/ 

# ^ ' 

TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: /T^'^fS Z Date: , 

Address: 'l^lf g VX^llVlS Jl v 

Stabilization Contractor: Professional Environmental Engineers Year: 20tl-lPAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video ofproperty (DVD) 

d Executive Summary 

w Signed Access Agreement for subject property 

S Pre-Renovation Form signed by Property Owner 

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

"(3 ^ Painting Agreement 

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

M Renovation Recordkeeping Checklist signed by Certified Renovator 

^1 / Photographs 

Ijlr , Satisfactory close-out check list signed by Property Owner 

U , Property close-out check list signed by EPA 

Property information from Douglas County Assessor's Office 

Hazard analysis, if prepared 

Q Safety Audit 

dr Other (describe): 

S/s7^oP­ (after file folder review) 

40377564 

Superfund 
2505 North 24'^, Suite 219 

Omaha, NE 68110 

(402) 504-4688 

Fax (402) 504-3281 

PROFESSIONAL 

ENVIRONMENTAL ENGINEERS, INC. 

"Providing cost-effective environmental solutions" 

Consulting • Engineering Design • Remediation • Abatement • Emergency Response 

Lead Base Stabilization Omaha, Ne 

Close Out Report 

2011 

SAID# 28352 

1518 Willis Av 

• Dates worked: 6/18 to 6/21 2011 

• Pre property condition: House and garage have vinyl siding with painted wood trims 

and foundation areas. Paint was flaking off in areas. 

• Problems encountered: None. 

• Owner request/concerns: N/A 

• Inspection/closeout dates. Owner 6/22/ir ^ ^ llrHi i 
2011 

PROFESSIONI^ 

2505 North 24^ Suite 219 ^ENVIRONMENTAL ENGINEERS, INC. 

Omaha, NE 68110 

(402) 504-4688 "Providing cost-effective environmental solutions" Fax (402) 504-3281 

Consulting • Engineering Design • Remediation • Abatement • Emergency Response 

EPA Close-Out Form 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-06) 

SAID: 

.msi^ 

Property Address: isi/fuiuis au^. 

Owner's Name: /Itiuifl Gassttt 

Performance Standards/Close-Out Criteria 

YES NO 

1. 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. 

2. Was all scraping and other preparation work completed satisfactorily? 

/ 

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, y 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? 

/ 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, etc. / properly removed? 

9. Is there any evidence ofproperty damage that was done by the contractor? Any property ^ damage needs to be completed prior to the EPA Close-Out. 

10. Has the property owner signed the completion form? 

1 / ¥[ 11. Are there any property items that were temporarily re-located by the contractor that need to K / be moved back? f 

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

^ i ^ 

unresolved? 

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

3 ^ ^ nj^in 

EPA COR Signature 

Date 
• • • • 

2011 

PROFESSIONAL 

ENVIRONMENTAL ENGINEERS, INC. 

"Providing cost-effective environmental solutions" 

Consulting • Engineering Design • Remediation • Abaiernenl • Emergency Response 

Property Owner Close-Out Form 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-06) 

SAID: ^?^3^ ^ 

Property Address: /j?/ f Wl//l'S /f} / 

Owner's Name: /^^//// V HtK^/',^/--

Performance Standards/Close-Out Criteria 

YES 

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

2. Was all scraping and other preparation work completed satisfactorily? 

v^ 

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

coats? y / 

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

v/ 

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? v/ 

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

l / 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, 

etc. properly removed? \ / 

9. Is there any evidence ofproperty 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? x / 

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

need to be moved back? V 

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: 

2505 North 24'^ Suite 219 

Onnaha. NE68110 

(402) 504-4688 

Fax (402) 504-3281 

NO 

/ 

y 

y 

tg-aa-( 

property Owner Signature 

Date 

r.,-?.7-i\ 

Professional E^ivirt^mental Engineers Signature 

Date 
Professional Environmental Engineers: EPA Paint Stabilization 2011 

Property Ad<lress jBf i \^(\\\\$ ) p K 

Stories/ Siding type li/Z Transite Wood Vinyl Metal Stucco 

Garage? 

Date access signed LJ : I \ r_J I I 

Yes 

f A\n \\ [ 

No 

^ 1 

Painted? 

Where? 

Yes 

1 

Siding 

Trim 

No 

Pre-video Cp/ / [ 

Post video 

Contractor Assigned 

Date started Li^l % ^l ( Date ended G ^ ^.-f" / / 

Weather Conditions 

Paint used 

Prime used 

^ 

IS 

Poly used ^ 

Problems/Issues 
(effective April 2010) 

RENOVATION RECORDKEEPIN G CHECKLIST 

Name of Firm: 'f^lfHf 

Date and Location of Renovation: ^ ^>^ - // / T/ / l/i/fj/iS //V^ 

Brief Description of Renovation: ^ M 6^0^- P<y?'7iJ-- /^^^^c f 

Name of Assigned Renovator: / v /cMcl^ (yi^ ^ 

Name(s) of Trained Workers: (j_lJaA/cfi) LoAr&d,, ^fz/j;^yJ0 fnhtRj^l-^^

 fm^A.l'^. 

Name of Dust Sampling Technician, Inspector, and/or Risk Assessorr, if used: ^-^ 

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

[^Certified renovator provided training to workers on (check all that apply): 

DPosting warning signs <&^etting up plastic containment barriers 

D Maintaining containment TJ Avoiding spread of dust to adjacent areas 

d^-^aste handling Srost-renovation cleaning 

D 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: 

Bwamin g signs posted at entrance to work area. 

0 Work area contained to prevent spread of dust and debris. 

TJ Windows in and within 20 feet ofthe work area are closed 

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

• Doors that must be used in the work area are covered to allow passage but prevent spread of dust. 

D Ground covered by plastic sheeting extending 10 feet from work area - plastic anchored to the 

building and weighted down by heavy objects. 

D Ifnecessary, vertical containment installed to prevent migration of dust and debris to adjacent 

property. 

^ \ Waste contained on-site and while being transported off-site. 
(effective April 2010) 

(^^D^^ork site properly cleaned after renovation. 

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

removal. 

D Work area HEPA vacuumed to get paint chips from ground surface, ifnecessary. 

n Certified renovator performed post-renovation cleaning verification (describe results): 

- 0 I certify under penalty of law that the above information is true and complete. 

i' -^/^// 

Name and Title ^^—^ ( J Date 
4/27/2011 jnrV^V2j _ Douglas County Account Information 

Douglas County, Nebraska ProiMRy Record - R0917000004 

Print Report 

View Interactive GIS Map Information is valid as of 2011-4-13 Treasurer's Tax Report 

New Feature ->->-> Subdivision Sales Search 

Owner 

GOSSETTMELVIA M^r\he( ~tP^ yi33K 

POBOxnyoy -

-eMAIIANLbUin-UUUU ^^^^zi 

Property Information 

Key Number: 1700 0004 09 

^ 

Account Type: Residential 

Parcel Number: 0917000004 

Parcel Address: 

Legal Description:

1518 WILLIS AV 

C>MAHANE 68110-0000 

 DARR PLACE LOT 6 BLOCK 0 LOT 6 40 X 95 

Value Information 

2010 

2009 

2008 

2007 

2006 

2005 

Land 

$2,100.00 

$2,100.00 

$2,100.00 

$2,100.00 

$2,100.00 

$2,100.00 

Improvement 

$29,900.00 

$29,900.00 

$29,900.00 

$30,800.00 

$30,800.00 

$30,800.00 

Total 

$32,000.00 

$32,000.00 

$32,000.00 

$32,900.00 

$32,900.00 

$32,900.00 

Sales Information 

Sales Date: 1999-03-19 

Deed Type: 

Price: 

D 

$14,500.00 

Book: 2116 Page: 348 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Information 

Acres 

0.08 

SF 

3800.0 

Units 

1.0 

Depth 

95.0 

Widtii 

40.0 

Vacant 

No 

Improvement Information 

.mapping-online.com/.../accountinfo.j. 1/3 
4/27/2011 ^Douglas County Account Information 

Building 1 

1518 Willis Ave 

• ffl 

iHhiti fl 

1 1/2 story Fin 

CLICK TD ENLARGE IMAGE 

Square Footage: 1070.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: ; Average 

Unit Type: Condition: Average 

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

HVAC: Central Air to Air Rooms: 7.0 

Exterior: Frame Vinyl Units: 1.0 

Interior: Drywall Baths: 2.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: : Block 

Sprinkler Square Footage: i 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1907 0% 1907 103 

Deta/7 Type Detail Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 616.0 

Basement Finished 256.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 216.0 

Porch End Solid Wall 180.0 

...mapping-online.com/.../accountinfo.j... 2/3 
CONSEN:m T FOR ACCESS TO PROPERT 'Hll Y 

OMAHA LEAD SITE REMEDIAL ACTION - LEAD-BASED PAINT STABILIZATION 

PROPERTY ID:

T i IXySO\L . PROPERTY ADDRESS:!51^ VOlWS |Av ^ 

OWNER NAME SAME: /- > . 

^'P.\V)^C X \ j=^^r^f<Sy^4V DAYTIME PHONE: 4f O - r^ / -^JZl O 

CELL PHONE: E-MAIL: 

OWNER'S ADDRESS IF DIFFERENT: CjP\^ ^ fO^^CCO^j- jL/O /-KOWL I I^V' 

TENANT'S NAME IF APPLICABLE: V 7 ^2i ^ 

DAYTIME PHONE: 


CELL PHONE: E-MAIL: 


Professional Environmental Engineers, Inc. (PE) is under contract (#EP-R7-08-06) with the U.S. Environmental Protection 

Agency (EPA) to stabilize lead based paint (LBP) on residential structures at a number of properties located in Omaha, 

Nebraska. The paint stabilization work is being done to protect the soil cleanups that are being performed by EPA contractors. 

Paint stabilization activities will include: scraping ofcracked or flaking LBP from structures, application of a prime coat and two 

(2) coats of paint Moving parts of windows and doors are not included and will not be addressed. 

Your cooperation is requested in giving permission to this EPA contractor (PE) to enter and have access to this property for the 

purpose of stabilizing lead -based paint as outlined on the property identified above. 

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 

can not provide assurances that the soil cleanup contractor will be bound to. I further understand that the soil cleanup 

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

my property. 

D Yes, I havs.read and understand the paragraph above. 

V _ 3 Signature of Propeity Owner Date 

I fully understand that by signing this Consent for Access, (1) this access will remain in effect until the work has been 

satisfactorily completed, (2) that the Property Owner or Tenant, if applicable, will be given the Housing and Urban Development 

(HUD) and EPA pamphlet, "Renovate Right, Important Lead Hazard information for Families, Day Care Providers, and 

Schools", (3) tbe Property Owner or tenant will remove all obstructions from surfaces to be painted, (4) will abide by health and 

safety guidance provided by EPA, (5) will allow photography ofproperty before and after the paint stabilization work, (6) will be 

contacted by a PE representative approximately 48 hours in advance of starting work, (7) agree not to obstruct or tamper with 

any ofthe LBP stabilization actions, and (8) will participate in final property inspection and sign the Completion Agreement and 

Property Owner Satisfaction Survey. 

Should you have any questions about the planed Lead Based-Paint stabilization activities for your property, please contact 

Professional Environmental Engineers, Inc. Project Manager, Willie Clay or Kelley Sanders At 402-504-4688. General questions 

about the Omaha Lead Site cleanup can be directed to Pauietta France-Isetts, EPA Remedial Project Manager 402-731-2454, or 

the EPA Public Information Centers at 402-991-9583 (North Omaha office) or 402-731-3045 (South Omaha office). 

D Yes, I grant access to my property and was given the pamphlet D No, 1 do not grant access to my property and I was 

"Renovate Right, Important Lead Information for Families, Child given the pamphlet "Renovate Right, Important Lead 

Care Providers, and Schools." Information for Families, Childe Care Providers, and Schools." 

WIignature Date Signature Date 

SPECIAL INSTRUCTIONS AND CONSIDERATIONS 
PAINT STABILIZATION PRE-PROPERTY 

PAINT MATCH ASSESSMENT 

PROPERTY ADDRESS: m DATE: v^"^'^^ ^v 

BVID: n'^i^o 

AREA(S) TO BE PAINTED: 

HOUSE PROPER: _ COLOR: Al \ ^)WM 

HOUSE TRIM: COLOR: 

GARAGE: COLOR: 

GARAGE TRIM: COLOR: 

PORCH: COLOR: 

/ 

PORCH TRIM: COLOR: ^^^\ ^ 

(COMPLETE ALL SECTION, YES, NO. OR NON-APPLICABLE) 

I AGREE TO THE COLORS LISTED ABOVE. ONCE THE PAINTING 

BEGINS, I UNDERSTAND I CAN NOT CHANGE THE ABOVE SELECTED COLORS: 

PROPERTY OWNER SIGNATURE: PE ACCESOR SIGNATURE: 

)( mdA^aJ^^:.A>^ 
PRE-RENOVATION FORM - OWNER 

This form is to be used by the firms contracted by the Environmental Protection Agency-Region 7 to perform Lead-Based 

Paint stabilization activities at the Omaha Lead Site, Omaha, Nebraska. 

Owner Confimiation 

Pamphlet Receipt 

5? I have received a copy ofthe lead hazard information pamphlet. Renovate Right: Important Lead Hazard Information for 

Families, Child Care Providers and Schools, informing me ofthe potential risk ofthe lead hazard exposure from renovation 

activity to be performed in/on my dwelling unit. I received this pamphlet before the work began. 

Owner Acluiowledgment 

D (A) I confirm that I own and live in this property, that no child under the age of 6 resides here, that no pregnant woman 

resides here, and that this property is not a child-occupied facility. 

Note: A child resides in the primary residence of his/her custodial parents, legal guardians, foster parents, or 

informal caretaker if the child lives and sleeps most of time at the caretaker's residence. 

Note: A child-occupied facility is a pre-1978 building visited regularly by the same child, under 6 years of age, on at 

least two different days within any week, for at least 3 hours each day, provided that the visits total at least 60 hours 

annually. 

^(B ) I understand that the renovation firm, contracted by the Environmental Protection Agency (EPA), will be using leadsafe work practices required by EPA's Renovation, Repair and Painting Rule. 

Y rn<r\w'^a ^oss^.VV 

Printed Name of Owner-Occupant 

Signature of Owner-Occupant Date 

^hn\ m 0\% M\ aV py(^(^y od^v-^^ 
f 

Sample Pre-Renovation Form 

This sample form may be used by firms to document compliance with the requirements ofthe Federal 

Lead-Based Paint Renovation, Repair, and Painting Program. 

Occupant Confirmation 

Pamphlet Receipt 

I have received a copy ofthe lead hazard information pamphlet infonning me ofthe potential risk ofthe 

lead hazard exposure from renovation activity to be performed in my dwelling unit. I received this 

pamphlet before the work began. 

Printed Name of Owner-occupant 

Signature of Owner-occupant Signature Date 

Renovator's Self Certification Option (for tenant-occupied dwellings only) 

Instructions to Renovator; If the lead hazard information pamphlet was delivered but a tenant signature was not 

obtainable, you may check the appropriate box below. 

Declined - 1 certify that 1 have made a good faith effort to deliver the lead hazard information pamphlet 

to the rental dwelling unit listed below at the date and time indicated and that the occupant declined to 

sign the confimiation of receipt. I further certify that 1 have left a copy ofthe pamphlet at the unit with 

the occupant. 

y Unavailable for signature - 1 certify that I have made a good faith effort to deliver the lead hazard 

information pamphlet 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 ofthe pamphlet al the unit by 

sliding it under the door or by (fill in how pamphlet was left). 

GinioDii 

Printed Name of Person\Centifying Delivery' Attempted Delivery Date 

)R^ ^liWiS »V 

Unit Address 

Note Regarding Mailing Option — As an alternative to delivery in person, you may mail the lead 

hazard infomiation pamphlet to the owner and/or tenant. Pamphlet must be mailed at least 7 days 

before renovation. Mailing must be documented by a certificate of mailing from the post office. 

IS 

G