TRANSMITTAL O F OMAH A LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: ^^^JPnC r Date: 0.^-^7 0 "cPCC^ ^ 

Address: ^ ^ ^ ^ A / cT ^ 4^ty . 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

Xl Video of propertv (DVP); Pre-Stabilization & Post-Stabilization Videos 

iir/ Executive Summary 

y Signed Access Agreement Form 

y Advance Notice Form 

n Pre-Stabilization Video Agreement Form 

\v Access Tracldng Form 

s/ Property Access Assessment Form 

U/ Neighbor Access Agreement Form 

i / Paint Match Form 

\ / Pre-Stabilization Property Safety Assessment Form 

y Work-Site Hazards Analysis Checklist 

M Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

W Douglas County Assessor Property information 

IV ^ Propert y Completio n Agreemen t For m Signed by Propert y Owne r 

IJ Propert y Close-Ou t Chec k Lis t Signed B y EP A 

Prndent Technologies, Inc. Signature '" ' '^Date 

A7i,J,jA-^4^^i-^. A^:r4L A^Jlo 

EPASignatiire * Date^ 

30054733 

M l 

Superfund 
TECHNOLOGIES, INC 

Property Summary 

Date: 9^/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: Sep 

Property Address: 4615 N 34 Av. SAID #: 49203 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 8/27/2009 

ii. Work Began: 9/04/2009 

ilL Close-Out Date: 9/05/2009 

B. Enclosures; 

1. Pre-Stabilization Video 

2. Post-Stabilization Video 

3. Signed Access Agreement Form 

4. Advance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracldng Form 

7. Property Access Assessment Form 

8. Neighbor Access Agreement Form 

9. Property Paint Match Form 

10. Pre-Stabilization Property Safety Assessment Form 

11. Work-Site Hazards Analysis Checklist 

12. Pre- Stabilization Property Hazard Assessment Photographs 

13. Douglas County Assessor Property Information 

14. Signed Property Completion Agreement Form 

15. Property Close-Out Check List Signed By EPA 
^^CHNraSXXSIBSw INC. ' 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) witii tlie U. S. Environmental Protection 

Agency (EPA) to stabilize Lead Based gaim (LBP^at a number of properties located in Omaha, Nebraska, including the 

property located at ^ f j S /v - A r niJc^> 

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 scraping paint and 

painting ofthe referenced property. Further, the owner/tenant verifies that they have received the LBP pamphlet "Renovate 

Right." 

By signing this document I agree to allow an EPA contractor to conduct a soil cleanup at my property following completion of 

lead-based paint stabilization, ifthe soil cleanup has not already been performed. I understand that the stabilization contractor 

cannot provide assurances of which contractor will be bound to the soil cleanup. I further understand that the soil cleanup 

contractor will make all reasonable efforts to address concems that I, as the property owner, may have regarding soil 

cleanup at my property. 

Yes, I have read and understand the paragraph above. 

/ * ^ "^/ yhy^ CM- ^ /2>iA(4 

lignature of Property Owner 

xi 

Date 

Ifyou have any questions about the LBP stabilization planned for your property, please contact Prudent's Customer 

Relations/OfFice Manager for the Lead Based Paint Stabilization, Mrs. Shannon Holt at (402) 504-1004 or (402)812-0223. 

General questions about the Omaha Lead Site cleanup can be directed to the EPA Public Information Centers at (402) 731­

3045 (South Omaha office) or (402) 991 -9583 (North Omaha office). 

Property Access Granted By: 

r-^4LJ^ ^^^C2y^ 

(Please Print Name) 

Property Owner Signature; 

(Signature) 

g ;-^^/^7 

/ (Date) 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
• TECHNOILOGIBS. IP-rcT" 

PROPERT KKUKCKITY inruKin/ INFORMATIO ^ N

(To^be i^^$^ent r property owner — please print) ^yA^— \ A (To be complete completedd bbyy r^$^ent

 and/o and/or proDei 

RESIDENT NAME: L>/f/€/ .>^^ . / /T// ftOf/iC J Owner / Renter J 

RESIDENT ADDRESS: 

IF RENTAL, PROPERT».OWNED BY:

AM .Tiic. 

OWNER'S MAILING ADDRESS; 

y^/ ^ //. .-34 AUS 

OWNER'S 1w-mf TELEPHONE NUMBER - HOME: 1 .WORK: _ j I. 

NUMBE N R OF OCCUPANTS UNDER 7 YEARS OLD: 0 NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER:

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

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

Al/ DM 

AUTHORirV FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities lo be implemented by EPA under this agreement are 

pursuant to Section 104 ofCERCLA, 42 U.S.C. 9604. EPA's right of access to the property is provided for in Section 104(e) ofCERCLA, 

42 U.S. C 9605(e), which provides entry for "determining the need for response, or choosing or taking any response action under this title, or 

otherwise enforcing the provisions ofthe title." 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 

Phone: (816) 363-3703 

Fax; (816) 363-3707 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577 
m 

TBCHNOLOGIESw INC. 

Advanced notice needed. 

After signing the access you allow Prudent to begin Lead Based 

Paint Stabilization. All Plants, weeds and any vehicles or items on 

open porch (enclosed porches will NOT be stabilized) must be 

removed prior to stabilization. All Pets must be out of yard during 

stabilization. How much notice do you need to have above 

mentioned tasks completed? If you are a landlord you will need to 

contact the tenant as Prudent Technologies will only inform you. 

Do you have any pets that reside in yard? 

Notice needed: :^ ^ A S&i/ imi^t 4€ tiiqiA k^ee 

Number to call to give notice: fwff^^ /o, j 

Whom we are giving notice to: / U/fj) ^(aOo4> UitN>Qy 

Home Owner's Signature 

7 'Al<b<A.~ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 

Fax:(816)363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210) 822-9588 

Fax:(210)579-6577 
TBCHNOfljOGIESi,] 

ACCESS INFORMATION TRACKING SHEET 

BVID PROPERTY ADDRESS: ^} ^: /f4fs^o2 

^ / / ^ ^ 

Property Owned By: 

ALM ^ .. (If new property owner) 

Owners Phone No's: 

Home: . Mi.fH.C. Work: 

CeU: Fax: —• 

AM( 45i'Si9j A,,a ^^^ A 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ^CESSO R COJVRACTDETAIL 

'ilTrU ^'OOfM (^/H^. ^ 

1 k^ 1 n I

Comments: jii£ii:_i.-.i!&^-A._dm_J^S'^5:^ . 

dUist-lMl8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES.] 

PRE-STABILIZATION VIDEO FORM 

1 UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABILIZATION VIDEO AT MY PROPERTY. 

THE VIDEO IS JUST A TOOL USED TO DOCUMENT THE CURRENT 

PROPERTY STATUS/CONDITION. A POST VIDEO WILL ALSO BE 

SHOT PRIOR TO COMPLETION OF STABILIZATION. 

OWNERS NAME: ^ ^ J^^ ^ 

PROPERTY ADDRESS: y^/r /f/. ?t ^ • 

BVID/SAID: 

^^^3 

HOMEOWNERS SIGNATURE: 

T<T.a ^ 

PRUDENT SENTATIVE SIGNATURE: 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

/UdNl 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS,] 

Access Assessment Form: (Must be completed for every property. 

Information must be obtained from a property walk thru, not given 

by owner) 

Is the property stucco or asbestos? 

If yes, is any of the stucco or asbestos damaged or cracked? 

If yes, stop as we can't stabilize this property. It requires special preparation 

techniques. It will be returned to EPA and they will assign at a later date. 

Does this property require lots of scrapOing? 

Does this property require a lift or scaffolding to reach upper levels? 

Does this property have lots of plants or items in areas where painting is 

required? 

Does this property have any significant structural damage? 

/ / ^ 

If yes, EXPLAIN? 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLO^ ^ 

Does this property have a garage? 

/Jd 

If yes, describe location of garage. 

Does this property have aluminum siding? 

^ ' m 

If yes, is it original factory finish or has it been painted over? 

Does this property have any other type of structural components? (I.e. roof 

shingles as siding)? 

If yes, EXPLAIN? 

Is this property vacant or oc ft/I /^'J^i 

Are there any pets at this property? 

/Qa 

Are there any low hanging power lines? 

iyie/n. 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS,] 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

I\jd 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
OOLOGIES. IN C 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: ^l> K //• ^ 4 fi/^ 

BVID: H4^ 3 

The following notes are for the benefit of paint crew only. 

Paint Yes Paint No Location Paint Description 

Siding A 

Soffit y 

Fascia y 

Comer Trim y 

Window Trims y 

Door Trims Jl J 1 1 y

Front Porch Ceiling /HI uhk A 

Front Porch Ceiling Beams y 

Front Porch Floor sm/ y I Front Porch Railings y 

Front Porch Steps y 

Siding Baseboards 

y ^ , y

Foundation (APfiAi^ o^k 1^ -f^^^M ' l/ou^t / 

(4l44t 6uik^i- i%i^iJ^p>^i^ f^£ %/^eJ /UlEMlofK A lyA-^ / 

/ Jr­

^ 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: ^^0*^*7.,^—'hH ^'^=Jj^nJyilP_ Date:^^t>2^^dl ^ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6677 
TECHNOLOGIBS,] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: H(ff^ /^' S T ^^ ' 

BVID/SAID: ^^Qi03 

PRUDENT ASSESSMENT REPERSENTATIVE: 

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.) 

6t^ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6677 
# 

TECHNCKX)GIBS. 

Checklist for the Worksite Hazard Analysis 

Address: ^ 1 ^ A/, AA^4v ^ 

Crew: Date: 

Item Hazar 

Overhead Lines kL4 L i r^/" ^i hee i^ ^ ySx^LAJL, O 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property .-tdAKx^C^Jt:^cn 3^ ^ 4i^y^-^ 

Neighbor Access Required 

High Traffic Area y / ^ 

Garage ^AtrO 

Structures uOo-ertJl ^7rv5sUiJ, •b->t^f.-A^jt^^ Z^tc ^ 

.^cn^^ Driveway < ^ ^ 

Sidewalk t/yy£^ue'r-~> 

Foundation 

Retaining Walls 

y^y i 

Fences 'A-i7>S^(AtAyL,A-4i ^SiJji^uy^' ^ shTfO 

Trees 

Foliage 

Genera 7p^^S^777: l Condition of yard 

Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood , , 

^^JjJiJU^ 

Crew Foreman/ Sub-Contractor Site Safety Officer 

m 

3080 Ward Parl<way, Suite 405 2S05 N. 24'" Street, Suite 308 V.4242 M^bfcal Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 



Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

V/1 have receiveci a copy of the pamphlet, Renovate Right: Important Lead Hazard 

Information 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. 

ited name of recipient Date "^ 

ature of recipient 

-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, Renovate Right: Important Lead Hazard Information for Families, 

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

the occupant. 

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

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

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

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

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

ir the dcjor 

Printed (name p^ person certifying Attempted delivery 

date and time 

lead pamphlet deliver/ 

Signature of person certifying lead pamphlet delivery 

Y^/r /j,34 /^ . 

Unit Address 

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 before renovation (Document with a certificate of mailing from the 

post office). 
Douglas Coimty Account Information Page 1 of2 im^t: 

Douglas County, Nebraska Property Record - R1801550000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJeW O n Ma p Infomiation is valid as of 2009-8-3 Treasurer's Tax Report 

New Feature ••-»- • Auto Sajes Search 

Owner 

CLUB INCORPORATED 

4.<\7J>5 4615 N 34 AVE 

OMAHA NE 68111-0000 

Property Informatio n 

Key Number: 0155 000018 

Account Type: Ex Charitable 

Parcel Number: 1801550000 

Parcel Address: 4615N34AV 

OMAHA NE 68111-0000 

Legal Description: MONMOUTH PARK LOT 14 BLOCK 5 S 50 W 30 FT LT 12 & 8 50 FT LT 13 & ALL 

LT 14 50 X 80 & 47 X 128 

Value Informatio n 

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Improvement 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Total 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

$0.00 

Land Information 

Acres 

0.16 

SF 

7296.0 

Units 

0.0 

Depth 

114.0 

Width 

64.0 

Vacant 

Yes 

Improvemen t Information 

Building 1 

No 

Skotch 

Availabla 

http://douglasne.mapping-online.coin/DouglasCoNe/static/accoimtinfo.jsp?accountno=R18... 8/25/2009 
Douglas County Account Infocaation Page 2 of2 iCJl^t 

Square Footage: 1692.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Average 

Built As: 2 Story Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.5 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Stories: 2.0 

Floorcover: Allowance Foundation: 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year 

year Built Physical Age Remodeled Remodeled Built 

1880 0% 1880 126 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 832.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Fixture Bath Half 1.0 

Porch Slab Roof Ceil 208.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R18... 8/25/2009 
# 

TECHNOLOGIBS^ INC 

Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: Vfe^g 

Property Address: VA/r ly- s r niA

 /

Owner's Name: /']nh A.ir Mf^j-R,l\ ^M d KfiFMheUd M m 

S.NO Performance Standards/close-Out Criteria Yes NO 

1 

Was the entire structure(s) painted with the exception ofthe stated, 

excluded areas? This would include painting of other associated 

features including fascia, eaves, siding, all trim, porches, box J 

beams, columns, rails, and exterior surfaces of garages. 

2 Was all scraping and other preparation work completed 

satisfactorily? J 

3 Were all required areas of the structure(s) primed as needed and 

painted with two top coats? i/ 

4 Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/cleaned? 

A 

5 

Did the contractor collect/vacuum all falling and scraped paint chips 

on the entire property, roadways, alleyways, public access areas J

and also remove any other generated debris? 1 

6 

Is the grass area that surrounds the structure(s) in reasonably good 

condition? 

J

7 Was the paint products utilized equivalent to a 30 year 

x/ product/quality? 

8 Are all items such as polyethylene sheeting, ladders, paint brushes, 

J

cones, barrier tape etc properly removed? 

9 Is there any evidence of property damage that was done by the 

contractor? Any property damage needs to be completed prior to 

A 

the EPA Close-Out. 

10 Are there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

A

11 Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? i/ 

12 Other Considerations? Property Owner Discussions? Additional 

Woric that is Required A 

Prudent Representative Signature: 

Date: ^-S'-d ^ 

Property Owner Signature: ^ 

Date: ^^^- ^ ^ 

8080 Ward Parkway, Suite 405 2506 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577