### TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R 

# SAID# : /oUfiq O Date : ^ f M | 0 ^ 

# Address : IU? ^ Tnunix Y (L\uiV \/W^ . Remediatio n Contractor : PROFESSIONA LENVIRONMENTA LENGINEER S Year : 200 9 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S i3e o ofpropert y (DVD ) cutiv e Summary Q

^ ^^..Signe dAcces s Agreemen t for subjec t property 0 Paintin g Agreemen t D J8€ti\emen t document s (i.e. , for damag e o r t o replac e plants , etc. ) >C K Photograph s fp^Mir e ^ B ^ Satisfactory restoratio n signe db y Property Ovmer D Property close-ou t chec k lis t signe db y EP A V y Property informatio n fromDougla s Count y Assessor' s Offic e D confirmatio n tha t leadpamphle t "Renovat e Right " was receive db y P0 _ D

., , \ 3020385 8 D ; 

# iimn n D
. Superfun d 

# X^^m^-^. , 

# T ^ Professions^tnvirbiunenta l Engineer s Signatur e 

# 'M&.f'^- ^ U i ^ a t250 5 Nort h 24 ^ Suit e 21 9 Omaha , N E 6811 0 (402 ) 504-468 8 Fa x(402 ) 504-328 1 

# PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC
. "Providin g cost-effectiv e environmenta l solutions " 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 200 9 SAID #6489 2 163 3 Countr y Clu b Av e

•Date s worked : 06/2 9 t o 06/3 0 200 9 •Pr e propert y condition : Propert y wa s i n fai r conditio n an dha dstucc o an dbric k sidin g wit hwoo dtri mareas , pain t wa s flaking of T i n som e area s o f th e stucc o an dtrim . Overal l hous e wa s i n goo dshape . •Problem s encountered : Non e •Owne r request/concerns : N/A •Inspection/closeou t dates . Owne r signe d07/20 , Inspecte db y P E projec t manager .

# CONSEN T OF RACCES S T O PROPERT Y OMAH A LEAD SIT E REMEDIALACTIO N - LEAD-BASE D PAINT STABILIZATIO N PROPERTY ID : Cch^^^^^ T PROPERTY ADDRESS : /^_?v ^ y^X, ^ h ^ y.lCflp/^ O OWNE RNAME : 

### 3b \t^x O C^^yy^^T ^ DAYTIM E PHONE : S'5'S

— 7 / " J ? CELLPHONE : E-MAIL : j'o^w*7 « C.-a^r > J ^ n (g)g^x . ri<:t~ ~ OWNER' S ADDRES S I FDIFFERENT : TENANT' S NAM E I FAPPLICABLE : DAYTIM EPHONE : ^^^^^^^Jl^^^ ^ CELLPHONE : E-MAIL : ^ ^ Professiona l Environmental Engineers , Inc . (PE ) i s unde r contrac t (#EP-R7-08-06 ) wit hth e U.S . Environmental Protectio n Agency (EPA ) t o stabiliz e lea dbase dpain t (LBP) o n residential structure s at anumbe r o

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

i s being don e t o protec t th e soil cleanup s tha t were performe db y EP A contractors . Pain t stabilizatio n activitie s wil l include : scrapin g o f cracke do r flaking LB P fro mstructures , applicatio n o f aprime coa t an d tw 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 din 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 lea d-base dpain t a s outline do n th e property identifie dabove . B

y signin g thi s document I agre e t o allo w a n EP A contracto r t o conduc t asoil cleanup a t m y property followin g completion o f lead-base dpain t stabilization . I understan dtha t th e stabilizatio n contracto r ca n no t provid e assurance s tha t th e soil cleanup contracto r wil l b e boun dto . I furthe r understan dtha t th e soil cleanup contracto r wil l make all reasonabl e effort s t o addres s concern s tha t I , a s th e property owner , ma y hav e regardm g soil cleanup at m y property . I full y understan dtha t b

y signin g thi s Consent for Access , (1 ) thi s acces s wil l remai n in effec t unti l th e wor k

ha s bee n satisfactoril y completed , (2 ) tha t th e Property Owner o r Tenant , i f applicable , wil l b e give n th e Housing an dUrban Developmen t (HUD ) an dEP A pamphlet , "Renovate Right , Importan t Lea dHazar dinformatio n fo r Families , Da y Car e Providers , an dSchools" , (3 ) th e Property Owner o r tenan t wil l remov e al l obstruction s fro msurface s t o b e painted , (4 ) wil l abid e b y healt han dsafet y guidanc e provide db y EPA , (5 ) wil l allo w photograph y o f property befor e an dafter th e pain t stabilizatio n work , (6 ) wil l b e contacte db y aP E representativ e approximatel y 4 8 hour s i n advanc e o f startin g work , (7 ) agre e no t t o obstruc t o r tampe r wit hany o f th e LB P stabilizatio n actions , an d(8 ) wil l participat e i n final property inspectio n an d sign th e Completio n Agreement an dPropert y Owner Satisfactio n Survey . Shoul dyo u hav e any question s abou t th e plane dLea dBased-Paint stabilizatio n activitie s for you r property , pleas e contac t Professiona l Environmental Engineers , Inc . Projec t Manager , Willi e Cla y A t 402-504-4688 . General question s abou t th e Omah aLea dSit e cleanup ca n b e directe dt o Paulett aFrance-Isetts , EP A Remedia l Projec t Manage r 402-731-2454 , o r th e EP A PjtfCli c Informatio n Center s at 402-991-958 3 (Nort hOmah aoffice ) o r 402-731-304 5 (Sout hOmah aoffice) . Yes , I gran t acces s t o m ypropert yan d wa s give n th e pamphle t D No , I d o no t gran t acces s t o m ypropert yan d I was "Renoteit e Righ t Importan t Lea d Informatio n forFamilies , Chil d give n th e pamphle t "Renovat e Right , Importan t Lea d CareP n Infomiatio n forFamilies , Child e Care Providers , an d Schools. " Signatur e \ Dat e Signatur e Dat e SPECIA L INSTRUCTION S AN D CONSIDERATION S

### PROPERT YADDRES S A^<J> ^ Cc^i^^i^<-i ^ ^ p QQQ ^ I PROPERT YADDRES S O F OWNE R I F DIFFEREN TTHA N PROPERT YBEIN G PAINTEO : PROPERT YADDRES S ZI P COD E I hav e receive d a cop yo fth e pamphlet , /temmrfeR^M : Importui t Laa d HaxmllnhmMlH m Fo rFmOos , (MUCa n Pravfdar s Ant fScftoof s infomiin g m e o f th e polentia i risl ( o f ttwlea d haz» d exposur e fio m renovation activit yt o b e peribnne d o n dwellin g unit
. I receive d thi s pamphle t befor e th e wor k began
.

DAT E ^ I



### Setf-CertWcatlo n OpHo n (Fo rTenant-Occupie d Dwellin g Only ) I fth e lea d pemphie t wa s delivere d bu t a tenan t signatur e VM S no t obtainable , yo u ma yChec k th e a ^ [ J Refusa l T o Sg n - 1 certif ytha t I hav e mad e a goo d fait h eflbr t I D drive rth e pamphlet , Renovat e Righ t Importan t Lea d Haza d Informatk m fo rFamilies
. Chil d Car e Provkler s ai d Schools ; t o th e rental dwellin g uni t liste d stov e a t th e dal e an d time indk:ate d ari d tha t th e occupan t refuse d t o sig n th e confimnatk m o freceip t I furthe rcertif ytha t I hav e lef t a cop yo fth e pamphle t a t th e uni t wtt h occupan t 

# D Unavailabl e Fo rSignalur e - I certif ytha t I hav e mad e a goo d felth effor t t o delive rth e pamphlet , Renovat e Right ; importan t Lea d Hazar d Infonnatio n fo rFonilies , Chil d Car e ProvMer e an d Schoois , t o th e renta l dwellin g uni t liste d bdo w an d ttiat tt)e occupan t wa s unavailabl e to sig n ttie confirmatio n o f receip t I furttie rcertif yttiat I hav e lef t a cop yo f ttie pamphle t a t ttie uni t b ysKdin g it unde rttie doo ro rsomewher e o n tiie premises
.

PRMTH t NAM E O F PERSO N CERHFYM e ATTEMPTB ) teJVER TDAT E AN D TM E LEA D PAMPHLE T DBJVBT r

SIGNATUR E O F P E PERSO N CERnFYM O LEA D PAMPtAE TDELI\CRr : 

### Not e Regardin g Mailin g Optio n ~ a s a n aUamath n t o delivetyir i person , yo u ma ytnsd l th e lea d pamphle t t o th e O M Pamphlet must b e nMded a t leas t 7 day s before renovation
. (Documen t wtt h a certHicat d o fmalfln g fro m th e pos t oflioa)
.

CONFIRMATIO N O F RECEP TO F LEA D PAMPHLE T08/0 8

## PAIN T STABILIZATIO N PRE-PROPERT Y PAIN T MATC H ASSESSMEN T PROPERT Y ADDRESS : 

# /^3 ^

/cu^y ^ (^/ h DATE : BVID:_£ ^



### AREA(S ) TO BE PAI N 1 ED : 

# A HOUS E PROPER : _ 

## COLOR : \\(M ^

HOUS E TRIM : COLOR :
GARAGE : COLOR : ''

• t. 

### GARAG E TRIM : COLOR : \ 

### PORCH : 

### COLOR : 1 

# y

• ^ 

### PORC H TRIM : COLOR : ^ ^
(COMPLET E AL L SECTION , YES , NO , OR NON-APPLICABLE )

I AGRE E TO 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 : PROPERTY OWNE R SIGNATURE : PE ACCESO R SIGNATURE :

## PROFESSIONA L ENVIRONMENTA L ENGINEERS , INC
. "Providin g cost-effectiv e environmenta l solutions " Consultin g • Engineerin g Desig n • Remediatio n • Abatemen t • Emergenc yRespons e 

### Propert y Owne r Close-Ou t For m (Lead-BasedPain t Stabilization EP A Contract EP-R7-08-06 ) 

## SAID : ioi4ftq a Propert y Address : I lp?>?> CnUn'hrN l Cltj h/[jf>_ . Owner' s Name : ^ ^ ^^^ H Cnrr\ a 

# o n Performanc e Standards/Close-Ou t Criteri a 250 5 Nort h 24 * Suit e 21 9 Omaha , N E 6811 0 (402 ) 504-468 8 Fa

x (402 ) 504-328 1



### YE S N O 1 . Wa s th e entir e structure(s ) painte dwithth e exceptio n ofth e stated , exclude d areas ? Thi s woul dinclud e paintin g ofothe 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 

## X garages . 2 . Wa s al l scrapin g an dothe r preparatio n wor k

complete dsatisfactorily ? y 3 . Were al l require darea s ofth e structure(s ) prime da s neede dan dpainte dwith tw o to p coats ? y ^ 

### 4 . Wa s th e pain t product s utilize dequivalen t t o a3 0 year product/quality ? y ^ 

### 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 contracto r collect/vacuimi al 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 remov e an y othe r generate ddebris ? X 7 . I s th e gras s are atha t surround s th e structure(s ) i n reasonabl y goo dcondition ? > < 

### 8 . Are all item s suc ha s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r tape , etc . properl y removed ? 

## i9 . I s ther e an y evidenc e ofpropert y damag e tha t was don e b y th e contractor ? An y property damag e need s t o b e complete dprio r t o th e EP A Close-Out . ^ 

### 10 . Ar e ther e an y property item s tha t wer e temporaril y re-locate db y th e contracto r tha t nee dt o b e move dback ? Y ^ 11 . Are ther e any (known ) lingerin g issue s withth e property owner(s ) tha t hav e ^ 

### bee n lef t unresolved ? Conmients :

-Si
_ 

### Ropert y Owne r

Signatur e / Dat e 

## 7^^ o - c 9 Professiona l ^pwonmenta l Engineer s Representativ e Dat e

### Dougla s Coimt y Accoim t Information Pag e 1 of 2 

# M7.R X Dougla s County , Nebrask a Propert yRecor d - R084377000 0 Prin t Reoor t NE W Featur e - Parce l Dimension s availabl e (S > scal e 0-5 0 f t wes t o f 52n d S t - VlO W O n Ma D Informatio n i s vali d a s o f 2009-6- 3 Treasurer' s Ta xReoor t Ne wFeatur e " * ^ • * Aut o Sale s Searc h Owne r CARRIGA N J O AN N 163 3 COUNTR Y CLU B AV E OMAH AN E 68104-000 0 

# 5S^-"7(3 3 Propert yInformatio n Ke yNumbe r 437 7 OOO O 0 8 Accoun t Type : Residentia l Parce l Numbe r 084377000 0 Parce l Address : 163 3 COUNTR Y CLU B A V OMAH AN E 68104-000 0 Lega l Description : COUNTR Y CLU B DIS T LO T 1 4 BLOC K2 8 LT 1 3 & S 1 0 FT 6 7 X 12 3 Valu e Informatio n Lan d Improvemen t Tota l 200 9 200 8 200 7 200 6 200 5 200 4 $22,300.0 0 $22,300.0 0 $22,300.0 0 $22,300.0 0 3 5 522,300.0 0 522,300.0 0 $149,300.0 0 $149,300.0 0 $149,300.0 0 $149,300.0 0 $149,300.0 0 $124,900.0 0 $171,600.0 0 $171,600.0 0 $171,600.0 0 $171,600.0 0 $171,600.0 0 $147,200.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0. 2 8911. 0 1. 0 133. 0 67. 0
. N o Improvemen t Informatio n Buildin g 1



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R084.. . 6/8/2009

### Dougla s County Accoun t Informatio n Pag e 2 of 2
Tw o Stor y 163 3 Cmjn ^

Clu b A v

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HllHIMMIMI!HIHIIBitH!.lMli«1!mgr m !aB<3^^ * i^ii% n f 3 I CLIC KT O ENLARG E IIVIAG E CLIC KT O ENLARG E IMAG E Squar e Footage : 1440. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Goo d Uni t Type : Condition : Averag e

Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 7. 0 Exterior : Masonr yFac e Bric k Units : 1. 0 Interior : Drywal l Baths : 1. 5 Roo f Cover : \ Slat e Bedrooms : 3. 0 Roo f Type : Gabl e Stories : 2. 0 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea r Percen t Adjuste d Yea r Yea rBuil t Physica l Ag e Remodele d Remodele d Buil t 193 0 0 % 193 0 7 9 Detai l Typ e Detai l Descriptio n Unit s Ad d O n Fenc e Woo d 1. 0 Applianc e Allowanc e 1. 0 Applianc e Fireplac e Masonr y 1. 0 Basemen t Bsmn t Bloc k 8 ft 700. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Fixtur e Bat h Hal f 1. 0 Garag e Attache d 300. 0 Porc h En d Soli d Wal l 240. 0 Porc h Ope n Sla b 120. 0 Porc h Ope n Sla b 150. 0 Porc h Sla b w/Step s 40. 0 Use r Roo f leaks i n spot s 1. 0


### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R084. . . 6/8/200 9