## TRANSMITTA Lof OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID# : 2206 0 Date : 12/16/200 8 Address : 320 3 Marc y S t Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S e

f Vide o o f propert y (DVD ) 0 Executiv e Summary 0 Signe dAcces s Agreemen t fo r subjec t propert y 0 Paintin g Agreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D Photograph s [ 5 Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A 0 Property informatio n fromDougla s County Assessor' s Offic e D D D


### Signatur e ^ Dat e

4030989 3 

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### PROPERT Y SUMMAR Y Date : 12/16/0 8 LB PSTABILIZATIO NEP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address : 320 3 Marc y S t SAID : 2206 0 

### A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : None A. 2 Issue s Resolved : None

A. 3 Uniqu e Findings : None 122A. 4 Othe r Relevan t Information : None Acces s Date : 09/09/0 8 Work Bega n 10/12/0 8 Closeout Date : 11/18/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . SignedAcces s Agreement 5 . Pre-Renovatio nForm 6 . Pain t Matc hForm 7 . Trackin g Form 8 . Dougla s County Assessor Propert y Informatio nPag e 9 . EP A Propert y Closeout for m 10 . Propert y Completio n Agreemen t

TECHNOLOGIES . INC .ENVIRONIVfENTAL & CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : JoLiP 2 //lard u ^ . Date : f/'^/O ^ 

# Phone : y^?-
- ?33 ^ 7^ 3 3 BVID : CL^OCf O Plant & Pennanent Landscaping T o Remain I n Plac e Item# Descriptio n an dLocatio n O

n Ma p 

# \ f ^



## Pre-Existing Conditio n o f Structure s 

# v / Doe s your Basement hav e ahistor y o f leaking ? Ye s — N o -> Item# Descriptio n & Locatio n On Ma p

Propert y Owne r Pruden t Emplovee 

## 66Jl^ ^

Signature : Iw^J l /&/t**w — 808 0 Vtar d Parkway , Suit e 40 5 260 6 N . 24* * Straet , Suit e 30 8 4242 Madica l Drive , Suit e 425 0 Kansa s City , MO 6411 4 Omaha , Nebraslc a 6811 0 Sa n Antonio , TX7822 0 Phone : (816 ) 363-3703 Phone : (402)604-100 4 Phone : (210)822-968 8 Fa y«1fi » ^KKJn m

# 220(0 0
Pruden t Technologies , Inc . (Prudent) i s unde r

contract (Contract #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agency (EPA) t o stabili2 » Lea dBase dPaint (LBP) a t anumbe r

ofpropertie s locatedi nOmaha , Nebraska , includin g th e propert y locatedat^'^Q ^ (TnaurxyL i ^- ^ . Th e EP A request s you r

permissio n t o allo w Pruden t t o perfor mLB PStabilizatio n a t thfs'property . B y signing thi s form, tiie propert y owne r

grant s permissio n t o Pruden t t o perfor mactivitie s relate dt o LB P Stabilizationincluding scraping paint andpaintin g ofth e referencedproperty . Further , th e owner/tenan t verifie s tha t they hav e receive dtiie LB Ppamphle t "Renovat e Right. " If

yo u hav e an y question s about th e LB Pstabilizatio n plannedfo r

you r

property , pleas e contact Prudent' s Administrative Cler k

fo r

th e Lea dBasedPain t Stabilization , Mrs . DeborahAkerele-Johnson . a

t (402) 504-1004 . Genera l question s about th e OmahaLea dSit e cleanu p ca n b e directe dto th e EP A Publi c Infonnation Center s a t (402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nort hOmaha office) . Propert y Acces s Grante dBy : (Mieale Prin t Name ) Propeit y Owne r Signabire : Y . (Signature )
RESIDEN TNAME : 

# flh/i N C7ft'r>le . PROPERT Y INFORMATIO N (T o b e compleft db y rttlden t and/o r propert y owne r ­ pleas e print ) Rente r 

## RKIMIITAMREM- . ^?M ^

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S b I F RENTAL , PROPERT YOWNE D BY : 

### OWNER' S MAIUN G ADDRESS ; ».-?0?/^. ^ flT ) f ) CCj- j S- L OWNER' S TELEPHON E NUMBER. HOME : lV^X) \ Q.^.^ - ^OQA'^RK : M^ i f55"^ - 3^ 1 / NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : . NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : NUMBE R O F CHILDRE N UNDE R 7 YEAR S OLO WH O PLA YI N TH E YAR D FO R 5 HOURS 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 EACnONS : Th e activitie s t o b e implemente db y EP Aunde r tU s agreemen t at e pursuan t t o Sectio n10 4 ofCERCLA . 4 2 U.S.C . 9604 . EPA' s right o f

acces s t o th e propert y i s provide dfor I nSectio n104(e ) ofCERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entr y fo r

"detenniningth e nee dfor response, o r choosin g ortakin g an y respons e actio nunde r fliis title , o r otherwis e enforcin g th e provision s o f Ih e title. "

424 2 Medica l Drive , Suit e 425 0 2S0 S N . 24' " Street , Suit e 30 8 18

0 Wart J Partway , Suit e 40 5 Sa n Antonio , T X 7822 9 Omaha , Nebrask a 6811 0 insa s City , M O 6411 4 Phone : f210»ft99.o«« « Phone : (402)504-100 4 none : (816 ) 363-3703

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# Curren t Sampl e Pre-Renovatio n For m EttecUv e unti l Apri l 2010 . Con^nfiatlo n of Receip t of Lea d Pamphle t CS n hav e receive d a cop y of th e pamphlet , Renovat e Right : importan t Lea d Hazar d intonnatio n fo rFamilies , Chil d Car e Provider s an d School s informin g me of th e potentia i ris k of th e iea d hazar d exposur e fro m renovatio n activity to be performe d in mydwellin g unit . I received thi s pamphle t befor e th e wor k began .

Self-Certlflcatlo n Optio n (fo rtenant-occupie d dwelling s only ) — 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 maychec k th e appropriat e bo xbelow . Q Refusa l to sig n — I certifytha t I hav e mad e a goo d fait h effor t to delive rth e pamphlet , flenovate Right : Importan t Lea d Hazar d Intormatio n fo rFamilies , Chil d Care F^vlder s atn d Schools , to th e rental dwellin g uni t liste d belo 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 confirmatio n of receipt. I furthe rcertifytha t I hav e left a cop y of th e pamphle tat th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e —I certifytha t I hav e mad e a goo d fait h effor t to delive rth e pamphlet , Ftenovat e Filght : Importan t Lea d Hazar d Intormatio n fo r Families , CNI d Car e provider s an d Schools , to th e rental dwellin 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 I hav e left a cop y of th e pamphle t at th e uni t byslidin g it unde rth e dpej ! ^ . , Printe d nam eof perso n certifyin g Atternpt ^ deliver y dat e an d tim e lea d pamphle t deliver y Signatur e of persc n deliver y oerse n certifyin certifyin g g lea

lea d d pamphle

pamphle t t deiive n 

# pMcikcL . /^G : Uni t Addres s Not e Regardin g Mailin g Optio n —As an altemativ e to deliver y

in person , yo u ma ymai l th e lea d pamphle t to th e owne rand/o rtenant . Pamphle t mus tbe maile d at leas t 7 day s befor e renovatio n (Documen t wit h a certificat e of mailin g fre m th e pos t office) .

# pain t matc hfor m, Pain t matchin g form : ^ ^ . /f«^///i ^ propert yaddress : ^a<5 3 r^uAo y^f ^

' ? BVID : 

# -^i^o^ O —^^^ - Area : ' "" ^ Color : &P/>a ^' ^

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^^^ ^ explanation : t.^^/A^j^ ^ Area : Color : / focZ/o n Explanation : .. . ^ , v/^^ ^ ^ / Area : color : Explanat i on : Area : color : Explanation : Pag e 1

# Acces s INFOmUMIO N TRAOQN G SHEE T 

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# pain t matc h for m PROPERT Y INTERNA L MEMO : ADDRESS : BVID :

Pag e 1

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## Douglas Count y Accoun t In£armation Fage 1 o t 3 Dougla s County , Nebrask a Propert yRecor d - R140468000 0 Prin t Reppr t NE

W Featur e - Parce l Dimentlon s availabl e Q scal e 0-50 ft wes t o

f 90t h S t - Viev vO n Ma p Informatio n i s vali d a s of 2008-7-1 4 Treasurer' s Ta xRepor t Ne wFeatur e ••-•• • Aut o Sale s Searc h Owne r

. ^ POOL E ALVIN C Hrv T ETA L N yO V ^ ^ - 320 3 MARCYS T• OMAHAN E 68105-000 0 Propert yInformatio n Ke yNumber : 046 8 000 0 1 4 Accoun t Type : Multipl e Re s Parce l Number : 140468000 0 Parce l Address : 320 3 MARC YS T OMAHAN E 68105-000 0 Lega l Description : HOUSE L & STEBBIN S SU B DI V LOT1 4 LO T9 BLOC K0 5 0 X 11 6 Valu e Informatio n Lan d /mprovemen t Tota l 200 8 $ 6,200.0 0 $80,700.0 0 $ 86,900.0 0 200 7 $ 6,200.0 0 $80,700.0 0 $ 86,900.0 0 200 6 $ 6,200.0 0 $ 75,800.0 0 $ 82,000.0 0 200 5 $ 6,200.0 0 $75,800.0 0 $ 82,000.0 0 200 4 $ 6,200.0 0 $ 75,800.0 0 $ 82,000.0 0 200 3 $ 6,200.0 0 $ 75,800.0 0 $ 82,000.0 0 Sale s Informatio n Sale s Date : 2004-08-0 3 Dee d Type : Q C Boofr : 200 4 Paffe ; j 10982 8 Price : $0.0 0 Grantor : Alvi n C Pool e Grantee : Alvi n C Pool e eta l Valid/lnvalid : Invali d Exclusio n Reason : Famil ySal e Sale s Date : 1997-05-2 7 Dee d Type : D BooAr ; 206 1 Page : 65 2 Price : $ 63,000.0 0 Grantor : 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R14.. . 8/26/200 8

## Douglas Count y Accoun t lo^nn i ation Page 2 of3 Grantee : Valid/Invalid : Vali d Exclusio n Reason : Sale s Date : 1995-10-1 3 Dee d Type : Book : 

### 201 6 Page : 70 5 Price : $53,500.0 0 Grantor : Grantee : Validnnvalid : Vali d Exclusio n Reason : Sale s Date : 1993-11-0 2 Dee d Type : Book : 196 4 Page : 25 7 Price : $36,000.0 0 Grantor : Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Infbrmatio n Acre s S F Unit e Dept h Widt h Vacan t 0.1 3 5800. 0 1. 0 116. 0 50. 0 

## N o Improvemen t Informatio n Buildin g 1

J 4 I ••i t i I * X ' ti r

H I „^!i / I

'•.3i!i..a! t TW O STOR Y SLLC.K.TQ.-gN.LA.RG£.lMA.6 I CLIC KTO ENLAR.9&-IMAG E Squar e Footage : 2374. 0 Percen t Complete : 

### 100.0 % Perimete r 0. 0 Quality : Averag e

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## Douglas Count y Accoun t Inf^natio n Page 3 of 3 

# f r Uni t Type : En d

Buil t As : 2 Stor y HVAC : Force d Ai r Exterior : Fram e Sidin g Interior : Drywal l Roo f Cover : Compositio n Shingi e

Roo f Type : Gabl e Floorcover : Allowanc e yea r Percen t YearBuil t Remodele d Remodele d 189 0 0 0 % Condition : Fai r ~--.Cond o Squar e Footage : 0. 0 Rooms : 7. 0

Units : 2. 0 Baths : 4. 5 Bedrooms : 3. 0 Stories : 2. 0 Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Adjuste d Yea r Physica l Ag e Buil t 189 0 11 7 Unit e 1. 0 1131. 0 1. 0 1. 0 4. 0 1. 0 484. 0

48. 0

1. 0 Detai l Typ e Applianc e Basemen t Fixtur e Fixtur e Fixtur e Fixtur e Garag e Porc h Use r Detai l Descriptio n Allowanc e Bsmn t Bloc k 8 ft Additiona l Fixture s Bas e Fixture s Bat h Ful l Bat h Hal f Detache d Sla b Roo f Cei l cod e 12 5 toremode l

U44^*/M ^ v1nnv« . AWIOV%f M nrr.rtnlin Ar»nm/nmialncPn>Jft/Qtatip/flrrnnnttnf n iRn*?arr.onn1no= R 1 4 R/7fi/700 R

## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) SMD:_J2MA£- 1 Propert y Address ; Dp 6 3 

# im ^ Owner' s Name : /Iwii ) 

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

### N O 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 woul d includ e paintin g o f othe rassociate d feature s includin g fasda , eaves , siding , al l trim , porches , bo x 

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

# V . 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 equivalen t t o a 3 0 yea rproduct/quality ? 

# V 5 .Are al i o f th e area s wher e contaminate d material s hav e bee n spille d ' / thoroughtyvacuumed / deaned ? / 6 . Di d th e contracto rcoiiect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , i 

# i/ . roadways , alleyways , publi cacces s areas an d als o remove an yothe rgenerate d debris? i 7 . I s th e gras s are a tha t surround s th e structure{s ) I n reasonabl ygoo d condition ? 

# 1 7 8 . Are ai l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . I properl yremoved ?\ 

# i / 9 . I s ther e anyevidence o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e / 

### 1 / need s t o b e complete d prio rt o th e EP Aqpse-Out ., 10 . Are ther e an ypropert yitem s tha t wer e temporatil yre-locate d byth e contracto r 

# L / ths t nee d t o b e move d back? 11 . Ar e ther e an y(known ) lingerin g issues wit h th e propertyowner(s ) tha t have bee n lef t uriresoh^ed ? 

# l A Othe rConsiderations?propert YOwne rDiscusstons?Additiona l Wor k tha t i s Require d



## Ou^yJU r^ . ^«-^-^— - 

## Pruden t Representativ e Dat e 

# ihn-6 i