### TRANSMITTA LO FOMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID# ; :7AO.^^: 7 Date : p^-iF/^
- ^APAJ ^ Address : ^.^O ^ ^ 7:Z ^ S7 ^ LB PStabilizatio n Contractor : PRUDEN T TECHNOLOGIES , IN C Year : 200 9 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 

# 4 Video o f propert y (DVD) : Pre-Stabilizatio n & Post-Stabilizatio nVideo s Executiv e Summar y 

# 4 SignedAcces s Agreement For m / 

### Advanc e Notic e For m / 

### Pre-Stabilizatio n Video Agreement Form Acces s Trackin g For m Property Acces s Assessmen t Form Neighbo r Acces s Agreement For m Pain t Matc hFor m 

# 4 Pre-Stabilizatio n Propert y Safet y Assessmen t Form 

# A Work-Site Hazard s Analysi s Checklis t / 

### Photographs : Pre-Stabilizatio n Propert v Hazar dAssessmen t Photograph s 

# 4 Dougla s Count y Assessor Propert y infonnatio n 

# 4 Property Completio n Agreement For mSignedb y Propert y Owne r Property Close-Out Check Lis t SignedBy EPA r>/«4U i . Pruden t Technologies , Inc . Signatur e 

# 430/0 ^

EP A Signatur e 

# 4y/i<^u

30054732 

# i l Superfun dTECHNOLOGIBS , IN C 

# Propert y Summar y Date ; 9/»y2009 | LB PSTABILIZATIO N EPA CONTRAC T EP-R7-08-0 7 | Mont hof : Se p Propert y Address : 450 9 S 1 9 St . SAI D # : 10567
A . Executiv e Summarv : a . Issue s Encountered : NON E b . Issue s Resolved : NON E c . Uniqu e Findings : NON E d . Othe r Relevant Information : i . Acces s Date : 9/01/2009 ii . Wor k Began : 9/09/200 9 ii

LClose-Ou t Date : 9/10/2009 B . Enclosures : 1 . Pre-Stabilizatio n Vide o 2 . Post-Stabilizatio n Vide o 3 . Signe dAcces s Agreement Form 4 . Advance-Notic e Form 5 . Pre-Stabilizatio n Vide o Agreement Form 6 . Acces s Trackin g Form 7 . Propert y Acces s Assessment Form 8 . Neighbo r Acces s Agreemen t Form 9 . Propert y Pain t Matc hForm 10 . Pre-Stabilizatio n Propert y Safet y Assessment For m 11 . Work-Sit e Hazard s Analysi s Checklis t 12 . Pre
- Stabilizatio n Propert y Hazar dAssessment Photograph s 13 . Dougla s County Assessor Propert y Informatio n 14 . Signe dPropert y Completio n Agreement Form 15 . Propert y Close-Ou t Chec k Lis t Signe dB y EP A

# m . TECHNOLOCIB & INC . Pruden t Technologies , Inc . (Prudent ) i s unde r contract (Contract #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t

o stabilize Lea dBase dPaint/LBP ) at g numbe r o

f propertie s locate di n Omaha, Nebraska , includin g the propert y locate da t ^^/) ^ 5- /^ " -^ T Th e EP A requests you r permissio n to allow Pruden t to perfor mLB PStabilization a t thi s property . By signing thi s form , th e propert y owne r grants permission t o Pruden t to perfor mactivitie s relatedt o LB PStabilization including scraping pain t and paintin g ofth e reference dproperty . Further, th e owner/tenan t verifie s tha t the y hav e receivedthe LB Ppamphle t "Renovat e Right. " B

y signin g thi s documen t I agree t o allo w a n EP A contracto r t

o conduct asoi l cleanu p a t m

y propert y followin g completio no f lead-base dpain t stabilization , ifth e soi l cleanu p has no t alread y bee nperformed . I understan dtha t the stabilizationcontracto r canno t provid e assurance s o f whic hcontracto r wil l be boun dto th e soi l cleanup . 1 furthe r understan dtha t the soi l cleanu p contracto r wil l mak e al l reasonable effort s t o addres s concems tha t I , as th e propert y owner, ma y hav e regardin g soi l cleanu p a t m y property . [K

] Yes , I hav e rea dan dunderstan dth e paragrap habove . 

### 1 ^



# P^. v Cx.\i\< \ 

# a ti<\og ^ Signatur e of Propert y Owne r Dat e Ifyou hav e an y question s abou t th e LB Pstabilization plannedfo r you r property , pleas e contact Prudent' s Custome r Relations/OfFic e Manage r fo r th e Lea dBase dPain t Stabilization , Mrs . Shanno n Holt , a t (402 ) 504-100 4 o r (402)812-0223 . Genera l question s abou t the Omah aLea dSit e cleanu p ca n be directedto th e EP A Public hiformatio nCenters a t (402 ) 73 1 ­ 3045 (Sout hOmah aoffice ) o r (402 ) 991-958 3 (Nort hOmah aoffice) . Propert y Acces s Grante dBy : (^• ^ (Pleas e Prin t Name ) Propert y Owne r Signatur e 

# .MA CLvy g 

# (SnUv ^ mfe ^ (Signature)



# '^'l-TI ^ (Date)

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TEC3Hn<4aLOCIBS , INC . PROPERTYINFORMATIO N (T o be complete d byresiden t and/o rpropert yowne r—please print ) RESIDEN TNAM E .•^miA/ieiT^ ^ r-/^/7£M/// f /^/)^;^,^ ^ Rente r RESIDEN TADDRES S DDRESS :
IF RENTAL , PROPERT ERT Y Y

OWME O BY : I
OWNER' S MAILIN G ADDRESS ; 

# M/l ^ OWNER' S TELEPHON E NUMBE R - HOME : { ^//Jl'513 g weWC : ( ^0-/^^1 ^

'^ i NUMBE R OF OCCUPANT S UNDE R 7 YEAR S OLD : / NUMBE R OF OCCUPANT S 7 YEAR S OL D AN D OLDER :

lUM B 

# A
NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WHO M PLA YIN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : 

# A^ COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. ) / ^ // ^

AU IHORir V FO RENVIRONMENTA LRESPONSEACTIONS : Th e activitie s to

he implemente d by EP A unde r thi s agreemen t ar

e pursuan t to Sectio n 10 4 ofCERCLA . 42 U.S.C . 9604 . EPA' s righ t of acces s to th e propert y

is provide dfo r in Sectio n 104(e ) ofCERCLA , 42 U.S . C 9605(e) , whicl i provide s entr y fo r "determinin g th e nee dfo r response , or choosin g

or takin g an y respons e actio n unde r thi s title , or otherwise enforcin g th e provision s ofth e title. "

808 0 War d Parkway , Suit e 40 5 250 5 N. 24' " Street , Suit e 30 8 4242 Medica l Drive , Suit e 425 0 Kansa s City , MO 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816) 363-370 3 Fax : (816 ) 363-370 7 Phone : (402)504-100 4 Fax : (402)504-100 5 Phone : (210)822-958 8 Fax : (210) 579-6577HBCHNOLOGIES. ] 

## Advance dnotic e needed . Afte r signin g th e acces s yo u allo w Pruden t t o begi nLea dBase d Pain t Stabilization . Al l Plants , weed s an dan y vehicle s o r item s o n ope n porc h(enclose dporche s wil l NO T b e stabilized ) mus t b e remove dprio r t o stabilization . Al l Pet s mus t b e ou t o f yar ddurin g stabilization . Ho w muc hnotic e d o yo u nee dt o hav e abov e mentione dtask s completed ? Ifyo u ar e alandlor dyo u wil l nee dt o contac t th e tenan t a s Pruden t Technologie s wil l onl y infor myou . D o yo u hav e an y pet s tha t resid e i n yard ? AJ ^ O/i/^- ^ Notic e neede d 

# ' J^^ / ft /Lrr/ f Numbe r t o cal l t o giv e notice : -7 0 / j^- ^y Who mw e ar e givin g notic e to : yi/4/Pi/iAj4 \ Hom e Owner' s Signatur e (LJ_'SX.vJ?i^< i kr^iLsjLu^i^SZ! ^

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax:(210)579-657 7TECHNOLOGIES, ] 

## PRE-STABILIZATIO NVIDE O FORM 1 UNDERSTAN D THA T PRUDENT TECHNOLOGIE S WIL LB ECOMIN G OUT T O SHOO T A PRE-STABILIZATIO N VIDE O AT MY PROPERTY . TH EVIDE O I S JUS T A TOO LUSE D T O DOCUMENT TH ECURREN T PROPERT Y STATUS/CONDITION . A POS T VIDE O WIL LALS O B E SHO T PRIO RT O COMPLETIO N O FSTABILIZATION . 

# OWNER S NAME : 5^^^^ ^ V' fi/itt\/^hJf^ i^jS'^V^ ^ PROPERT Y ADDRESS : 

# y^^ f 

# < / f 

# ^ BVID/SAID : 

# /^^ n HOMEOWNER S SIGNATURE : m CT i tvvA. q ^^o\>c\ < 

## PRUDEN T REPRESENTATIV ESIGNATURE : AN Y CONDITION S NEED T O B EAWAR EO FBEFORESHOOTIN G VIDEO : (LE . PETS , NOTIC ENEEDED) : 

# /{/^^( ^

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNC^jOGnS, ] 

## ACCES S INFORMATIO N TRACKIN GSHEE T BVID:/^52^* 7 PROPERT Y ADDRESS : V^- f :^
- / f ^ Propert y Owne dBy : (I f ne w propert y owner )

Home : l^tA.A.^X
- Work : Owner s Phon e No's : Cell:-S/-5I-.2^jiS/

—Fax: ~ Acces s Contractor : AS WPDA ME S PEOthe r (Prudent ) DAT E TIM E CCESSO R C O T DETAI L -y^y/o/hi^ . 

# -A ia^ 

# /^/m ^

Comments : 

# A^.L-.^J7!A/LAQAS2ZZ
808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES^ ] 

## Acces s Assessmen t Form : (Mus t b e complete dfo r ever y property . Informatio nmus t b e obtaine dfro mapropert y wal k thru , no t give n b y owner )
I s th e propert y stucc o o r asbestos ?
I f

yes , i s an y ofth e stucc o o r asbesto s damage do r cracked ? I f

yes , sto p a s w e can' t stabiliz e thi s property . I t require s specia l preparatio n techniques . I t wil l b e returne dt o EP A an dthe y wil l assig na t alate r date . Doe s thi s propert y requir e lot s o f scrapping ? 

# /h^d i Doe s thi s propert y requir e alif t o r scaffoldin g t o reac huppe r levels ? Doe s thi s propert y hav e lot s o f plant s o r item s i narea s wher e paintin g i s required ? 

# ^/)M £ Doe s thi s propert y hav e an y significan t structura l damage ? 

# ft h4ii
- ^Wc» J dM06t I f

yes , EXPLAIN ?

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES, ] 

## Doe s thi s propert y hav e agarage ?
I f

yes , describ e locatio no f garage . _. Doe s thi s propert y hav e aluminu msiding ?
I f

yes , i s i t origina l factor y finis ho r ha s i t bee npainte dover ?
Doe s thi s propert y hav e an y othe r typ e o f structura l components ? (I.e . roo f shingle s a s siding) ? I f

yes , EXPLAIN ?
I s thi s propert y vacan t o r occupied? ^ Ar e ther e an y pet s a t thi s property ? 

# N o Ar e ther e an y lo w hangin g powe r Unes ? ­

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

### 40L0GIBS . n«ic . PAIN T MATCHIN GFORM : 1 . T O B EFILLE D OU T ONL Y I FMATCHIN GCOLO R PROPERT Y ADDRESS : T^'^ ^ S
- /H ^ BVID : /C)^ ^ / Th e followin g note s ar e fo r th e benefi t of pain t cre w only . Pain t Ye s Pain t N o Locatio n Pain t Descriptio n Sidin g 

# ^7A ^ Soffi t ^ 

# y Fascia 

# l/\ u Coki ^ Corne r Tri m Windo w Trims Doo r Trims 

# y 

# i l Fron t Porc hCeiling 

# — 7 ^ ,01 " 

# y Fron t Porc hCeiling Beam s 

# L y ^ 

### Fron t Porc hFloo r 

# ^^A4 ^ c y 

# m Fron t Porc hRailing s Fron t Porc hStep s 

# "gfe/^ ^ ^0 ^ ULK> Sidin g Baseboards 

# if^^k^J Foundatio n 

# Uii^ e 

# i J



# f^/jf ^ CouAjzfioj' k H J ^^(^stc'/ e f ^ VUM£4L . X ^ 

# 6m6 i Iky.^^ . Tf\ii / Uo o J Ujki>H f 

# f\i4i l ? M 4^^47^ ^ UN E' 

## ^ERw r • I UNDERSTAN D SHERWI N WILLIAM S WILLMATC H M Y CURREN T COLORS . Homeowne r signature : IrTcy t C^ Q (^X^ O Vyi-'ct u e"*-^ Date : f/~Ay ^

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7OOLOGIES . INC . 2 . T O B EFILLE D OU T ONL Y I FCHANGIN GCOLO R PROPERT Y ADDRESS : BVID : Locatio n Pain t Descriptio n Pain t Ye s Pain t N o Sidin g Soffi t Fasci a Come r Trim Windo w Trim s Door Trim s Front Porc hCeilin g Front PorchCeilin g Beam s Front Porc hFloor Front PorchRailing s Front PorchStep s Sidin g Baseboard s Foundatio n

• 1 AGRE ET O TH ECOLOR S INDICATE D ABOVE . I UNDERSTAN T THA T 1 CANNO T CHANG ETH ESELECTE D COLOR S LATE RO N A S PRUDEN T WOUL D HAV EPURCHASE D TH EPAIN T SPECIFICALL Y FO RTH E REFERENCE D PROPERTY . ALS O I UNDERSTAN D THA T COLOR S SELECTE D MA Y NO T LOO K EXACTL Y A S I T I S SHOW N O N SWATCHE S AFTE R PAINTIN GO N M Y PROPERTY , Homeowne r signature: . Date : 808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNCnXXHES , ] 

### NEIGHBORHOO D PROPERT Y ACCES S FOR M I S THEREA NEIGHBORIN GPROPERT Y THA T NEED S T O B EACCESSED ALONG WIT H ASSIGNE D PROPERT Y T O COMPLET ESTABILIZATIO N PROCESS ? 

# 90 6 I FI T IS , GE T ACCES S FRO M ALLREQUIRE D NEIGHBORHOO D PROPERTIES .

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7\ TECHNOIJOGIBS. ] 

## PRE-STABILIZATIO N PROPERT Y SAFET Y ASSESSMENT FORM PROPERT Y ADDRESS : <J<r/) ^ < / ^ ^F ~ BVID/SAID : /O^^- y PRUDEN T ASSESSMEN T REPERSENTATIVE :

REPERSENTATIV EREMARKS/FINDINGS : (POWER-LIN EPROXIMIT Y T O PROPERTY , SCAFFOLDING / LADDERS / LIFT S NEEDED , UNSAF EAREAS , UNSAF ENEIGHBORHOOD...ETC. ) 

# A ) l

808 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone:(816)363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7

# P
Checklis t fo r th e Worksit e Hazar dAnalysi s £ ) Addres s Cre w Date :



# 'K^ ^

308 0 War d Parkway , Suit e 40 5 250 5 N . 24' " Street , Suit e 30 8 ica l Drive , Suit e 425 0 Kansa s City . M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 L Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax : (402)504-100 5 Fax : (210 ) 579-657 7 

# r

# 1 

# 1 ^


### " "• 1

y

### Dougla s Count y Accoun t Informatio n Pag e I of 2 vjma\ 

## ^02.
- 751-^1S> 8 Dougla s County , Nebrask a Propert yRecor d - R175572000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t o f 52n d S t - VJe W O n Ma p Informatio n i s vali d a s o f 2009-8- 3 Treasurer' s Ta xRepor t Ne wFeatur e " * • • Hi* Aut o Sale s Searc h 

### Owne r RODRIGUE Z SALVADO R ETA L 450 9 S 1 9 S T OMAH AN E 68107-000 0 

# - , o o y^p^-^ " r,y^ ^ \

D^ n Propert yInformatio n Ke yNumber : 557 2 OOO O 1 7 Accoun t Type : Residentia l Parce l Number : 175572000 0 Parce l Address : Lega l Description : 450 9 S 1 9 S T OMAH AN E 68107-000 0 MISSOUR I AV E PAR KLO T2 0 BLOC K1 4 0 X 13 0 Valu e Informatio n 200 9 200 8 200 7 

### 200 6 200 5 200 4 Lan d $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 $5,800.0 0 Improv emen t $73,900,0 0 $73,900.0 0 $73,900.0 0 $67,800.0 0 $67,800.0 0 $67,800.0 0 Tota l $79,700.0 0 $79,700.0 0 $79,700.0 0 

### $73,600.0 0 $73,600.0 0 $73,600.0 0 Sale s Informatio n Sale s Date : 2001-09-2 8 Dee d Type : Price : W D $73,500.0 0 

### Book : 219 3 Page : 53 6 Grantor : Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s 0.1 1 S F 5200. 0 Unit s 1. 0 Dept h 

### 130. 0 Widt h 40. 0 Vacan t N o Improvement Informatio n 

### http://dougIasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=RI7. . . 8/25/200 9

### Dougla s Coimt y Accoun t Inforaetio n Pag e 2 of 2 ra^ti Buildin g 1 4soesi»s T SKcMnee r uoos a n u t t I lausaf t OMCI M FntMi r aoDSt n 9oros«n «ij r 1 1/ 2 Stor y BanntBlodid k af f • ao o 5 4 F l CLIC KT O ENLARG E IMAG E CLIC KT O ENLARG E IMAG E Squar e Footage : 1227. 0 Percen t Complete ; 100.0 % Perimete r 0. 0 Quality : Averag e Uni t Type : Condition : Goo d

Buil t As : 1 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Force d Ai r Rooms : 6. 0 Exterior : Fram e Sidin g Units : 1.0 Interior : Drywal l Baths : 1.0 Roo f Cover : Compositio n Shingl e Bedrooms : 3. 0

Roo f Type : Gabl e Stories : 1. 5 Floorcover : Allowanc e Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Yea r Percen t Adjuste d Yea r Yea rBuil t Physica l Ag e Remodele d Remodele d Buil t 190 6 190 6 10 3 Deta/ 7 Typ e Detai l Descriptio n Unit s Ad d O n Fenc e Chai n Lin k 1. 0 Applianc e Allowanc e 1.0 Basemen t Bsmn t Bloc k 8 ft 880. 0 Fixtur e Bas e Fixture s 1.0 Fixtur e Bat h Ful l 1.0 Garag e Detache d 280. 0 Porc h En d Scree n 160. 0 Porc h En d Scree n 120. 0 Use r Atti cFul l Finis h 352. 0



### http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R17. . . 8/25/200 9

# Curren t Sampl e Pre-Renovatio n For m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t m \ hav e receivec i a copyo f th e pamphlet , Renovate Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d School s informin g m e o f th e potentia l ris k of th e lead hazar d exposur e fro m renovatio n activit yt o be performe d i n m ydwellin g unit . I receive d thi s pamphlet befor e th e wor k began . 

# £A ^ '^A^^ 9 Printe d nam e o f recipien tDate 

### /I^Wcv^c i Q<^c\r^*^*"°' ^ Signatur e o f recipien t Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — if th e lead pamphlet was delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e appropriat e bo xbelow . •Refusa l t o sig n —I certif ythat i hav e mad e a goo d fait h effor t t o delive rth e pamphlet . Renovate Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d Schools , t o th e renta l dwelling.uni t liste d belowa t th e dat e an d tim e indicate d an d that th e occupan t refuse d t o sig n th e confirmatio n o

f receipt . I furthe rcertif ythat I hav e lef t a copyof th e pamphlet a t th e uni t wit h th e occupant . •Unavailabl e fo rsignatur e — I certif ythat I hav e mad e a goo d fait h effor t t o delive rth e pamphlet . Renovate Right : Importan t Lea d Hazar d Informatio n fo r Families , Chil d Car e provider s an d Schools , t o th e renta l dwellin g uni t liste d belowan d that th e occupan t wa s unavailabl e t o sig n th e confirmatio n of receipt .

furthe rcertif ythat I hav e lef t a copyo f th e pamphlet a t th e uni t b yslidin g i t 6

rthe^ioor . ^ Printe d nam e o f person.certifyin g Attempte d deliver y dat e an d tim e lead pamphlet deliver y Signatur e o f perso^i certifyin g lead pamphlet deliver y 

# ^5- ^ rr . /f'» ' A f
Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n alternative t o deliver yi n person , yo u ma ymai l th e lead pamphlet t o th e owne rand/o rtenant . Pamphle t must b e maile d a

t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e of mailin g fro m th e pos t office) .TECHNOLOGlBS i IN C 

## Pruden t Propert yCiose-Ou t For m (Lead-Base d Pain t Stabilization ) 10^6 1 SAID : 

# k^o ^ Propert yAddress : Owner' s Name : 4\i4Yr^ft^7i/Z ' K^tL^o^ujf ^ S.N O Performanc e Standards/close-Ou t Criteri a Ye s N O 1 Was 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 

### \ y beams , columns , rails , an d exterio rsurface s o f garages . 2 Wa s al l scrapin g an d othe rpreparatio n wor k complete d satisfactorily ? 

### \y 3 Wer e al l require d area s o f th e structure(s ) prime d a s neede d an d 

### \ y painte d wit h tw o to p coats ? 4 Ar e al l ofth e area s wher e contaminate d material s hav e bee n spille d 

### \ y thoroughl yvacuumed / cleaned ? 5 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 cacces s area s 

# y an d als o remov e an yothe rgenerate d debris ? 6 I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d \ y condition ? 7 Was th e pain t product s utilize d equivalen t t o a 3 0 yea r product/quality ? [ / 8 Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et cproperi yremoved ? 

# y 9 I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o 

### y th e EP AClose-Out . 1 0 Ar e ther e an ypropert yitem s tha t wer e temporaril yre-locate d b yth e < y contracto rtha t nee d t o b e move d back ? 1 1 Ar e ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) c / tha t have bee n lef t unresolved ? 1 2 Othe rConsiderations ? Propert yOwne rDiscussions ? Additiona l ^ Wori ( tha t i s Require d 

### Pruden t Representativ e Signature : Date : Propert yOwne rSignature : f\l^^y, ^

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808 0 War d Parkway , Suit e 40 5 250 5 N . 24* ^ street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone:(816)363-370 3 Phone : (402)604-100 4 Phone : (210)822-968 8 Fax : (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7