 

; Account Type: Residential 

; Parcel Number: 1602910000 

i Parcel Address: 4728 N 38 ST i OMAHANE 68111-0000 

Legal Description: LAKE VIEW ADD LOT 6 BLOCK 1 N 3 FT LT 7 & ALL 53 X 127 

1 • 

Vaiiie Informatio n 

1 Land Improvement Total 

2008 $3,200.00 $46,500.00 $49,700.00 

2007 $3,200.00 $46,500.00 $49,700.00 

2006 $3,200.00 $46,500.00 $49,700.00 

2005 $3,200.00 $18,100.00 $21,300.00 

2004 $3,200.00 $16,400.00 $19,600.00 

2003 $3,200.00 $16,400.00 $19,600.00 1 

L^nd Informatio n 

Acres SF Unita Depth Widtii Vacant 

; 0.15 6731.0 1.0 127.0 53.0 No 

Imi^rovement Informatio n 

Builjding 1 

i 
1

Douglas County Account InfiKmation Page2ol2 £atms 

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 CLICK TO ENl^RGE IMAGE

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1 1

Square Footage: 

Perimeter 

Unit Type: 

Built As: 

HVAC: 

Exterior: 

interior: 

Roof Cover: 

Roof Type: 

Floorcover: 

1 

YearBuilt 

! 

; 1900 

Detail Type 

Appliance 

Basement 

Fixture 

Fixture 

Gardige 

Porch 

Porch 

1661.0 

0.0 

1 1/2 Story Fin 

Central Air to Air 

Frame Aluminum 

Drywall 

Composition Shingle 

Gable 

Allowance 

year Percent 

Remodeled Remodeled 

0 0% 

Detail Description 

Allowance 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

Detached 

End Screen 

End Screen 

•-.•••- I • • t-.i- :.,{ ' " • 

1/2 STORY 

•iimnltiKit** 

lOM.iiq.*. 

 C.y.CKTQJ.HLA.R6EJMAgE

Percent Compiete: 

Quality: 

Condition: 

Condo Square Footage: 

Rooms: 

Units: 

Baths: 

Bedrooms: 

Stories: 

Foundation: 

Sprinkler Square Footage: 

Adjusted Year 

] 

100.0% 

Average 

Fair 

0.0 

6.0 

1.0 

1.0 

3.0 

1.5 

Block 

0.0 

Physical Age Built 

1900 106 

Unita 

1.0 

1048.0 

1.0 

1.0 

252.0 

96.0 

66.0 

httD://douelasne.mat)DinB-online.com/DouslasCoNe/static/accountinfo.isD?accountno=R16... 9/24/2008 
paint match .farm; Paint matching form: — 

property address: */7;z^ N^ p^Sf^ 

BVID: ;?^^75 

Area: ^^^-/ ^ ^^^^^^

Explanation: 

Area: color: 

Exi)l anati on: 

Ar0a: Color: 

Explanation: 

Area: color: 

Explanation: 

i 

Area: color: 

Explanation: 

\ 

, page 1 

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^"^ ' 
Priidsnt Propertv' Oose-Out fQ?m {i^ad-Based Palsiit Stsbiiliatlors.i 

Ovifnsr's j>aame: J^^'/ ^ €^^t^*^fi^ b (^JcUc fuJ-C U ) 

i 

YSS iNC ­

ji . Wss the entire striicture{s) painted w'itri the exception of ths stated, sxduded areas? This would 

induce psi.nti.ng of other ssscdated fsstures indudlng fascia, eaves, siding, a!i trim, porches, box 

( bs3ins, eoiurr!r.s, rails, and exterior suHaces of gsrsges. 

|2. Was Si! scraping and other pjreparattion work completed satssfactoriiy? w 

|3. vVere all required areas ofthe stnicturets) primed as needed and painted with two top costs? Vl 

I j ­ vT s4.

 Was the paint products utiiiaed equivatent to a 30 year product/oijaiity? 

15. Are all of the areas where co ntaminsted materials have been soiiied y^\ j

 thoroLghhy vacuumed/ deaned 

j5. Did the contractor coliect/vactjum alt falsing and scraped paint chips en the entire oroserty, i \ 

I roadways, aiieyways, public access areas and also remove any other generated debns? 

7. isthe grass area that surrounds t.he stpjcture(s) in reasor^ably good condition? 

S. Are ail items such as poiyethylene sheeting, iadders, paint brushes, cor.es, barrier tape etc. 

V-f 

properiy removed? j ^ 

3. Is there any evidence of property damage that was done by the contrsctor? .Any property damage 

needs to be completed prior to the EPA. C'osa-Out. \ ' ^ 

10. Are there any property Items fhat were terrsporatily rs-ioc=ted by ths co.'ttrsctcr 

that need to be moved bacJc?; 

11. .Aj"e there any (known) lingerinig Issues with ths property ownerisj that have tse-n ;gf; un.fesoived? {^y­ i

 Other ConsidersticnsPproperty OAT.er OiscussionsT.gjdditloriai Woric that is Required 

\ i / CUr-dy^ ^.^d¥^s/tiy<l r^£. Prucf@!it Representative 

Date IdLJnjO^ m/mf /