TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 22060 Date: 12/16/2008 

Address: 3203 Marcy St 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

ef Video of property (DVD) 

0 Executive Summary 

0 Signed Access Agreement for subject property 

0 Painting Agreement 

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

D Photographs 

[5 Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

0 Property information from Douglas County Assessor's Office 

D 

D 

D 

Signature ^ Date 

40309893 

wm 

Superfund 
PROPERTY SUMMARY 

Date: 12/16/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address: 3203 Marcy St SAID: 22060 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

122A.4 Other Relevant Information: None 

Access Date: 09/09/08 

Work Began 10/12/08 

Closeout Date: 11/18/08 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracking Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOLOGIES. INC. 
ENVIRONIVfENTAL& 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: JoLiP 2 //lard u ^ . Date: f/'^/O ^ 

Phone: y^?-- ?33 ^ 7^ 3 3 BVID: CL^OCf O 

Plant & Pennanent Landscaping To Remain In Place 

Item# 

Description and Location 

On Map 

\f ^ 

Pre-Existing Condition of Structures 

v/ Does your Basement have a history of leaking? Yes — No -> 

Item# Description & Location 

On Map 

Property Owner Prudent Emplovee 

66Jl^ ^ Signature: Iw^J l /&/t**w— 

8080 Vtard Parkway, Suite 405 2606 N. 24** Straet, Suite 308 4242 Madical Drive, Suite 4250 

Kansas City, MO 64114 Omaha, Nebraslca 68110 San Antonio, TX78220 

Phone: (816) 363-3703 Phone: (402)604-1004 Phone: (210)822-9688 

Fay «1fi» ^KKJnm 
220(00 

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

Environmental Protection Agency (EPA) to stabili2» Lead Based Paint (LBP) at a number ofproperties 

located in Omaha, Nebraska, including the property located at^'^Q ^ (TnaurxyLi ^-^ . 

The EPA requests your permission to allow Prudent to perform LBP Stabilization at thfs'property. By 

signing this form, tiie property owner grants permission to Prudent to perform activities related to LBP 

Stabilization including scraping paint and painting ofthe referenced property. Further, the owner/tenant 

verifies that they have received tiie LBP pamphlet "Renovate Right." 

If you have any questions about the LBP stabilization planned for your property, please contact Prudent's 

Administrative Clerk for the Lead Based Paint Stabilization, Mrs. Deborah Akerele-Johnson. 

at (402) 504-1004. General questions about the Omaha Lead Site cleanup can be directed to the EPA 

Public Infonnation Centers at (402) 731-3045 (Soutii Omaha office) or (402) 991-9583 (North Omaha 

office). 

Property Access Granted By: 

(Mieale Print Name) 

Propeity Owner Signabire: Y. 

(Signature) 

RESIDENT NAME: flh/iN C7ft'r>le. 

PROPERTY INFORMATION 

(To be compleftd by rttldent and/or property owner ­ please print) 

Renter 

RKIMIITAMREM-. ^?M ^ mljRt ^ S b 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAIUNG ADDRESS; ».-?0?/^.^ flT ) f) CCj-j S- L 

OWNER'S TELEPHONE NUMBER. HOME: lV^X)\ Q.^.^- ^OQA'^RK: M^ i f55"^- 3^ 1 / 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: . NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

NUMBER OF CHILDREN UNDER 7 YEARS OLO WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACnONS: The activities to be implemented by EPA under tUs agreement ate 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) ofCERCLA, 42 U.S. C 9605(e), which provides entry 

for "detenniningthe need for response, or choosing ortaking any response action under fliis title, or otherwise enforcing the provisions of Ihe title." 

2S0S 4242 Medical Drive, Suite 4250 N. 24'" Street, Suite 308 180 WartJ Partway, Suite 405 Omaha San Antonio, TX 78229 , Nebraska 68110 insas City, MO 64114 Phone: f210»ft99.o««« Phone : (402)504-1004 none: (816) 363-3703 .., I04C\ 9C9 o^ft ^ 
Current Sample Pre-Renovation Form 

EttecUve until April 2010. 

Con^nfiatlon of Receipt of Lead Pamphlet 

CSn have received a copy of the pamphlet, Renovate Right: important Lead Hazard 

intonnation for Families, Child Care Providers and Schools informing me of 

the potentiai risk of the iead hazard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the work began. 

Self-Certlflcatlon 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. 

Q Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, flenovate Right: Important Lead Hazard Intormation for Families, 

Child Care F^vlders atnd 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. 

Q Unavailable for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Ftenovate Filght: Important Lead Hazard Intormation for 

Families, CNId 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 dpej! ^ . , 

Printed name of person certifying Atternpt^ delivery 

date and time 

lead pamphlet delivery 

Signature of persc oersenn certifyin certifyingg lea leadd pamphle pamphlet

t deiive delivern y

pMcikcL. /^G : 

Unit Address 

Note Regarding Mailing Option — As an altemative 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 frem the 

post office). 
paint match form , 
 Paint matching form: ^ ^. /f«^///i^ 

property address: ^a<53 r^uAoy ^f^ ' ? 

BVID: -^i^o^O —^^^-

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Explanation: 

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explanation: t.^^/A^j^ ^ 

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Area: color: 

Explanati on: 

Area: color: 

Explanation: 

Page 1 
Acces s INFOmUMION TRAOQNG SHEET [ Z] 

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paint match form 


PROPERTY INTERNAL MEMO: 


ADDRESS: 


BVID: 


Page 1 

Douglas County Account In£armatio n£mi n Fage 1 ot 3 

Douglas County, Nebraska Property Record - R1404680000 

Print Repprt 

NEW Feature - Parcel Dimentlons available Q scale 0-50 ft west of 90th St - Vievv On Ma p Information is valid as of 2008-7-14 Treasurer's Tax Report 

New Feature ••-•• • Auto Sales Search 

Owner . ^ 

POOLE ALVINC HrvT 

ETAL N yO V 

^ ^ - 3203 MARCY ST • 

OMAHANE 68105-0000 

Property Informatio n 

Key Number: 0468 0000 14 

Account Type: Multiple Res 

Parcel Number: 1404680000 

Parcel Address: 3203 MARCY ST 

OMAHANE 68105-0000 

Legal Description: HOUSEL & STEBBINS SUB DIV LOT 14 LOT 9 BLOCK 0 50 X 116 

Value Informatio n 

Land /mprovement Total 

2008 $6,200.00 $80,700.00 $86,900.00 

2007 $6,200.00 $80,700.00 $86,900.00 

2006 $6,200.00 $75,800.00 $82,000.00 

2005 $6,200.00 $75,800.00 $82,000.00 

2004 $6,200.00 $75,800.00 $82,000.00 

2003 $6,200.00 $75,800.00 $82,000.00 

Sales Informatio n 

Sales Date: 2004-08-03 

Deed Type: QC Boofr: 2004 Paffe; j 109828 

Price: $0.00 

Grantor: Alvin C Poole 

Grantee: Alvin C Poole etal 

Valid/lnvalid: Invalid 

Exclusion Reason: Family Sale 

Sales Date: 1997-05-27 

Deed Type: D BooAr; 2061 Page: 652 

Price: $63,000.00 

Grantor: 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R14... 8/26/2008 
Douglas County Account lo^nni ation Page 2 of3 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1995-10-13 

Deed Type: Book: 2016 Page: 705 

Price: $53,500.00 

Grantor: 

Grantee: 

Validnnvalid: Valid 

Exclusion Reason: 

Sales Date: 1993-11-02 

Deed Type: Book: 1964 Page: 257 

Price: $36,000.00 

Grantor: 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Infbrmatio n 

Acres SF Unite Depth Width Vacant 

0.13 5800.0 1.0 116.0 50.0 No 

Improvement Informatio n 

Building 1 

J 4 I 

••it 

i 

I * 

X' ti r 

H I 

„^!i / I 

'•.3i!i..a!t TWO STORY 

SLLC.K.TQ.-gN.LA.RG£.lMA.6I CLICK TO ENLAR.9&-IMAGE 

Square Footage: 2374.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

.IIA , ^»vl/^^r>^m1«Ip/^rt\To/oto+i/>/ao/^r\llntin•fi-> lcn9or»->/Minfnn=17 1/I ff/TA/IOnO 
Douglas County Account Inf^nation Page 3 of 3 fr 

Unit Type: End 

Built As: 2 Story 

HVAC: Forced Air 

Exterior: Frame Siding 

Interior: Drywall 

Roof Cover: Composition Shingie 

Roof Type: Gable 

Floorcover: Allowance 

year Percent YearBuilt Remodeled Remodeled 

1890 0 0% 

Condition: Fair 

~--.Condo Square Footage: 0.0 

Rooms: 7.0 

Units: 2.0 

Baths: 4.5 

Bedrooms: 3.0 

Stories: 2.0 

Foundation: Block 

Sprinkler Square Footage: 0.0 

Adjusted Year Physical Age Built 

1890 117 

Unite 

1.0 

1131.0 

1.0 

1.0 

4.0 

1.0 

484.0 

48.0 

1.0 

Detail Type 

Appliance 

Basement 

Fixture 

Fixture 

Fixture 

Fixture 

Garage 

Porch 

User 

Detail Description 

Allowance 

Bsmnt Block 8 ft 

Additional Fixtures 

Base Fixtures 

Bath Full 

Bath Half 

Detached 

Slab Roof Ceil 

code 125 toremodel 

U44^*/M ^ v1nnv«. A WIOV%f M nrr.rtnlinA r»nm/nmialncPn>Jft/Qtatip/flrrnnnttnfn iRn*?arr.onn1no=R 14 R/7fi/700R 
Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SMD:_J2MA£- 1 

Property Address; D p 6 3 

Owner's Name: /Iwii ) im^ 

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 fasda, eaves, siding, all trim, porches, box 

U 

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

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

V. 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 30 year product/quality? V 

5. Are ali of the areas where contaminated materials have been spilled 

' /

thoroughty vacuumed/ deaned? / 

6. Did the contractor coiiect/vacuum all falling and scraped paint chips on the entire property, 

i i/. roadways, alleyways, public access areas and also remove any other generated debris?i 

7. Is the grass area that surrounds the structure{s) In reasonably good condition? 

17 

8. Are ail items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. I 

properly removed? \ i/ 

9. Is there any evidence of property damage that was done by the contractor? Any property damage 

/ 

1 / needs to be completed prior to the EPA qpse-Out.

 , 

10. Are there any property items that were temporatily re-located by the contractor L/ thst need to be moved back? 

11. Are there any (known) lingering issues with the property owner(s) that have been left uriresoh^ed? 

Othe lA r Considerations?propertY Owner Discusstons?Additional Work that is Required 

Ou^yJUr ^ . ^«-^-^— -

Prudent Representative 

Date ihn-6i