## TRANSMITTA Lof OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID :3509 8 Date : 12/23/200 8 Address : 251 5 TempletonS t Remediation Contractor : Pruden t Technologie s Year : 200 8 PAINT STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 0 ' Video o f propert y (DVD ) Executiv e Summar y SignedAcces s Agreemen t fo r

subject propert y Painting Agreemen t Settlemen t docimients (i.e. , fo r

damag e o r

to replac e plants , etc. ) Photograph s Satisfactor y restoratio n signedby Propert y Owne r Propert y close-out chec k

lis t signedby EP A Propert y information fromDougla s Count y Assessor' s Office D D D 

# A 'eun 

## Signa ' 

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4030989 0 

# i n Superfun d

### PROPERT Y SUMMAR Y Date : 12/23/0 8 LB PSTABILIZATIO N EPA CONTRAT EP-R7-08-0 7 Monthof : Decembe r Propert y Address : 251 5 Templeto n S t SAID : 3509 8 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : None
A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None
A. 4 Othe r Relevan t Information : None Acces s Date : 09/26/0 8 Wor k Began : 09/30/0 8 Closeou t Date : 10/14/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . Signe dAcces s Agreement 5 . Pre-Renovatio n Form 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOGIES , INC
.ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^/ 5 T^rnp U fo^ n 5 f Date : V^W^ ^ Phone: M^ ^ ^4^1 0 BVID : 35>0^ g Plant & Permanen t Landscaping T o Remain In Plac e 

## Itein # Descriptio n andLocatio n On Ma p 

# o k

Pre-Existin g Conditio n o f Stnicture s Doe s your Basement hav e ahistor y o f leaking ? Ye s — 

# No.v: r Item# Descriptio n & Locatio n On Ma p ^ i^tcJ h totf^et c Ue^i, ^ J^<me>^ ^ ^ ^ Corrtt-l ^



## Propert y Owne r Prudent Employ ; Signatui e Signature : 

# lib^i*^ ^ 1^^^ ^ ^y/>i ^ 808 0 Vtar d Pariamy , Suit e 40 5 2505 N
. 24* ^

Stree t Suit a 30 8 424 2 Madica l Drive , Sult a 425 0 Kansa s CHy , M O 6411 4 Omaha , Nebraska 6811 0 Sa n Antonio , T X 7822 9 Phom : (816 ) 363-3703 Phone : (402)504-100 4 Phona : (210)822-658 8 ««A4 i ««V « «AA a Ea v(9 1 m KI^AKT t

# 'T/^Of' S

Pnident Technologies , Inc . (Pnident) i s unde r

contrac t (Contrac t #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agency (EPA ) t o stabiliz e Lea dBase dPaint (LBP) a t aniunbe r

ofpropertie s locate di n Omaha , Nebraska , includin g the propert y locateda t Th e EP A request s you r

pennissio n t o allo w Pruden t to perfonn LB PStabilizatio n a t thi s property . B y signing thi s form, tiie propert y owne r

grant s pennissio n to Pruden t t o perfor mactivitie s relate dto LB P Stabilization including scrapin g paint an dpaintin g o f th e referencedproperty . Further , th e owner/tenan t verifie s tha t they hav e receive dtiie LB Ppamphlet "Renovat e Right. " If

you hav e an y question s about th e LB Pstabilizatio n planne dfo r

you r

property , pleas e contact Prudent' s Administrative Cler k

fo r

th e Lea dBasedPaint Stabilization , Mrs . Debora hAkerele-Johnson . a

t (402 ) 504-1004 . Genera l question s abou t tiie Omah aLea dSit e cleanu p ca n b e directe dt o the EP A Publi c Information Center s a t (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nortii Omah a ofifice) . . ^ Piq>ert yAccess Grante d By : Prin t Nanw ) 

# ^6/ - oi - Propert y Owne r Signature : 

# ± (Date ) PROPERT Y INFORMATIO N (T o b e complete db y reiiden t and/o r propert y owner^
- pleaa e print ) RESIDEN TNAME : 

## hff^e L fpitct/lj - Rente r 

# '2SI5 ' Je^tvjk M ^- ^ RESIDEN TADDRESS : I F RENTAL , PROPERT YOWNE D BY : 

# Sd/A e OWNER'SMAIUNOADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : '^- ^ " WORK : 

## .HOME:j5^faLi2£l ^ I "^ O '" J
_ 

### J L NUMBER O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : 3 NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E
. DOGS
. ENTR YGATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS ; Th e activitie g t o b e implemente db y EP Aunde r da s agreemen t ar e pursuan t t o Sectio n10 4 OfCERCLA , 4 2 U.S.C . 9604 . EPA' s righ t o f

acces s t o tiie propeit y isprovide dfo r i

nSectio n104(e ) ofCERCLA , 4 2 U.S . C 960S(e) , whic hpfoivide s entr y for "detenniningth e nee dfor response , o r choosin g ortakin g an y respons e actio nunde r thi s title , o r oAerwis e enforcin g (h e provision s o f th e title. "

:08 0 War d Paricway , Sult a 40 5 250 5 N
. 24* ^ Street , Suit e 30 8 424 2 Medica l Drtve , Suit a 425 0 lansa s City , M O 6411 4 'hone : (816 ) 363-370 3 Omaha , Nebrask a 6811 0 Phone : (402)504-100 4 Sa n Antonio , T X 7822 9 Phone : (210)822-958 8 .sw . ia4e \ q« 4 OTA T

# Curren t Sampl e PrARenovatio n For m Effectiv e unti l Apri i 2010 . 

# Z rmatio n of Receip t of Lea d Pamphle t av

e receive d a cop y of th e pamphlet , Renovat e Fti^t : Importan t Lea d Hazar d Infbrmatio n fo rFamilies , Chil d Car e Provider s an d School s informin g me of th e potentia l risl < of th e lea d hazar d exposur e fro m renovatio n activit y to be parformo d in m\ / ^fcwallin g unft
. i received tlii a pamphle t iaefor e th e vvor( < began
. Printe nameLDfjBcipien / / Dat e fi d nam^jpfjBcipien t /y ^ Signatar s of rsciplen t Self-Certificatio n Optio n (fb rtenant-occupie d dweiling s onl ^ — If th e lea d pamphle t wa s 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
. Q Refusa l to sig n —I certif ytha t i hav e mad e a goo d M h effor t to delive rtti e pamphlet , Renovat e fVght : Importan t Ljea d Hazar d Informatio n fo rFamilies , Chil d Car e Providers an d Schools , to th e renta l dwellin g uni t liste d t)eio wat th e dat e an d tim e indicate d an d tha t th e occupan t refuse d to sig n th e confinmatio n of receipt
. I furthe rcertifytha t I hav e left a cop yof th e pamphle t at th e uni t wit h th e occupant . Q Unavaiiabl e fo rsignatur e —I certif ytha t I hav e mad e a goo d fait h effor t to delive rth e pamphlet , Ftenovat e fVght : Importan t Lea d Ha^ui d Infonnatio n fo r Fijnilies , CNI d Car e provider s an d Schools , to th e renta l dweiiin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e to sig n th e confirmatio n of receipt
. I furthe rcertifytha t l^av e lef t a cop yof th e pamphle t at th e uni t byslidin g it unde rth e door
. 

# V' i^^ert J fW< ^ Printe d nam e of perso n certifyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver y Signatur e of perso n ceniiyin g lea d pamphle t delivet y 

# ^.^^ / M
Uni t Addres s Not e Regardin g Mailin g Optio n — As an alternativ e to deliver y in person , yo u ma ymai i th e lea d pamphle t to th e owne rand/o rtenant . Pamphle t mus t be maile d at leas t 7 day s befor e renovatio n (Documen t wit h a certificat e of mailin g fro m th e postofRce)
.

# pa i n t matc hJorm
­ pain t matchin g form : propert y address : :?5>' ^ /e^kih n BVID : 

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## Pag e 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R164439000 0 Prin t Repor t NE W Featur e - Parce l Dimension s avaiiabi e @ scal e 0-S O f t wes t o f 90t h S t - Vie.!|W_O n .MSP
. Informatio n i s vali d a s of 2008-9- 4 Treasurer' s fa xRepor t Ne wFeatur e -•->• • Aut o Sale s Searc h Owne r GRAN TALIWA N 251 5 TEMPLETO N S T OIVIAHAN E 68111-000 0 Propert yInformatio n Ke yNumber : 

### 443 9 000 0 1 6 Accoun t Type : Residentia l Parce l Number : 164439000 0 Parce l Address : 251 5 TEMPLETO N S T OMAHAN E 68111-000 0 Lega l Description : LUK E & TEMPLETON S LO T3 7 BLOC K0 LT3 6 & W 1 0 F T6 0 X 13 2 Valu e Infor n matio 200 8 200 7 200 6 200 5 200 4 200 3 Lan d $2,900.0 0 $2,900.0 0 $2,900.0 0 $2,900.0 0 

### $2,900.0 0 $2,900.0 0 I mprovemen t $20,300.0 0 $20,300.0 0 $20,300.0 0 

### $13,600.0 0 $12,300.0 0 $12,300.0 0 Tota l $23,200.0 0 $23,200.0 0 $23,200.0 0 

### $16,500.0 0 $15,200.0 0 

### $15,200.0 0 Lan d Infor matio n Acre s 

### 0.1 8 S F Unit a 7920. 0 1. 0 Dept h Widt h 132. 0 Vacan t 

### 60. 0 N o Improvement Info n rmatio 

### Buildin g 1



## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R16.. . 9/24/200 8. J . .ww«./i.uii . xiiivjiuiatiui i 

## Pag e 2 of 2 

# Bi t

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HVAC : Exterior : interior : Roo f Cover :

Roo f Type : Floorcover : yearSwf t 1522. 0 0. 0 1 1/ 2 Stor yFi n Force d Ai r Fram e Viny l Plaste r Compositio n Shingl e Gabl e Allowanc e Yea r Remodele d 189 5 0 Oetai V Typ e Applianc e Basemen t Fixtur e Fixtur e Porc h Porc h Use r Percen t Remodele d 0 % Oefai V Descriptio n Allowanc e Bsmn t Bloc k 8 ft Bas e Fixture s Bat h Ful l En d Soii d Wal l Sla b w/Step s SOURC E 2 .•«i j '.

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Units : Baths : Bedrooms : Stories : Foundation : Sprinlde rSquar e Footage : | 100.0 % Fai r Poo r 0. 0 8. 0 1. 0 1. 0 4. 0 1. 5 0. 0 Adjuste d Yea r Buil t 189 5 Physica l Ag e r 11 3 Unit s 1. 0 912. 0 1. 0 1. 0 154. 0 70. 0

1. 0



## http://douglasne.mapping-oiiline.coin/DouglasCoNe/static/accountiiifo.jsp?accountno=R16.. . 9/24/200 8

## Pruden t Propert yCiose-Ou t For m (Lead-Base d Pain t Stabiiization ) SAID:36-(?? g Propert y AAAress i ^SiS ' ^Je^yi^yl ^ ) ^ ­ Owner' s Name : 

## Performanc e Standards/ciose-Ou t Criteri a YE S 

### N O 1 .Wa s th e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woui d inciud e paintin g o f othe rassodate d feature s inciudin g fascia , eaves , siding , al l trim , porches , bo x ^ beams , coiumns , rails , an d exterio rsurface s o f garages . 2 .Wa s ai l scrapin g an d othe rpreparattio n wori ccomplete d satisfactorily ? 3 .Were al l require d areas o f th e structure{s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 .

Wa s th e pain t product s utilize d equivaien t t o a 3 0 yea rproduct/quality ? Are al l ofth e areas wher e contaminate d material s have bee n spiiie d thoroughl yvacuumed / deaned ? 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 , roadvtfays , alleyways , publi cacces s areas an d als o remov e an yothe rgenerate d debris ? < 7 .

i s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# 2 L Are al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . 

# K properi yremoved ? 

### 9 . I s ther e an ye^denc 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 comptete d prio rt o th e EP AClose-Ou t 

### 10 . Ar e ther e an ypropert yitem s tha t wer e temporatil yre-locate d byth e contracto r < tha t nee d t o b e move d bade ? 

### 11 . Are ther e an y(known ) lingerin g issues wit h th e propert yowner(s ) tha t have bee n lef t unresolved ? 

# X Othe rConsiderations?propertyOwne rDiscussions?Additlona l Wori ctha t i s Require d 

# jtiA'^ ^