TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: /nns ^ Date: Of,jfnj^ciin 

Address: ^fi5^ ^ ,<? ."^R .^T, 

Stabilization Contractor: Prudent Technologies, Inc. Year: 2010_ 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

y Video of property (DVD) DTg- QftA, prsT 

0^ Executive Summary 

Sf Signed Access Agreement for subject property 

5/ Pre-Renovation Form signed by Property Owner 

D Pre-Renovation Form for Occupant/Tenant, if applicable 

y Painting Agreement 

D Settlement documents (i.e., for damage or to replace plants, etc.) 

y Renovation Recordkeeping Checklist signed by Certified Renovator 

H Photographs 

y Satisfactory close-out check list signed by Property Owner 

D Property close-out check list signed by EPA 

y Property information from Douglas County Assessor's Office 

t / Hazard analysis, if prepared 

D Safety Audit 

30203793 

n Other, (describe): . ||||||| 

Superfund 

.Erudcnt Technology, Inc. Signatiire I^ate ( 

-m^^ ^ /0//3//0 

EPA CORSimature HDate 

(afterfile folder review) 
TECHNQLOGIBS.] 

Property Summary 

I Date; 6/29/2010 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of; June 

Property Address: 4546 S 38 St. SAID#: 10035 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 04/06/2010 

ii. Work Began: 04/27/2010 

iii. Close-Out Date: 04/27/2010 

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 Tracking 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 
i^w'ti* 

4aLOCIBS,INC. 

Prudent 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 

located in Omaha, Nebraska, including the property located at: 

^.^ ^ ^ ^rp ^- ^ 

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, if the soil cleanup has not already been 

performed. I understand that the stabilization contractor cannot provide assurances of which 

contractor vdll be bound to the soil cleanup. I further imderstand 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. 

f ] Yes, I have read and understand the paragraph above. 

Property Owner's Signature Date 

If you have any questions about the LBP stabilization plarmed for your property, please contact 

Prudent's Customer Relations/Office Manager for the Lead Based Paint Stabilization, Mr. Chandra 

Shekar at 402- 504-1004 or 402-889-3821. General questions about the Omaha Lead Site cleanup can 

be directed to the EPA Public hiformation Centers at (402) 731-3045 (South Omaha office) or (402) 

991-9583 (North Omaha office). 

Propertv Access Granted Bv: 

Property Owner's Signature Date 

Please Print Name 

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 

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

Fax: (816) 363-3707 Fax: (402) 504-1005 Fax: (210) 579-6577 
TKCIHINOLXXSIBS. INC. ~ «£j£» 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner ~ please print) 

RESIDENT NAME: Owner Tenant 

RESIDENT ADDRESS: 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS: 

OWNER'S TELEPHONE NUMBER: 

Home: Work: Cell: 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 

TOTAL NUMBER OF OCCUPANTS: 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS 

OR MORE PER WEEK: " 

COMMENTS OR SPECIAL INSTRUCTIONS (such as does, entrv gates, etc.^; 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented 

by EPA under this agreement are pursuant to Section 104 of CERCLA, 42 U.S.C. 9604. EPA's right 

of access to the property is provided for in Section 104(e) of CERCLA, 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." 

Property Owner Signature: A AA si5- c<^Vr^ A ^ '/—f, 'to 

(Signature) 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 
'TBCHNOLOCnSi,INC 

PRE & POST PAINT STABILIZATION VIDEO AND PICTURES 

I understand that prudent Technologies (Prudent) will be coming out to shoot a PreStabilization video and to take pictures of my property. Prudent will use the videos and 

pictures to document the current property status/condition. Also, Prudent will shoot a video 

shot following the completion of the paint stabilization. I give permission to videos and 

pictures of my property. 

Please list any special conditions that Prudent eniployees need to be aware of before 

shooting a video (suoh as pets, prior notice, etc.). 

Property Address 

y-^-/o 

Owneerr s Name Signature Date 

ADVANCE NOTICE REQUIREMENT 

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. Please indicate below how much advance notice you need to have the abovementioned tasks completed. If you are a landlord you will need to contact the tenant as 

Prudent will only inform the property owners. 

Do you have any pets that reside in yard: -

Notice needed: 

Phone number to call to give notice: 

Whom we are giving notice to: 

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 
Current Sampl Sa e Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

^ I have received 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. 

Printed name of recipient Date 

Signature of recipient 

Self-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 Leadijazard 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 further certify that I have left a copy of the pamphlet at the unit by sliding It 

under the door. 

Printed name of person certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person certifying lead pamphlet delivery 

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). 
tMCT 

ACCESS ASSESSMENT FORM: 

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 scrapping? 

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? 

Does this property have a garage? 

If yes, describe location of garage. 

Does this property have aluminum siding? 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 occupied? 

Are there any pets at this property? 

Are there any low hanging power lines? 

Do we need neighbor's access? If yes please explain 

and get neighbor's property address and owner 

information. If possible, get signature from the 

neighbor. 

- p«>.*-U 

V f ^ 

T ^ <? 

>J*? 

y ^ 

MP 

> I ^ 

o 

-^r<g> 

V'S 

--Yio 

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 
INC 

PAINT MATCHING FORM: 

I. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: ^ *^ Lf A ^ ^C" ^ . ^ f 

BVID: 

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

Paint Yes Paint No Location Paint Description 

Siding y 

Soffit y 

Fascia y 

Comer Trim ( / 

Window Trims 1/ 

Door Trims / 

Front Porch Ceiling fr >t^ 1^-*- s- :y^^k 

Front Porch Ceiling Beams / 

- Front Porch Floor / 

Front Porch Railings 

/ 

Front Porch Steps 

/ 

Siding Baseboards y 

Foundation 

< • 

^e^r dtfVj^ / 

r ^ 

ui^{

y^ 

^".^

 o^ e. 

. 

{J o

Ouy)e.f

 ir/^e Wj<in 

 w^M 4p^r y OocOn — 

y^ 

y 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: X ,<^'VSrlC'S,'^ ^ Qt-Vada^ Date: ^^^ <^" ^<3 

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: (8l6) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
(effective April 2010) 

RENOVATION RECORDKEEPING CHECKLIST 

Name of Finn: %>{enn ^^ ^ 

^ 

Date and Location of Renovation: 7f9v7-p^'<^ ^'yHCp'?^- ^S> 'PJ^ 

Brief Description of Renovation: (P/V'/i^-Jf / '^Cjq^ ^ a/AfJ ^{\V^€ y 

Name of Assigned Renovator: K \^g>y\>>rA fr^tA'^-.­

Name(s) of Trained Workers: h{\\rvK<n 3r^i^. ^ (^bgcJ cvrfcf ^ yl^ya t <^ 

/' ^'y,us^m.\\'Q Name of Dust Sampling Technician, Inspector, and/or Risk Assessor, if used: 

ies of renovator and dust sampling technician qualifications (training certificates, certifications) on file. 

Certifie^^novator provided training to workers on (check all that apply) 

• Posting waming signs GSetti Q Setting up plastic containment barriers 

^y . / DyMaintaining contaimnent u Avoiding spread of dust to adjacent areas D^amtaining contamment u A 

• WWast a e handling Q Post-renovation cleaning 

U Test kits used by certified renovator to determine whether lead was present on components affected by 

renovation (identify kits used and describe sampling locations and results: N / / y \ 

g signs posted at entrance to work area. 

Work area contained to prevent spread ofdust and debris. 

t^^uidows in and within 20 feet ofthe work area are closed 

^Doors in and within 20 feet ofthe work areas are closed and sealed 

u Doors that must be used in the work area are covered to allow passage but prevent spread ofdust. 

I^Groimd covered by plastic sheeting extending 10 feetfi'om work area - plastic anchored to the 

buifiding and weighted down by heavy objects. 

0 If necessary, vertical containment installed to prevent migration ofdust and debris to adjacent 

property. 

D Waste contained on-site and while being transported off-site. 

Renovation Recordkeeping Checklist Omaha Lead Site 
(effective April 2010) 

0 Work site properly cleaned after renovation. 

£f All chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for 

renipval. 

[/Work area HEPA vacuumed to get paint chips from groimd surface, if necessary. 

D Certified renovator performed n eleanin verification (describe results): •apost-renovatio post-renovation eieamngg v 

•:-^-zi>e<? ,yr j 

S^ I certify under penalty of law that the above information is true and complete. 

Name and Title Date 

Renovation Recordkeeping Checklist Omaha Lead Site 
TECHNC»X)GI1S. INC. 

Checklist for the Worksite Hazard Analysis 

Address: A'P^l p !S 5 ? ^a t 

Crew: Date: 01)4^ A^'\ 0 

Item OK? / Hazard Corrective Action 

y Overhead Lines 

In-transit Vehicle Clearance 

^ Levels around high wires 

Vehicle Clearance around 

^ high wires when working 

Phone y lines 

Cable lines 

y Gas Line y^ 

Water Line 

y . Sewer Line y. 

Septic Tank 

y^ 

Propane/Butane y ^ 

Access to/on Property ^^z-

Neighbor Access Required y ^ 

High Traffic Area y ^ 

Garage y ^ 

structures 

y^ 

Driveway y^ 

Sidewalk y ^ 

Foundation 

y ^ 

Retaining Walls y. Fences y.- Trees y Foliage y^ 

General Condition of yard y 

Damaged Areas: sink 

y^ holes/rotted wood 

Sprinkler System y 

Pets •^y. 

Insects 

y^ 

Weather Conditions y^ 

Unsafe driving conditions y^ 

Unsafe neighborhood y 

Sub-Contractor 

8080 Warij^arkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Sulte.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) 679-6577 



0 

ENVIRONMENTAL & CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

OMAHA LEAD BASED PAINT REMEDIATION 

Property Owner Close-Out Form 2010 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-07) 

SAID: l6c) 3:?. 

Property Address: ^X-^J^ ^ ^ j y ,*^ y 

Owner's Name: ^Ay^j^/^/ ^ ^ ^ iyjy?j: ^ 

Performance Standards/Close-Out Criteria VES 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 beams, colunms, rails, and exterior surfaces of garages. 

2. Was all scraping and other preparation work completed satisfactorily*/ y 

3. Were all required areas ofthe structure(s) primed as needed and painted with two top coats? 

4. Was the paint products utilized equivalent to a 25 year product/quality? 

5. Are all ofthe areas where contaminated materials have been spilled thoroughly vacuumed/ 

cleaned? 

6. Did the contractor collect/vacuum all falling and scraped paint chips on the entire property, 

roadways, alleyways, public access areas and also remove any other generated debris? 

7. Is the grass area that surrounds the structure(s) in reasonably good condition? y 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, etc. y 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 the EPA Close-Out. 

10. Are you satisfied with the work performed? Ty 

11. Are there any property items that were temporarily re-located by the contractor that need y to be moved back? 

12. Are there any (known) lingering issues with the property owner(s) that have been left 

unresolved? 

Other Considerations/Property Owner Discussions/Additional Work that is Required: 

<f j-X-^ />o^<^ 

Property O ature Date 

Prudent Ted , Inc. Signature ^4^ ^ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 218 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 
Douglas County Account Information Page 1 of3 

Douglas County, Nebraska Property Record - R0731240000 

Print Report 

NEW Feature - Parcel Dimensions available (3 scale 0-50 ft west of 52nd St - VJeW OH Ma O Information is valid as of 2010-3-16 Treasurer's Tax Report 

New Feature •* •• ?* Auto Sales Search 

Owner 

CAVADA ANDRES 

ETAL 

4424 S 26 ST 

OMAHA NE 68107-0000 

Property Informatio n 

Key Number 3124 OOOO 07 

Account Type: Multiple Res 

Parcel Number 0731240000 

Parcel Address: 4546 S 38 ST 

OMAHA NE 68107-0000 

Legal Description: BURLINGTON CENTER LOT 19 BLOCK 1 LTS 18 & 19 80 X 120 

Value Informatio n 

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$8,000.00 

$8,000.00 

$8,000.00 

$8,000.00 

$8,000.00 

$8,000.00 

Improvement 

$40,700.00 

$40,700.00 

$43,700.00 

$43,700.00 

$37,600.00 

$34,200.00 

Total 

$48,700.00 

$48,700.00 

$51,700.00 

$51,700.00 

$45,600.00 

$42,200.00 

Sales Informatio n 

Sales Date: 2003-12-04 

Deed Type: 

Price: 

Grantor 

WD 

$38,000.00 

HOMEBUYERS INC 

Book: 2003 Page: 239628 

Grantee: ADRES CAVADA ETAL 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 2003-11-21 

Deed Type: TRD Book: 2003 Page: 228121 

Price: $0.00 

Grantor THOMAS OSTDIEK 

http://douglasne.niapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R0731240000 3/23/2010 
Douglas County Account Information Page 2 of 3 

Grantee: HOMEBUYERS INC 

Valid/Invalid: Invalid 

Exclusion Reason: Foreclosure 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.22 9600.0 1.0 120.0 80.0 No 

Improvemen t Informatio n 

Building 1 

1 1/2 Story Unnn 4546 S 38 St tnalDea. 

IrcliuMVKal OdtqR 

1?4lHll IBS' 

-UB_ J2? 

> 

1 

tSiql t 

---ISa^SftfiL*jnQpiw«rM*iliawl>iLw—JU— 

CLICK TO ENLARGE IMAGE 

Square Footage: 1023.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: End Condition: Fair 

Built As: 1 1/2 Story Unfin Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 7.0 

Exterior: Frame Siding Units: 2.0 

Interior: Drywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 5.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1905 0% 1905 105 

Detail Type Detail Description Units 

Add On Frame Utility 21.0 

Add On Unfinished Attic W/floor 882.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 1023.0 

Basement Minimal Finish 850.0 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp7accoun tno=R0731240000 3/23/2010 
Douglas County Account Information Page 3 of3 

Basement 

Fixture 

Fixture 

Porch 

Porch 

Porch 

User 

Outside Entrance 

Base Fixtures 

Bath Full 

End Solid Wall 

Slab Roof Ceiling 

Wood Deck 

2 UNIT CONVERSION 

1.0 

1.0 

2.0 

124.0 

132.0 

64.0 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R0731240000 3/23/2010