TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: JP^f^^/ ^ Date: 

Address: tT.^iT^LT A / ^< y .^y . 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Videoof property (DVD): Pre-Stabilization & Post-Stabilization Videos 

M Executive Summary 

Qe Signed Access Agreement Form 

Q^ Advance Notice Form 

M Pre-Stabilization Video Agreement Form 

m Access Tracking Form 

u Property Access Assessment Form 

n Neighbor Access Agreement Form 

t / Paint Matcli Form 

M Pre-Stabilization Property Safety Assessment Form 

0^ Work-Site Hazards Analysis Checklist 

B^ Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

B Douglas County Assessor Property information 

0 Property Completion Agreement Form Signed by Property Owner 

ly Property Close-Out Check List Signed By EPA 

jf\ ^ ^^^^^.^'^'^^

Prudent Tecnnologiesnnc. Signature

 ^— 

 Date 

' ' DatT 

30054925 

•HI 

Superfund 
TRCHNOLOGIBSb INC 

Property Summary 

Date: 11/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov 

Property Address: 3933 N 23 St. SAID #: 33643 

A. Executive Summary; 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 9/23/2009 

u. Work Began: 9/28/2009 

iii. Close-Out Date: 9/29/2009 

B. Enclosures; 

1. Pre-Stabiiization 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 
' TBCHNCaxXilBS. 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 3 ^ 3 3 ^ 2-^^i i 5 ^ , 0\f \ ^ K« , W^ C=-

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 of the 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 perfonned. 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, 1 have read and understand the paragraph above. 

Signature of Property Owner 

Date 

If you 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 oflHce) or (402) 991 -9583 (North Omaha office). 

Property Access Granted By: * 

(Please Print Name) 

Property Owner Signature: YAL. i}.%h 

(Signature) 

(Date) 

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

Kansas City, MO 64114 Omaha, Nebraslta 63110 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 
IBS, INC. 

PROPERTY INFORMATION 

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

RESIDENT NAME: R^ymrT Dcj Moor o Owner { Renter 

RESIDENT ADDRESS: _ _ ^ ^ 1 

• RENTAL^I^TY OWN^r^BY^^ ^ ^ ^^^ ^ (^^0^^! ! JrW^jJpO^rdl, ll ^ 

IWNER'S MAILING ADDRESS; ^ h r s ^ / i o .i i ^ 

IPJoSn Dc^y^^Pr . (7ml)^. Mf loVl^ I 

OWNER'S TELEPHONE NUMBER - HOME: 

NUMBER OF OCCUPANTS UNDER 7 YEARS 0LD:X 7 NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

NUMJBEMJBI R 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.) 

r^ry^rl yard 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement arc 

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) 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 of the title." 

^ /XM ^. % M el-^^lo'f 

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 
TECHNOLOGIES,] 

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? 

NO 

Notice needed:^^ /^^ ^ Nofjcuz^ 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owner's Signature 

x^3C ^• 

t!J2-sj o l 

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 
TECHNOLOGIES,] 

PRE-STABILIZATION VIDEO FORM 

I 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: UcUhi^^H JD^^^T^^^ ^ ^^ ^ 

U 1x1 Z3^" 5!- PROPERTY ADDRESS : 3^ 3 3 

BVID/SAID: 3 3 ^^ ^ 

HOMEOWNERS SIGNATURE: K/^^^ww ^ 

PRUDENT REPRESENTATIVE SIGNATURE: Ck^ ^ J<^^ She.k<^r 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

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 
TECHNOLOGIES;] 

ACCESS INFORMATION TRACKING SHEET 

BVID: ?>b&M 3 PROPERTY ADDRESS: '^^^' b ^ ^ ^ ^ 

Property Owned By: 

(If new property owner) 

Owners Phone No's: Home: Work: 

Cell: Fax: -

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

^I'^h ^' ^ uz^^^ ^fTwf-^ • 

11 ypff J

> • 

Comments: 

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 
TECHN09LOGIES» 1 

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 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? y<A 

Does this property have any significant structural da^mage? 

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 
TECHNOUWIES,] 

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 propertVvacannbr 

Are there any pets at this property? 

Are there any low hanging power lines? 

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)822-9688 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 679-6577 
TECHNGIJOGIBS ; ] 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

(00 

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 
aaijOGiEs.iNC 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: '^^'^ 5 M 2.^^ ^ S l ^ O vo«K«, W ^ 

BVID; 33 6 ^ "^ 

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

Paint Yes Paint No Location Paint Description 

Siding P\\hr\^r\\\}cx\ yy 

Soffit VJOVN\K_ ^ 

Fascia S ^ \ y 

Comer Trim 

Window Trims C^tCW^ f ft^OLC\^ 

\ ^ 

Door Trims °f^^ < ^\ac\^ \ ^ 

Front Porch Ceiling -

Front Porch Ceiling Beams r" 

Front Porch Floor -

Front Porch Railings -

Front Porch Steps f^-uy^ \ ^ 

Siding Baseboards 

Foundation uCrVvA VC 

WOVNS K _ ^^oy^<i. i^J«'--fi| \ ^ 

^JrwjLi 

L ^ 

o 4 0 ^ 

^T^- V OLA^^V . JfA^ imV( ^ \V(L e.'/.\^V{»^ cj6\cir '\ f 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: >C/y%w^ d ^ /h(/[A m Date: 6/:2-^/o9 

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 
TECHNOIJOGIBS,] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

ADDRESS: U t r e U <f cW . J- x W rt^ S^ ^ . PROPERTY 

BVID/SAID: 2>'b C» ^ 3 

PRUDENT ASSESSMENT REPERSENTATIVE: 

eonje^t (\A<Y ^ 

REPERSENTATIVE REMARKS/FINDINGS: 

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

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

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 Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

^ 1 have received a copy of the pamphlet. Renovate Right: Important Lead Hazard 

/ Information for Families, Child Care Providers and Schools infomiing 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. 

Rrintedd nam namee c 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. 

i^i^navailable 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 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 

« f\ date and time 

^J JtiiJli^ ^ '®^^ 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). 
TKMNOLOGIBS^INC. 

Checklist for the Worksite Hazard Analysis 

Address: ^^ ^ M • &ti& Ot . 

Crew: Date: 

Item OK? Hazard Corrective Action 

Overhead Lines 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines : ^ - (U>y^'W\p^^^ ^ ^ ^ZSZ" LOUJO^ QiH^r^'^ciWd^l^ 

Gas Line 

Water Line 

-^=3^ 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required 

High Traffic Area 

Garage 

Structures UXxuLyyir^ '/^juckur^. ^6fy^r4h^^ZZ 

Driveway ci-^ 

Sidewalk 

Foundation 

Retaining Wails 

Fences 

Trees 

Foliage 

General Condition of yard 

Damage t.€rtt/w3^ :- UL>J-i^J^(jdJA.lyy ^ d Areas: sink 

holes/rotted wood ( ^ ^ 

^ ^ ^ Sprinkler System 

Cyfetractor fficer 

8080 Ward Parkwj 2505 N. 24'" Street, Suite 308 4242 lltedical Drive, Suite 4250 

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

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

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


:li¥/M . *? .• y ,a "^^'' \ f>^k. • / m 

. # 4 J 

* r' 

y.. ^ijj^ ^ 

Douglas County Account Information Page 1 of 3 

Douglas County, Nebraska Property Record ^ R2013610000 

Print Reoort 

NEW Feature - Parcel Dimensions availabie &. scaie 0-50 ft west of 52nd St - VlOW OH MS P Information is valid as of 2009-9-15 Treasurer's Tax Reoort 

New Feature •• -* ' ^ Auto Sales Search 

Owner 

WRIGHTSELL INVESTMENTS LLC 

ETAL 

12657 DEER CREEK DR 

OMAHA NE 68142-0000 

Property Informatio n 

Key Number: 13610000 20 

Account Type: Residential 

Parcel Number: 2013610000 

Parcel Address: 3933 N 23 ST 

OMAHA NE 68110-0000 

Legal Description: PLAINVtEW LOT 18 BLOCK 3 50 X 124 

Value Informatio n 

Land Improvement Total 

2009 $7,000.00 $32,700.00 $39,700.00 

2008 $7,000.00 $32,700.00 $39,700.00 

2007 $7,000.00 $32,700.00 $39,700.00 

2006 $7,000.00 $32,700.00 $39,700.00 

2005 $7,000.00 $12,700.00 $19,700.00 

2004 $7,000.00 $11,500.00 $18,500.00 

Sales Informatio n 

Sales Date: 2006-01-23 

Deed Type: QCM Book: 2006 Page: 007796 

Price: $0.00 

Grantor: Latrell Wrightsell eta! 

Grantee: Wrightsell Investments 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Sales Date: 2006-01-09 

Deed Type: QCM Book: 2006 Page: 002694 

Price: $0.00 

Grantor: Wrightsell Investments 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R2013610000 9/16/2009 
Douglas County Account Information Page 2 of3 

Grantee: Latrell Wrightsell etal 

Valid/Invalid: Invalid 

Exclusion Reason: Conrective Deed 

Sales Date: 2006-01-06 

Deed Type: QCM Book: 2006 Page: 002004 

Price: $0.00 

Grantor: WRIGHTSELL INVESTMENTS LLC 

Grantee: LATRELL WRIGHTELL ETAL 

Valid/Invalid: Invalid 

Exclusion Reason: Multiple Owner - Trade 

Sales Date: 2004-11-16 

Deed Type: QCM Book: 2004 Page: 160767 

Price: $0.00 

Grantor: LATRELL WRIGHTSELL ETAL 

Grantee: WRIGHTSELL INVESTMENTS LLC 

Valid/Invalid: Invalid 

Exclusion Reason: Multiple Parcel Sale 

Sales Date: 2001-01-05 

Deed Type: D Book: 2171 Page: 653 

Price: $23,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6200.0 1.0 124.0 50.0 No 

Improvemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accoimtinfo.jsp?accountno=R2013610000 9/16/2009 
Douglas County Account Information Page 3 of3 i 

3«33N23a. o r 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 936.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Poor 

Built As: Ranch Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Frame Vinyl Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 1.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1904 0% 1904 105 

Detail Type Detail Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 461.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 480.0 

Porch End Screen 60.0 

Porch End Screen 133.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2013610000 9/16/2009 
IBS, INC. 

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

SAID: 336^3 

Property Address: 3^36 ) ^J °^ ^ SAOwner's Name: cA^JtAo/rgj i > ^^vQC^U-^ l 

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

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

' excluded areas? This would Include painting of other associated 

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

beams, columns, rails, and exterior surfaces of garages. A 1 

2 Was all scraping and other preparation work completed i 

satisfactorily? n 

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

painted with two top coats? X 

1 4 

Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

X • 

5 

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

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

i 

and also remove any other generated debris? X i 

6 Is the grass area that surrounds the structure(s) in reasonably good 1 condition? y 1 

17 Was the paint products utilized equivalent to a 30 year 

i 

product/quality? y 1 

|8 

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

cones, barrier tape etc properly removed? y

: 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 Ciose-Out Xi ,0 

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

11 

Ar

contracto

e there an

r tha

y (known

t need t

)

o

 lingerin

 be move

g issue

d back

s wit

? 

h the property owner(s) 

y

that have been left unresolved? 

x\ 

il2 

Other Considerations? Property Owner Discussions? Additional i 

Work that is Required 1 x4 

Prudent Representative Signature: 

Date: 

Property Owner Signature: (j^y\/\/^ OC 

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 
TBCHKOIXXSIBS^ INC 

EPA Close-Out Form (Lead-Based Paint Stabilization) 

BVID: "^B ^ ^ ? 

Property Address: 

u s^ 

Owner's Name: vJAc|li\keti U o 

Performance Standards/close-Out Criteria 

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

excluded areas? This would include painting of other associated 

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

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

Was all scraping and other preparation work completed 

satisfactorily? 

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

painted with two top coats? 

Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/cleaned? 

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? 

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

condition? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

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

cones, barrier tape etc properiy removed? 

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

contractor? Any property damage needs to be completed prior to 

the EPA Ciose-Out. 

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

contractor that need to be moved back? 

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 

S.NO 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

Yes 

y 

y 

y 

y 

v^ 

/ 

y 

y 

NO 

y 

y 

y 

i / 

EPA COR/ Representative Signature 

Date: ////^ ^