### TRANSMITTA L o f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAI D # : 4Z.4D 0 Date : S-2n-lC ) Address : HIH S >A . Z^ ^ cS^ h Stabiiizatio n Contractor : Professiona l Environmenta l Engineer s Year : 2010 _ PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S y ^ Video o f propert y (DVD ) * ^ Executiv e Sunmiar y J ^ Signe dAcces s Agreemen t fo r

subject propert y D Pre-Renovation For msigne dby Propert y Owne r D Pre-Renovation For mfo r

Occupant/Tenant , i f applicabl e " ^ Paintin g Agreemen t 0 Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc. ) G ( Renovatio n Recordkeepin g Checklis t signe db y Certifie dRenovato r y£ . Photograph s ^ Satisfactor y close-ou t chec k lis t signe db y Propert y Owne r ^ Propert y close-ou t chec k lis t signe db y EP A ^ Propert y informatio n finomDougla s Cotmt y Assessor' s OfBc e D Hazar danalysis , i f prepare d 

# ° *^^"*' D Othe r (describe) :



# 4M 

# "^^yuJ L^ Professioiia l Envtr^nmenta l Engineer s Signatur e InvlF^Amenta l Engineer s Signatur e 

# innilii i ''"•""pSSn d 

# CAM S ^ Dot e EP A CO RSignatur e Date " (afte r file folae r review )

### 201 0 

# PROFESSIONAL ' 250 5 Nort h 24 ^ Suit e 21 9 

# ENVIRONMENTA L ENGINEERS , INC . Omaha . N E 6811 0 (402 ) 504-468 8 

### "Providin g cost-effectiv e environmenta l solutions " Fax(402 ) 504-328 1 Consultin g • Engineerin g Desig n • Remediatio n • Abatemen t • Emergenc yRespons e 

### EP A Close-Ou t For m (Lead-Base dPain t Stabilizatio n EPA Contrac t EP-R7-08-06 ) SAID : 

# V J ^lO O Property Address : 

## 70> i Owner' s Name : Performanc e Standards/Close-Ou t Criteri a YE S 

### NO 1 . Wa s th e entir e structure(s ) painte dwit h th e exceptio n ofth e stated , exclude dareas ? Thi s woul dinclud e paintin g o f othe r associate dfeature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an dexterio r surface s o f garages . 2 . Wa s al l scrapin g an dothe r preparatio n wor k

complete dsatisfactorily ? 3 . Were al l requiredarea s ofth e structure(s ) prime da s neede dan dpainte dwith tw o to p coats ? 4 . Wa s th e pain t product s utilize dequivalen t t o a2 5 year product/quality ? 5 . Ar e al l ofth e area s wher e contaminate dmaterial s hav e bee n spille dthoroughl y vacuumed/ cleaned ? 6 . Di dth e contractor collect/vacuu mal l fallin g an dscrape dpain t chip s o n th e entir e property , roadways , alleyways , publi c acces s area s an dals o remove an y othe r generate ddebris ? 7 . I s th e grass are athat surround s th e structure(s ) in reasonably goo dcondition ? 8 . Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r tape , etc . properl y removed? 9 . I s ther e an y evidenc e ofpropert y damag e that was don e by th e contractor ? An y propert y y damag e need s t o b e complete dprio r t o th e EPA Close-Out . 10 . Ha s th e property owne r signe dth e completio n form ? 11 . Ar e ther e an y property item s that wer e temporaril y re-locatedb y th e contractor that nee dt o b e move dback ? 12 . Ar e ther e an y (known ) lingerin g issue s with th e property owner(s ) that hav e bee n lef t imresolved ? Othe r Considerations/Property Owne r Discussions/Additiona l Wor k

that i s Required : 

### (Vt/z o - HOUSL , 

### At J ejAt&Y ' ' loo**
- &f ^ li^* 5 ^i* k i aiMiu| ' aY<A^


## ^^fL^jUAUiJ^j:^^ . 

# 4 ^ 10 _ CO RSignatur e Date

# PROFESSIONA L 250 5 Nort h 24 ^ Suit e 21 9 

# ENVIRONMENTA L ENGINEERS , INC . Omaha , NE 6811 0 (402 ) 504-468 8 

### "Providin g cost-effectiv e environmenta l solutions " Fa x(402 ) 504-328 1 Consultin g * Engineerin g Desig n • Remediatio n • Abatemen t • EiTi6igeni.: vRespons e 

### ZD\ 0 

## Property Owne r Close-Ou t Form (Lead-BasedPain t Stabilizatio n EP A Contract EP-R7-08-06 ) SAID : 

# W6 6 Propert y Address : 

# 770- ? (^ . Z(^^ . Owner' s Name : 

# M\ i ^ 

# ^m( j Performanc e Standards/Close-Ou t Criteri a YE S NO 1. Was the entir e structure(s ) paintedwit h the exceptio n ofth e stated , exclude d areas ? Thi s wouldinclude paintin g of othe r

associate dfeature s including fascia , 

# y eaves , siding , all trim , porches , box beams , columns , rails , an dexterior surface s of garages . 

# y­ 2. Was all scraping andothe r

preparatio n wor k

completedsatisfactorily ? 3. Wer e all require darea s ofth e structure(s ) primed as neede dan dpaintedwit h 

# -y tw o top coats ? 4. Was the pain t product s utilize dequivalen t to a 30 yea r

product/quality ? 5. Ar e all ofth e area s wher e contaminatedmaterial s have bee n spilledthoroughly vacuimied / cleaned ? 

# y 6. Didthe contractor collect/vacuumal l falling an dscrapedpain t chip son the entir e property , roadways , alleyways , publi c acces s area s an dals o remove an y 

# y othe r

generateddebris ? y - Is th e gras s are atha t surround s the structure(s ) in reasonably goodcondition ? 8. Ar e all item s suc h

as polyethylene sheeting , ladders , pain t brushes , cones , 

# yy barrie r

tape , etc . properl y removed ? 9. Isthereanyevidenceofpropertydamagetha t wa s done by the contractor ? An y 

## y ^ propert y damag e need s to be completedprior to th e EP A Close-Out . 10 . Ar e ther e an y propert y item s tha t wer e temporarily re-located by the contractor tha t need tobe movedback ? _^ ^ 11 . Ar e there an y (known) lingering issue s wit h th e propert y owner(s ) tha t hav e bee n lef t unresolved ? ^_ ^ Comments : 

## //t-UuiJL . jMt S f^Pcc t I I 

# S'lq-z n jrt v Signature d Dat e Propert y Owne Owne r r

Signatur e O ^ -^-yp-yy ^ Professioiia l l Exivirdfunenta l Engineer s Representativ e ssion uivi i Dat e

## PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC . ''°'TrSa'tNE68?! o "Providin g cost-effectiv e environmenta l solutions " ^^ ^

jjjg j 504-328 1 Consultin g • Engineerin g Desig n • Remediatio n • Abatemen t • Emergenc yRespons e



### Lea dBas e Stabilizatio n Omaha , N e Clos e Ou t Repor t 201 0 SAID#4240 0 770 5 N . 29" ' S t

•Date s worked : 05/13/1 0 t o 05/15/1 0 •Pr e propert y condition : Hous e ha s woo dsidin g wit h pain t in poo r conditio n al l over ; pain t wa s comin g of f

in bi g chunks . Pain t chip s in yard . •Problem s encountered : EP A inspecte dpropert y an dsa w ther e wer e area s tha t neede d mor e attention . Owne r the n starte dmaldn g complaint s an dwoul dno t le t painter s bac k o n property . Sh e als o claime dpainte r movedai r conditione r uni t an dbrok e th e cap tha t hold s Freon . P E i s takin g car e of repairs . •Owne r request/concerns : Owne r wante drepair s t o A/ C uni t an dcomplaine dabou t th e pain t onl y afte r EPA inspecte dproperty . Sh e wa s happ y wit h th e pain t an dwrot e goo d comment s o n closeou t form . •Inspection/closeou t dates . Owne r 05/19/10 , EPA 06/01/1 0 hous e neede dmor c work , re inspecte d06/08/1 0 issue s resolved .EP A Pain t Stabilizatio n 201 0 sAiD # ^3>^Q O Propert yAddres s H IP S K) - ^ ^ ^ ^ Storie s V J ^ Garage ? 

# V^ s Acces s signe d A-~Cf?y^]C ^ Pre-vide o 4'0^-1 6 Postvids o 5 "^" ^ I Q Contracto rAssigne d 

# (Vinm S h\f^i m Dat e starte d .^/ / ^^2^// ^ WeatheiTtsm p ^ ^ * Dat e ende d Pain t use d 

# SLSQA- L Prim e use d 

# I A Pol yuse d (Q Q Problems/Issue s 

## t^ > nt - -P-kadc'^nC ) ^ ^Q\nV^din \ p s o v^ruv^cj i t o <Ji < ^e , ^^ ,

# >ra i CONSEN T FO RACCES S T O PROPERT Y OMAHA LEA D SIT E REMEDIA L ACTIO N - LEAD-BASE D PAIN T STABILIZATIO N PROPERTY ID : ^^Qd O PROPERT Y ADDRESS : T 1 O S A / gK ? v5^^ . OWNE RNAIVIE: > , DAYTIIVI E PHONE : ('VOSL)^?< / - 0~y<y 7 CEL L PHONE : AJOA/f i

_E-MAIL : Ajpyy c OWNER' S ADDRES S I FDIFFERENT : 

### Spyt ^ TENANT' S NAM E I FAPPLICABLE : RQ^mrU i DAYTIM E PHONE : CELLPHONE : _ - E-MAIL : Profenlona l Environmenta l Engineers , Inc . (PE ) i s unde r contrac t (#EP-R7-08-06 ) wit h th e U.S . Environmental Protectio n Agenc y (EPA ) t o stabiliz e lea dbase dpain t (LBP ) o n residential structure s a t anumbe r o

f propertie s locate di n Omaha , Nebraska . Th e pain t stabilizatio n wor k

i s bein g don e t o protec t th e soi l cleanup s tha t ar e bein g performe db y EP A contractors . Pain t stabilizatio n activitie s will Include : scrapin g of cracke do r flaking LB P fro mstructures , applicatio n of aprim e coat an dtw o (2 ) coat s o f paint . Moving part s o f window s an ddoor s ar e no t include dan dwil l no t b e addressed . Your cooperatio n i s requeste dI n givin g permissio n t o thi s EP A contracto r (PE ) t o ente r an dhav e acces s t o thi s property for th e purpos e o f stabilizin g lead-tiase dpain t a s outline don th e property identifie dabove . By signin g thi s documen t I agre e t o allo w a n EP A contracto r t o conduc t asoil cleanu p a t m y property following completio n o f lead-base dpain t stabilization , i f th e soil cleanu p ha s no t alread y bee n performed . I understan dtha t th e stabilizatio n contracto r ca

n no t provid e assurance s tha t th e soil cleanu p contracto r wil l b e boundto. I furthe r undentan dtha t th e soil cleanu p contracto r wil l make al l reasonabl e effort s t o addres s concern s tha t I , a s th e property owner , ma y hav e regardin g soil cleanu p a t m

y property . D Yet4nv e raad an d underttan d th a paragrap h abova . 

## ^'^'/ O ^ y SIgnatu mo f Propert y Owne r ^ ^ I full y understan dtha t by signin g thi s Consent for Access , (I ) thi s acces s wil l re m satisfactoril y completed , (2 ) tha t th e Property Owne r o r Tenant , i f applicable , wi i (HUD ) an dEP A pamphlet , "Renovat e Right , Importan t LeadHazar dinformati o Schools" , (3 ) th e Propert y Owne r o r tenan t wil l remov e ai l obstruction s fro msu r safet y guidanc e provide db y EPA , (5 ) wil l allo w photograph y of property befor e f contacte db y aPE representativ e approximatel y 4 8 hour s i n advanc e of startin g v any ofth e LB P stabilizatio n actions , an d(8 ) will participat e i n Tina l property insp Property Owne r Satisfactio n Survey .


# - 1 Shoul dyo u hav e an y question s abou t th e plane dLea dBased-Paint stabilizatio n a Professiona l Environmenta l Engineers , inc . Projec t Manager , Willi e Cla y A t 402 - Lea dSite cleanup ca n b e directe dt o Paulett aFrance-lsetts , EP A Remedia l Proje « Informatio n Center s a t 402-991-958 3 (Nort h Omah aoffice) o r 402-731-304 5 (So u 

# M Yes , I gran t accat t t o m yproptrt yan d w n give n th a pamph M D No,ldonot | moifflt e Mght , Impoitui t Laa d Inforaiatio n forFamHIat , Chil d give n th e pamp t Car e Froviden , an d Schoolt. " Infonnatio n forF-amiiiet , i.niia e uar e rrovioere , an a scnooit. * 

# J/M> A ^ . U^^^-,S'/ 0
SPECIA L INSTRUCTION S AN D CONSIDERATION S Signatur e Dat e

## PAIN T STABIUZATIO N PRE-PROPERT Y PAIN T MATC H ASSESSMEN T PROPERT Y ADDRES S 

# •.zn^^ii^= ± DATE : ^fi'^'Xoi o BVI D

AREA(S ) T O B E PAINTED : [HOUS E PROPER : Si ^ ^/^^^ ^ COLOR : B^/''^^ A b/ f fM-Hf P HOUS E TRIM : ^ t J Q? J Cf f O COLOR : p^i T gri/^?a L
GARAGE : 6? / 2^ ^ COLOR : GARAG E TRIM : COLOR : IPORCH : COLOR : PORC H TRIM : COLOR : (COMPLET E AL L SECTION . YES . NO , O R NON^PPLICABLE )

I AGRE E T O TH E COLOR S LISTE D ABOVE . ONC E TH E PAINTIN G BEGINS , I UNDERSTAN D I CA N NO T CHANG E TH E ABOV E SELECTE D COLORS : PROPERT Y OWNE R SIGNATURE : PE ACCESO R SIGNATURE :


# • ^N^^ > . J ^Thi s sampl e for m ma ybe use d byrenovatio n firm s to clocunien t complianc e wit h th e Federa l pre-i^iovatio n educatio n aii d renovation , repair , an d paintin g regulations . Occupan t Confirmatio n Pamphle t Receip t Q I hav e receive d a cop y ot th e lea d haiaii d informatio n pamphie riirfoirnin g meof th e potentia l ris k of th e lea d hazar d exposur e fro m renovatio n activit y to be performe d in nr

ydwellin g unit . I receive d thi s pamphle t befor e th e wor Kbegan . Owner-occupan t Opt-ou t Acknowledgmen t Q (A ) I confir m tha t I ow n ari d liv e in thi s properly , tha t no chil d unde rth e ag e of 6 reside s here , tha t no pi«gnan t woma n reside s here , an d tiia t thi s propeit y is no t a child-OL;cupid a lacility . Note : A chil d reside s in th e primar yresidenc eof hi s orhe rcustodia l parents , lega l guardians , foste rparents , orinforma l caretake r if th e chil d live s an d sleep s mos t of th e tim e at th e caretaker ^

residence . Note : A child-occupie d facility is a pre-197 8 buildin g visite d regularl y byth e sam e child , unde i 6 year sof age , on at leas t tw o difleren l day s withi n an yweek , fo r at leas t 3 hour s eac h day . provide d tha t th e visit s tota l al leas t 60 riour s annually . If Bo xA is checked , chec k eithe rBo xB orBo x C. bu t no t both . a (B) I reques t tha t th e renovatio n fin n us e th e lead-saf e wor k praclice s rbquire d byEPA' s Renovation , Repair , an d Paintin g Rule ; or (J (C) I understan d tlia t th e fir m perfomiin g th e renovatio n wil l no t be reqiiire d to us e tti e

lfead-.saf e wor k practice s recjuire d t) yEPAI s Renovation , Repair , an d Paintin g Rule . Prime d Nam e of Owtiei-occupan i Signciture ot Owner-oixupan t Signatur e Dat e Renovator' s Sel f Certificatio n Optio n (fo rtenant-occupie d dwelling a only ) Instnjction s to Renovator : If th e lea d hazar d informatio n pamphle t wa s deliveiB d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e approjjriat e bo xbelow . Q Decline d - 1 certifytha t I have mad e a goo d fait h effor t to delive rth e lea d hazar d infomiatio n pamphle t 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 tha t th e occupuii t decline d to sig n th e confirmatio n of receipt . I furthe i certifycha t t hav e lef t a cop y of tfi e painphle t at th e uni t wit h th e occupant. Q Unavailabl e fo rsignatur e - 1 certifytha t I hav e mad e a goo d fait h effor t to delive r th e lea d hazar d Infbrmatio n pamphle t to th e nanta i dwellin g uni t liste d t>elo w an d tha t tfi e occupan t wci s unavallabl o to .sig n th e confimialio n of rte<:eipt . I furtlie rcertif ytha t I hav e lef t a (xip y ut tti e pampttle t at tfi e uni tbyslidin g it unfte i th e doo rur by(fil l in howpaniphie .

swparnphie t t wa wa s s left)

left) . __ ! e 9f Attempte Attempte d Deliver Deliver yDat e Printe d Nam e * Perso n Certifyin Certifyin g Deliver Deliver y Signatur e q^ Perso n Certiiyin g Lea d Pamphle t Deliver y T ^ > T 

## • S^^J^; ^ Uni t Addres s Not e Regardin g Mailin g Optio n — As an alternativ e to deliver y

in ixsrson . yo u ma ymai l th e lea d hazar d infornnatio n pamphle t to th e owne rand/o i teiianl . Pamphle t mus i be maile d at leas l sevH n day s befor e renovatinn . Mailin g mus i ti e d<v;uiiHjiiii::i i hya o^^rtifiual e of mailiix i fior n It w rx'S l office . Note : Hil t toii n \f > no l eftsttwt ! unti ! /\)jri i 5CilO .

### Dougla s Count y Accoun t Infomiatio n Pag e 1 of 2 

# ^540 ^ Dougla s County , Nebrask a Propert yRecor d - R110438000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 ft wes t o f 52n d S t - Vie w O n Ma p Informatio n i s vali d a s of 2010-3-1 6 Treasurer' s Ta xRepor t Ne w Featur e ->-+- > Aut o Sale s Searc h Owne r SLEDG E KELL I A 

# yoof^ q 770 5 N 2 9 S T OMAHAN E 68112-000 0 

# 9,'^^-oiH n Propert yInformatio n Ke yNumber : 043 8 000 0 1 1 Accoun t Type : Residentia l Parce l Numbe r 110438000 0 Parce l Address : 770 5 N 2 9 ST OI^AHAN E 68112-000 0 Lega l Description : FLORENC E LO T 7 BLOC K8 1 W 1/ 2 ALLE Y AD J & 6 6 X 142 Valu e Infornnatio n Lan d Improvemen t Tota l 200 9 $7,700.0 0 $42,500.0 0 $50,200.0 0 200 8 $7,700.0 0 $42,500.0 0 $50,200.0 0 200 7 $7,700.0 0 $42,500.0 0 $50,200.0 0 200 6 $7,700.0 0 $38,900.0 0 $46,600.0 0 200 5 $7,700.0 0 $37,300.0 0 $45,000.0 0 200 4 $7,700.0 0 $37,300.0 0 $45,000.0 0 Sale s Informatio n Sale s Date : 2002-10-1 1 Dee d Type : W D Book : 222 4 Page : 75 0 Price : $66,500.0 0 Grantor : Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.2 1 9372. 0 1. 0 142. 0 66. 0 N o Improvemen t Informatio n 

### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R l 1.. . 3/29/201 0

### Dougla s Count y Accoun t Inforrnatio n Pag e 2 of 2 inat K

su a noc rceu c raticn
FIn l Pi«a r 7M0sq.fl .

1. 5 STOR Y UNFINISHE D Bsmn t Bloc k 8 ft 76 8 0 &q . f t CLIC KTO ENLARG E IMAG E Squar e Footage : | 768. 0 Percen t Complete : 100.0 % Perimete r' 0. 0 Quality : Averag e Uni t Type : Condition : Fai r

Buil t As : 1 1/ 2 Stor yUnfi n Cond o Squar e Footage : 0. 0 HVAC : I Force d Ai r Rooms : 5. 0 - 1 - 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 : Gabl e Stories : 1. 5 Floorcover : Allowanc e Foundation : Sprinkle rSquar e Footage : 0. 0 yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 191 6 0 % 191 6 9 4 Detai Y Typ e Detai l Descriptio n Unit s Applianc e Allowanc e 1. 0 Basemen t Bsmn t Bloc k 8 ft 768. 0 Fixtur e Additiona l Fixture s 1. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Garag e Attache d 352. 0 Porc h En d Scree n 168. 0 Porc h En d Scree n 40. 0 Porc h Sla b Roo f Ceilin g 96. 0 Use r UNFIN . ATTI C NONCACULATE D 0. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rll. . . 3/29/201 0(efTectiv e Apri l 2010 ) 

### RENOVATIO N RECORDKEEPIN G CHECKLIS T Nam e o f Firm : [M\[lfl S 

# fidri mkf]k , fll/IHD ^ 

### Dat e an dLocatio n o f Renovation : "? IC Q ^/ . ZQti ) i>\ - Brie f Descriptio n o f Renovation : Ua A j{nVi \I7(l k 16 0 Nam e o f Assigne dRenovator : (ofli l CmOiff\\ Name(s ) o f Traine dWorkers : p'd ^ (^hffAJ . C ^' ^ I^YVA^ ^ 

### Nam e o f Dus t Samplin g Technician , Inspector , and/o r Risk Assessor , i f used : D Copie s o f renovato r an ddus t samplin g technicia n qualification s (trainin g certificates , certifications ) o n file . D Certifie drenovato r provide dtrainin g t o worker s o n (chec k al l tha t apply) : D Postin g wamin g sign s D Settin g u p plasti c contaiiunen t bairier s aMaintainin g contaiiunen t D Avoidin g sprea do f dus t t o adjacen t area s D Wast e handlin g D Post-renovatio n cleanin g n Tes t kit s use db y certifie drenovato r t o determin e whethe r lea dwa s presen t o n component s affecte db y renovatio n (identify kit s use dan ddescrib e samplin g location s an dresults : D/^amin g sign s poste da t entranc e t o work area . Q/Wor k are acontaine dt o preven t sprea dofdus t an ddebris . p^indow s i n an dwithi n 2 0 fee t ofth e wor k are aar e close d J^f'Dpfit s i n an dwithi n 2 0 fee t ofth e wor k area s ar e close dan dseale d D Dopr s tha t mus t b e use di n th e wor k are aar e covere dt o allo w passag e bu t preven t sprea dofdust . Q^roun dcovere db y plasti c sheetin g extendin g 1 0 fee t fro mwor k are a- plasti c anchore dt o th e buildin g an dweighte ddow n b y heav y objects . D I f necessary , vertica l containmen t installe dt o preven t migratio n ofdus t an ddebri s t o adjacen t property . J^^ast e containe don-sit e an dwhil e bein g transporte dofF-site .

Renovatio n Recordkeepin g Checklis t Omah a Lea d Sit e(efTectiv e Apri l 2010 )

'0'Work sit e properl y cleane dafte r renovation . ^^XhAlH:hip s an ddebri s picke dup , protectiv e sheetin g misted , folde ddirt y sid e inward , an dtape dfo r ' removal .

^^.•"Wor k

are aHEP A vacuume dt o ge t pain t chip s fro mgroun dsurface , i f necessary . Certifie drenovato r performe dpost-renovatio n cleanin g verificatio n (describ e results) :

I certif y unde r penalty o f la

w that th e abov e informatio n Is tru e an dcomplete . ^ . 

## B^/j 2

Nam e an dTitl e Dat e

Renovatio n Recordkeepin g Checklis t Omah a Lea d Sit e