TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: c^fs^S Date: Afjnf>.J2.aJr^ 

Address: /^/ ^ S!p^,^rcr Sh 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^ Video of property (DVD) Org - gA ^ pOST 

Iv Executive Summary 

m Signed Access Agreement for subject property 

B Pre-Renovation Form signed by Property Owner 

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

0 Painting Agreement 

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

5f Renovation Recordkeeping Checklist signed by Certified Renovator 

^ 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 Coimty Assessor's Office 

gf Hazard analysis, if prepared 

D Safety Audit 

30203823 

D Other (describe): nm 

Superfund 

EPA COR Signature TJate 

(after file folder review) 
TBCHNOLOCIBS. 1 

Property Summary 

Date: 07/8/2010 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: July 

Property Address; 1465 Spencer St SAID #: 30665 

A. Executive Summary: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 04/26/2010 

ii. Work Began: 05/28/2010 

iu. Close-Out Date: 05/28/2010 

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 
^SCHNOLOGIBS, IN C 

Prudent Technologies, Inc. (Prudent) is under contract (Contract # EP-R7-08-07) with the U. S. 

Enviroiraiental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a nimiber of properties 

located in Omaha, Nebraska, includingtiie property located at: ) ^ ^ <; ^ p^.j^r c-r~ Sj ^ 

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 

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. 

[ ^JYes, I have read and understand the paragraph above. 

I Property Owner's Signature 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, 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 Information Centers at (402) 731-3045 (South Omaha office) or (402) 

991-9583 (North Omaha office). 

Propertv Access Granted Bv: 

V - ^ ^ -^oyfa 

I T5'rrvt^o-t*f^7 r^\Trr»<ai*'e QirmQ+ii-r o Property Owner's Signature Date 

h £CVU:A ^- <^'^rj&S<, 

lease 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 

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

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

PROPERTY INFORMATION 

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

RESIDENT NAME:: Iv ^oVu? ^ W xCe. \ L.. \>SUY-Cig.^ fi> ^ Tenant 

RESIDENT ADDRESS: JM^S " Sv''-^'^*' ^ ^^ ^ 

r>^7^V>A K3e. C.<^\\ o 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS: So^r^y ^ 

OWNER'S TELEPHONE NUMBER: 

Home: Mo2^ fe<M ~\?t,^ork: _ 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: ^Oji 

COMMENTS OR SPECIAL INSTRUCTIONS (such as dogs, 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 of the title." 

Property Owner Signature: 9\jJXku y ^ S^UA^y ^ 

X (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 
f 

/

slAiiMd. 

PRE & POST PAINT STABILIZATION VIDEO AND PICTURES 

1 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 employees need to be aware of before 

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

\MC,S perV-\ LJ£J C AKJ ^ Qm^Ln . KV.^ e^^\(X> 

Property Address 

Owner'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: JJA . 

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 Sample 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. 

V-—cih--^^^^^'6 

' Printed name of recipientt 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 Lead Hazard Infomnation 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). 
m 

raer 

PAIN T MATCHIN G FORM : 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: 

BVID: 

\M fa ^ Qpp.^e ^y^ 

6 8:/3"t, 

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

Location Paint Description Paint Yes Paint No 

Siding 

Soffit 

Fascia 

V\^\ 

Utr®<ft 

W^A 

y 

^ 

Comer Trim ^C^Dc P 

Window Trims 

^LASOPC ^ 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

Front Porch Floor 

i^(n>-dB "e^^eJlff <> l ^Jl 

£j^( y ^\< A 

eJrusSicfir^^A^ 

Xy" 

\y ^ 

Front Porch Railings 

Front Porch Steps 

Siding Baseboards 

<e>ju-g Jurt-^.c^, 

pen? c^ ( fOpf pcx^A^ ye^J 

f-^ 

\ y 

Foundation 

joJ^K ^ 

fir^cjfc^ (mx^

VOC5>P<5L 

 dL-L \poa^^ ^ y 

y^ 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowne jLooUt^JU z&UfiiU^ r signature: Date: y-^6-^<^^' ^ 

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^ 

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 

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. 

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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 
TECHNDUXSIES^INC. 

ACCESS INFORMATION TRACKING SHEET 

BVID: PROPERTY ADDRESS: 

Property Owned By: -il-VA.Uft^f L D^.c q €.^nr^ ^3 

(If new property owner) 

Owners Phone No's: Home :'?±4r.ii.1r.L^^ork: 

Cell: Fax: —

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

Hh «^-^S KOL*-- ^ I-<SL ^r^^.jJK'Jll. 

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 
(effective April 2010) 

RENOVATION RECOS^KEEPING CHECKLIST 

Name of Firm: •dAt i 

Date and Location of Renovation: S^OS ^ "/i ^ //^-S^^^Ofy^sg/^ - J/ " 

Brief Description of Renovation: fypjOfjA 

Name of Assigned Renovator: .. 

Name(s) of Trained Workers: j/Jf^.^f'j^'2/r?7 /zixtMU-y^ . y ^ A^y ^ (jC^uJUi-eH). .ffli^Wy^.^>a ^ 

Nartie of Dust Sampling Technician, Inspector, and/or Risk Assessor, if used: 

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

0^l5ertified renovator provided training to workers on (check all that apply): 

E-P^ing warning signs ^-Setting up plastic contaiimient barriers 

CUMaintaining containment Q-Avoiding spread of dust to adjacent areas 

H'^^te handling B'i'ost-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: 

0^amin g signs posted at entrance to work area. 

B'^Work area contained to prevent spread ofdust and debris. 

[zKwindows in and within 20 feet of the work area are closed 

CHJoors Ul and within 20 feet of the work areas are closed and sealed 

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

Eijround covered by plastic sheeting extending 10 feetfi-om work area - plastic anchored to the 

building and weighted down by heavy objects. 

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

/property. 

[j Waste contained on-site and while being transported off-site. 

Renovation Recordkeeping Checklist Omaha Lead Site 
(effective April 2010) 

Q^^Work site properly cleaned after renovation. 

[jkAll chips and debris picked up, protective sheeting misted, folded dirty side inward, and taped for 

removal. 

7ork area HEPA vacuumed to get paint chipsfi-om groimd surface, if necessary. 

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

I certify under penalty of law that the above infomiation is true and complete. 

^' ^ :>SyS 

Name and Title Date 

Renovation Recordkeeping Checklist Omaha Lead Site 
TECHNOIiOGIES, INC 

Checklist for the Worksite Hazard Analysis . 

Address: 

Crew: 

Item I OK? i , ^ Hpari Corrective Action 

Overhead Lines 

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

 / ^ terfepencBA^ 

Neighbor Access Required ^ Vx23 

High Traffic Area 

Garage 

iCu> ;=T2^ 

Structures -Ul 

^ nt>ll^A.)&tyz^^n~y^v^ l^^pciA\ - ^ 

Driveway Tim l^LLl 

Sidewalk /^^ P^ff'T^ tif dML tx -fp-n^ -hrcnaf \lI3b^d ^ 

Foundation 

Retaining Walls n JO 

Fences 

Trees 

Foliage-S^^liy.^/ jy ^ ,^:i ^ 

General Condition i"/"trotkit b&^^'yepi

 i^'rvJiz^4^\'^ ^ Damaged Areas: sink ^— j ^ ~^'7\| ' b 7"— 7 ' " ^ ^ 

holes/rotted wood \}>t ^ ^ i^&-^ C^H'^i^ hdcCv^f^ T V c' c//? 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

^"^X^kW i V MA S^^ -O ^ -^ ^"^^ 

Foreman/ Sjib-dontractor Officer 

8080 Ward Parkway, Suite 406 2505 N. 24*" Street, Suite 308 f 242 Medical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraska 68110 i n 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 
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TECHNOLOGIES, INC. 

OMAHA LEAD BASED PAINT REMEDIATION 

Property Owner Close-Out Form 2010 

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

SAID: J^^<r ^ 

Property Address: /^ ^ ^ y/^/^y\AZ^l(^ ^7 7 

Owner's Name: /PC/r-j^/ ^ ^L/^/^^.^i^ 

Performance Standards/Close-Out Criteria 

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 of the 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 of the 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? 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, 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 the EPA Close-Out. 

10. Are you satisfied with the work performed? 

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

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: 

kL 7/^.' y ^ \i')ci\p^^^^ 

Property Owner Signature Date 

Prudent Technologies. Inc. Signature Date 

-:j.-,2 ivisuira' :-/: ;. : 

YES NO 

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Douglas County Account Infomiation Page 1 of2 

Douglas County, Nebraska Property Record - R2249500000 

Print Reoort 

NEW Feature - Parcel Dimensions available &. scale 0-50 ft west of 52nd St - VIG W O n Ma P Information is valid as of 2010-3-16 Treasurer's Tax Report 

New Feature -» r¥. •• Auto Sales Search 

Owner 

BURGESS RUTHIE L 

1465 SPENCER AVE 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 4950 0000 22 

Account Type: Residential 

Parcel Number: 2249500000 

Parcel Address: 1465 SPENCER ST 

OMAHA NE 68110-0000 

Legal Description: SULPHUR SPRING LOT 4 BLOCK 4 50 X 124 

Value Informatio n 

Land Improvement Total 

2009 

2008 

2007 

2006 

2005 

2004 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

$2,600.00 

$26,700.00 

$26,700.00 

$26,100.00 

$26,100.00 

$26,100.00 

$9,800.00 

$29,300.00 

$29,300.00 

$28,700.00 

$28,700.00 

$28,700.00 

$12,400.00 

Sales Informatio n 

Sales Date: 2003-06-26 

Deed Type: QC Book: 2003 Page: 121286 

Price: $0.00 

Grantor. ROBERT BURGESS 

Grantee: RUTHIE BURGESS 

Valid/Invalid: Invalid 

Exclusion Reason: Family Sale 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6200.0 1.0 124.0 50.0 No 

Improvemen t Informatio n 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R2249500000 3/23/2010 
1

Douglas County Account Information Page 2 of2 

Building 1 

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 CLICK TO ENLARGE IMA( 3E 

Square Footage:

Perimeter

Unit Type: 

Built As: 

HVAC: 

Exterior: 

Interior: 

Roof Cover: 

Roof Type: 

Floorcover: 

Year Built 

 1165.0 

 0.0 

2 1/2 Story Unfin 

Forced Air 

Frame Vinyl 

Drywall 

Composition Shingle 

Hip 

Allowance 

Year 

Remodeled 

1907 0 

Detail Type 

Appliance 

Appliance 

Basement 

Fixture 

Fixture 

Porch 

Porch 

User 

1

1 

Percent 

Remodeled 

0% 

DefaiY Description 

Allowance 

Security System 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

End Solid Wall 

End Solid Wall 

See notes 

t4e5S(wnMf 

Swwdnew 

—a*-.. 

FnRnr 

i t IM 

3iO«Hyttm -SU«»*' 

<Mlt>(| 

 CLICK TO ENLARGE IMAGE 

Percent Complete: 

Quality: 

Condition: 

Condo Square Footage: 

Rooms: 

Units: 

Baths: 

Bedrooms: 

Stories: 

Foundation: 

Sprinkler Square Footage: 

Adjusted Year 

100.0% 

Average 

Average 

0.0 

6.0 

1.0 

1.0 

3.0 

2.5 

Block 

0.0 

Physical Age Built 

1907 103 

Units 

1.0 

1.0 

572.0 

1.0 

1.0 

44.0 

176.0 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/statlc/accountinfo.jsp7accoun tno=R2249500000 3/23/2010 

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