### TRANSMITTA L of OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAI D # : 2708 1 Address : 430 3 Patric k Av e Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S 1 ^ Vide o o f propert y (DVD ) 0 Executiv e Summar y H ' Signe dAcces s Agreemen t fo r subjec t propert y ffl^ Paintin g Agreemen t D Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc. ) D Photograph s B

f Satisfactor y restoratio n signe db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A H' Propert y informatio n fromDougla s Coimt y Assessor' s Offic e D D D 

### Signatur e . TJat e

4031039 9 

# I H Superfun dPROPERT Y SUMMAR Y Date : 12/03/0 8 LB P STABILIZATIO N EPA CONTRAT EP-R7-08-0 7 Month of : Decembe r Propert y Address ; 430 3 Patric k Ave SAID : 2708 1 A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : None A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 10/20/0 8 Wor k Bega n Date : 11/02/0 8 Closeout Date : 11/13/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio n For m 6 . Pain t Matc h For m 7 . Trackin g For m 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EPA Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES . INC .

# H) INVIRONMBNTAL A CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICI S 

# r Propert y Statu s For m Date Date 

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# A*^= VSi^ S f^clfiV t /^'^^?~^ BVID : ^^o9 f Plan t & Pennanen t Landscaping To Remai n In Plac e Descriptio n an dLocatio Q 

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### Doe s you r Basemen t hav e ahistor yof leaking ? Ye s —- No Item ^ Dracriptio n& Locatio n O&Ma p 

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# V ll Propeit y Owae r Pruden t Emp i Signature ; 

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Pmden t Technolo^es , Inc . (Pnident ) i s under contract (Contract #EP-RT-OS-OT ) wit h th e U . S . Emironmenta l Protectio n Agenc y (EPA ) t o stabiliz e Lea dBase dPahi t OL/BF ) at anumbe r

of propertie s locatedmOmaha , Nebraska , includin g di e propert y locateda t T>?^ 3 

### P^tfyic k A^ ^ 

### The EP A requests your permissio n t o allo w Pruden t to perfor mLB P Stabilizatio n at tiiis property . B y signb g tiiis form, tiie propert y owne r grant s permission to Prudent t o perfor mactivitie s relatedt o LB P Stabilizatio n indudm g scrapin g pain t an dpamting oftii e referencedproperty . Furtiier , tiie owner/tenan t verifie s tint tiuy hav e receive dth e LB P pamphlet '^Renovat e Right " Ifyo u hav e an y question s abou t tiie LB P stabilizatio n plannedfo r

your property , pleas e contac t Prudent* s ^%ii^|gt^v e Cler k

fo r

th e Lea dBase dPaint Stabilization , Mrs . Debora h hXeenAaJLtAktamn ^ at

(402) S04»1004 . Cenerai question s abouttiie OmahaLea dSite cleanup can b e du:ecte dto tiie EP A Public hiformatio n Center s a t (402 ) 731-304 5 (Soutii Omah aoffice ) o r (402 ) 991-958 3 (Norti i Omah a

I (Plns e Print Nni ^ PlopciQ ^ Oner SiiniBir K ^ (Signtfurd^ (Date) PROPERT YINFORMATIO N (T o b e ceaplett d b yrtiidci t tid/e rpnpcrtj romif r- plcu e prta Q ReSIDOirNAME : ftl ^

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Rmte r RESDBI TADDRESS : IPREIITAL,PROPERTYOWNEDBY : ^ ^ 17 ^ OWNERr a MAIUN O A0DRS88 ; -^Jtf ^ /o<Sh/^J^ ^ OWNBTSTOfPHONENUMBER.HOME : r^fi^'^r~W/ / WORK ; I \ NUMBE R O P OCCUPAHTS UNDE R 7 YEAR S OLQ^; ^

NUMBE R O P OCCUPArfT S 7 YEAR S OL D AN D OLO I NUIBBROPCHILORE N UNDGR T YEAR S OU>VVH O PlA YI N TH E YAR D FO R 8 HOUR S O R MOR E PE R VVEB ^ COHHEKnORSPECUkLINSTmiCTIONS : (LE . DOGS , ENTR YQATES , ETC. ) 

# A W AUTHOim YFO R ENVKONMEOTA L KESPOr ^ ACTIONS ; Tl wMHvWe t t o be fanplem^^ erCSRCLA.42UAC96M . EPA'tri8btoraooeNtoAepnpei9i>piovi(MibriaSecilonl04(e)ofCBRCLA,42U.S.C9605(eXi>b M fbr'^dttBimtalsilh e oeo d Ib rniponi ^ o rcfaoMitt f ortd±i s «i yictpon ^

# Curren t Sampl e Pre-Renovatio n For m EffeoiiMunaiApiflzoio . Conflmnao n ofReceip t ofLoa d Pamphle t J P I >ie w received a cop yd th e pannphlei.fi9noyalofl(ghfc<fT^port8fr t Lea d H ^ ^^ trtjmafaifarftmfflb^ChgtfOafB/^ ^

th s potanila l risK oflh e lee d hazar d espoBur e ftoin renovation activit y perfcime d In tn ydwellin g unit . I received thi s pamphle t befbr e th e vvor k began . Printe d nam e tfrectalen t . /^ Dat e Signaiur e orrecipient'^ 8eH<!erailc8Ho n OpDo n (Ib rtenant<«ccupie d dweHlng a only ) — Ifth s lea d painphle t VV8 8 delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec Kth e appropriat e bo xbelow . Q Refusa l to sign— I certif ytha t I hav e mad e a goo d M h effort to deOverlh e panpPiBt , Renovat e fVghblnvxxlan t Lee d Hazan i hfonnetio n torFe^ ^ C Wcar e flwIblflfgantfScrtoote, to th e renta l dwellin g unft liste d dat e an d tkn e kxfcate d an d tha t th e occupan t reluse d to sig n th e confirmatio n cfleoeip L I Affthe rcartil ytha t I hav e lef t a cop y ofth e pemphie t at th e urt t wit h inaoccuponi . Q UnawalUbl e (O raignahr a •- 1 certif ytha t I hav e mad e a goo d fait h effort to deO wth e pamphlet./%mv«t o n!g/)t ; lirnpor ^ Amlss i CM d O m pnovtter a arx ySc/wofe , to th e rerita l d^ ^ belo wan d tiia t th e occupan t wa s unavailabl e to sig n th e confimiatio n ofreosipt . I fUrttje rceitit ytha t I hav e lef t a cop y ofth e pamphle t at th e uni t byslidin g it % %^/> . sonoertHyin g Attempte d dellvei y

/ i dateandtim e /h ^ lea d pamphle t delivery ^6tA- ­ fiOerso Signatur e ofipmo n n certHyin g lea d pamphle t deliver y 

# ^S/) J W^/?ic ^ ^ IMtAddiw s Not e Regaidin g Mailin g Option—A s an aitemativ a to deHvo yIn person , yo u ma yma l th e lea d pamphle t to th e owne rand/o rtenanL Pamphle t mus t be maile d at leas t 7 da ^ befor e renovatio n (Documen t vvit h a certificat e ofmailin g fro m th e postoliios) .

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### Pag e 1 of 2 

# 3^9-06 1 Dougla s County , Nebrask a Propert yRecor d - R081971000 0 Prin t Repor t NE W Featur e - Parce l Dimension s avaiiabi e @ scal e 0-6 0 ft wes t o f 90t h S t - Vle W O H Ma p Informatio n i s vali d a s o f 2008-9- 4 Treasurer' s Ta xRepor t Ne w Featur e -•-+- > Aut o Sale s Searc h Owne r HETRIC KMARILY N 430 3 PATRIC KAV E OMAH A N E 68111-000 0 

# ^^3^/ 1 Propert yInformatio n Ke yNumber : -. 1971000 0 0 8 Accoun t Type : : Residentia l Parce l Number : \ 081971000 0 Parce/Address : 430 3 PATRIC KA V OMAH A N E 68111-000 0 Lega l Description : \ CLIFTO N HIL L LO T 1 BLOC K1 5 5 0 X 8 2 Valu e Informatio n V Lan d I Improvemen t Tota l 200 8 $5,300.0 0 ] $34,960.0 6 $40,200.0 0 200 7 $5,300.0 0 : $34,900.6 6 $40,266.0 6 200 6 $5,300.0 0 $40,200.6 0 200 5 $5,300.0 0 I $11.~800.6o $17.100.0 0 200 4 $5,300.0 0 : $10,700.6 6 "$16,660.0 0 200 3 $5,300.0 0 I $10,700.0 0 $16,000.0 0 Lan d Informatio n •• : Acre s 0.0 9 [••"• • \ S F 4100. 0 "T " Unit s 1. 0 Depti i 82. 0 ( Widt h 

# v 50. 0 Vacan t N o Improvemen t Informatio n Buildin g 1



### http://douglasne.mapping-online.eom/DouglasCoNe/static/accountinfo. j sp?accountno=R08.. . 10/9/200 8> | ' CLIC KTO_E;JLARG E IMAG E J Squar e Footage : 1040. 0 Perimete r 6. 0 Uni t Type :

Buil t As : Ranc h

HVAC : I Force d Ai r ! Exterior : ! Fram e Sidin g ! (-. . Interior : j Drywal l I Roo f Cover : Compositio n Shingl e

Roo f Type : Gabl e Floorcover : Allowanc e Yea r Percen t YearBuil t Remodele d Remodele d 189 5 

### 6 % Detai l Typ e i Detai l Descriptio n Ad d On " ' "_ ; Fenc e Chai n Lin k Applianc e Allowanc e Basemen t I Bsmn t Bloc k 8 f t Fixtur e i Bas e Fixture s Fixtur e i Bat h Full _ Porc h ; Woo d Dec k Use r Partia l Basemen t 

### Pag e 2 of 2

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10*0. 0 !.< ! »: . RANC H

VtJ"****" " CLIC KTO ENLARG E IMAG E Percen t Complete : !. 100.0 % Quality : 1 Fai r Condition : I Fai r Cond o Squar e Footage : : 0. 0 Rooms : ! 5. 0

_Units : ; 1. 0 Baths : I 1. 0 Bedrooms : 1. 0 Stories : 1: 6 Foundation : Bloc k -h Sprinkle rSquar e Footage : ' 0. 0 Adjuste d Yea r Physica l Ag e Buil t 189 5 11 3 Unit a i" o -..„, . 520. 0 ••-J ­ 1~

0 25. 0 520. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?aceountno=R08.. . 10/9/200 8

# dER> V Jun e 26,200 8 (lates t revtsion ) 

## EP A Propeit y Close-Ou t For m(Lead-Base dPain t Stabilizatioii ) iPtPDMrtylDNBmbM : 

### Stac k iB dVeUd i Ffoport y I D Nam I ' 

### PrapertjrAddiCM : OirBer*9ffasie: . 

## Perfomianc e Standards/Qose-On t Criteri a ye s n o I .Wast e «Bliiefiiaotara(s)i»iBtedwi & th e exceftio o c f tb e stated , exchid ^ Thiswool d iodadepabitia g o f odie r associite d(batnre s includin g tbscia , esves , siding , al l trim , porches , bo x beiBa8.coliimM,ndb . an dextcrtwsurfiwe s of garages . , / 

### 2 .WnaUKiq)in g tn dotiterprepsrado nwoi k complete dsatisfiutority ? ^ 

### 3 .

WwiHwffllw darea s offlie«troc<ure(8)prtoe da s neede dan dp ^ ^ 

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, WsitepaiatpiOduetSQtiJisQdequhndeiittoaSOyearpR^ ^ t / 

### 5 .Ar e ai l o f di e area s wher e cootanuDate dmaterial s hav e bee nspille dthoroughl y vacuuned'cleaned ? y 6 .IHdtt e contracto r eollect/vacnu mal l &Uing andscrape dpain t chip s o nth e entir e property , wad»a!ys,slleywtys.poblicacc<iS 5 area s aiK l als o remov e any otfawgBoe^ ^ 

## y 7 .

bibognwsmtha t snmmnd s di e stroctare(8 ) i nreasonably goo dcondition ? y 8 .A niDitensstidiBspdyo^le w sheeting , ladders , paint Imabes , cones , barrie r ta^ ^ t / IMMWO/ ., • - ; 

### 9 .

bflw o an y evidenc e o f propert y damag e tha t wa s don e b y th e contractor ? An y piropert y damag e < / 

### need s t o b e complete dprio r t o di e EP AClos^Om . . . 10 . Al t dier e an y piopeit y item s dia t wer e temporarityre'Iocate db y tb e contracto r tiia t nee dt o b e t y 

### novedbadc ? 11 . AiedM O an y (known ) lingerin g issue s wid i di e property ownisr(s ) dia t hav e bee nlef t imresoived ? t y 

### O&erCnisideiHtions/Piopert y Owne r Discussions/Additiona l Wor k tha t i s Require d

Jpoi/ n J&eu.t * 

### BP AGdR/iRepvesentativ e ,,_. ^ hat e uh/0 9

### Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) 

## SAl k HAI J ^ . I . Probert yAddress ; M ^ C^O ^

n^V/g C N U > Owi^er' s Name ; IA^>-*l\«iy \ ^A^Vt'^lt^ ^ 

### Perfbrmanc e Standards/ciose-Ou t Criteri a YE S N O Wa s th e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x \ 

# i beams , columns , rails , an d exterio rsurface s o f garages . 2 .w ^

al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 .Wpre al l require d areas o f th e 5tructure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 

# X . 4 .

Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 

# X 5 .An e al l o f th e areas wher e contaminate d material s hav e bee n spille d thproughl yvacuumed / cleaned ? 

# ) L 6 .Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi c acces s areas an d als o remove an yothe rgenerate d debris ? 

# X 7 .

I s tp e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# X 8 .Ar a al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properi yremoved ? 

# i 9 .

I s ther e an yevidence o f propert ydamag e tha t wa s don e byth e contractor ? An ypropert ydamag e neqd s t o be complete d prio rt o th e EP A Close-Out . 

# X 10 . Areper e an ypropert yitem s tha t wer e temporatil yre-locate d b yth e contracto r tha t nee d t o b e move d back? 

# 1 11 .Ar e ther e an y(known ) iingerin g issues wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? 

# y Oth g Consid6rations?propert yOwne rDiscussions?Additiona l Wor k tha t i s Require d 

## Ccu\JL yJL ^ esentativ e C ^ '(^MA^^-^ ^ / . 

# iy^/r 1