TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#; f?3o.=^l Date; ^ R | nLQ>)gloa^ 

Address: li) ^ "^B S l 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

^

-V^

^

{/

sf

m

0

^

Q^

sf

^

t^

^

Si

D

 Video of property (DVD): Pre-Stabiiization & Pusi-atabiriAatiun-Vtdeoy 

 Executive Summary 

 Signed Access Agreement Form 

 Advance Notice Form 

 Pre-Stabilization Video Agreement Form 

 Access Tracidng Form 

 Property Access Assessment Form 

 Neiglibor Access Agreement Form 

 Paint Match Form 

 Pre-Stabilization Property Safety Assessment Form 

 Work-Site Hazards Analysis Checklist 

 Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

 Douglas County Assessor Property information 

 Property Completion Agreement Form Signed by Property Owner 

 Property Close-Out Check List Signed By EPA 

Pnident Technologies, Inc. Signature Date 

EPA Signature Date" 

30055398 

•HI 

Superfund 
TECHNOLOGIES, INC. 

Property Summary 

Date: 8/03/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: Aug 

Property Address; 111 S 38 St SAID #: 23031 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 7/07/2009 

ii. Work Began: 7/14/2009 

iii. Close-Out Date: 7/16/2009 

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 
TECHNOLOGIES. IIMC. 

PROPERTY INFORMATION 

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

RESIDENT NAME: .NA fnauHr ^ CLLL. Owner 

RESIDENT ADDRESS: 

AL. PROPERTY,OWNED BYj: 

^>^y v &^6 t U^ , rC^<./. 

OWNER'S MAILING ADDRESS; 

L,XlS( 

OWNER'S TELEPHONE NUMBER - HOME: 1^07-) ^/tz > 7^ytoW0RK: _J 1. 

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

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHOM 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 ACTIONS: The activities to be implemented by EPA under this agreement are 

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 "determining the need for response, or choosing or taking any response action under this title, or 

otherwise enforcing the provisions ofthe titie." 

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 
TECHNOLOCIBS. INC. 

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

Agency (EPA) to stabilize Lea^ Based Pauit (LB£).at a number of properties located in Omaha, Nebraska, including the 

property located at // / ^ ' ^fi ^ T 

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 ofthe 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, ifthe soil cleanup has not already been perfonned. I understand diat 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. 

es, I have read and understand the paragraph above 

> ^ 

Owner 

7-7-09 

Date 

Ifyou 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, Mrs. Shannon Holt, at (402) 504-1004 or (402)812-0223. 

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). 

Property Access Granted By: 

rf0,kA 

(Please Print Name) 

Property Owner 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 

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

Advanced notice needed. 

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 ofyard during 

stabilization. How much notice do you need to have above 

mentioned tasks completed? Ifyou are a landlord you will need to 

contact the tenant as Prudent Technologies will only inform you. 

Do you have any pets that reside in yard? 

2^^ • 5 Notice needed: 

Number to call to give notice: 

Whom we are giving notice to: 

""TM°""""'"'"" ^ 

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 
^S^^"*" ^ 

('^ \ 

TECHNOLOGIES, INC. 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABILIZATION VIDEO AT MY PROPERTY. 

THE VIDEO IS JUST A TOOL USED TO DOCUMENT THE CURRENT 

PROPERTY STATUS/CONDITION. A POST VIDEO WILL ALSO BE 

SHOT PRIOR TO COMPLETION OF STABILIZATION. 

OWNERS NAME: - 6^ 67^tc ^ r-ecLAj^ 

PROPERTY ADDRESS: /// 5 SZ S+ 

BVID/SAID: %30S l 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVE SIGNATU 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): 

'^^(K^ r 

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 
A^l""''-! 

TECHNOLOGIES. INC. 

ACCESS INFORMATION TRACKING SHEET 

BVID : msl PROPERTY ADDRESS: 

Property Owned By: 

(If new property owner) 

Owners Phone No's: 

Home: Work: 

C.XV.MtJmL- Fax:-

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME M:CESSOR CONRACL DETAIL 

1-1-0^ "^'.00 p^ i<fAi^ M^AlkJ - Q-^k£ /[lafiCf. 

Com I ^M

M&sii^Z.,j£^QS:jfj^MmjLe-.4^^ 

•fa 

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 
TECHNOLOGIES. ] 

Access Assessment Form: (Must be completed for every property. 

Information must be obtained from a property walk thru, not given 

by owner) 

Is the property stucco or asbestos? 

If yes, is any ofthe 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? . J 

n ' \ 

Does this property require a lift or wafTolding^to reach upper levels? 

Does this property have lots of plants or items in areas where painting is / 

required? ^ ^JOUJUC^ (jj) II CM \ 0^0 1 J^ . 

Does this property have any significant structural damage? " / /L/ A J ,j 

^ 1/ ^T (^ ^ IS W fTim. 

If yes, EXPLAIN? 

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 
TECHNOLOGIES^ INC 

Does this property have a garage? 

^0 

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 of occupied^ 

Are there any pets at this property? 

Are there any low hanging power lines? 

^d^ ^ 4 

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 
TECHNOLOGIES, INC 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

AlO 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

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 
TECHNOLOGIES, INC 

PAINT MATCHING FORM: 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTYADDRESS: // / S S> ^ ^ 

BVID: ^63 1 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: 

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 
^ ^ 

TECHNOLOGIES; INC 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTYADDRESS: // / $^ ^^' ^ <^( f 

BVID/SAID: ^26 ^ ' 

PRUDENT ASSESSMENT REPERSENTATIVE: 

******IF SAFETY RISK PROPERTY MUST BE TURNED OVER TO 

KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A CREW/SUB. 

REPERSENTATIVE REMARKS/FINDINGS: 

« . 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/LADDERS/LIFTS 

NEEDED, UNSAFE AREAS, UNSAFE NEIGHBORHOOD...ETC.) 

REQUIRES K.ROTHER APPROVAL 

SUBMITTED TO K.ROTHER ON: 

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 
TECHNOLOGIES, INC. 

Checklist for the Worksite Hazard Analysis B^ i 

Address: l \ \ 

Crew: Date: "7 [ ?^| Ot^ft^ 

Item OK? Hazard Corrective Action 

Overhead Lines i ^ -V ^ r^wl'l^' Ikii ^ILIAX^ V v^^»> ^ S ^ ^y^A4. - ^ In-transit Vehicle Clearance F 

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 

Neighbor Access Required ^ -QTLIL* Nt^lK J^c^ Go^3

High Trafiic Area 

Garage 

Structures ^ ^ ^ - ^ f^Vx^Cx ) "bo "^ ^ V'*!- \^A<h^ 

Driveway ^t 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Foliage 

General Condition ofyard XV Coif b\ [L^ lwr>t y OA Kt>^ ^ Q>^ ga<^ /kcL .bAtL \>LMW^ 

Daniaged ^ Areas: sink »rjUL(l V5. V ^^^-^lUi^vOwAAKk ^«-W pcLi^ ^ 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions fUit"-^ 

Unsafe driving conditions ^AO. juziuj- Unsafe neighborhood U-CW.=>*^ ' ^ . 

O^'ViL Vuoo-oj <yx tu , Sc>VA.Tts/K«^ . d' ^ b^Vo/^'wJ 

Cr ^ Foremanikn// Sub Sub-Contracto ­ r Site Safety OfHcer 

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 



J«a* ^ 

T­

-«! * 

\^ 

i 1 It H ! 

S SS 3 ^ 
illi 

flHI 

\ u s 3g S^ 
n s^y MfiMHtt^^HiBiSii 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

V^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. 

tr^.ujl f^GL A 

y-i-o"! 

e of recipient 

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 Information 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 

it the door. 

m 

7'7'd9 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature otperson certifying lead pamphlet delivery 

/// ^-3^^^ <ff 

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). 
Douglas County Account Infi^nation Page 1 of3 

Douglas County, Nebraska Property Record - R1423560000 

Print Report 

Information is valid as of 2009-6-16 '*^'^ '"'"TM ' "'"^^ DTM^"^""^ -^^''^^le @ scale o-so ft west of 52nd st - View on Map 

Treasurer s Tax Report 

New Feature ->->-> Auto Sales Search 

Owner 

GAUDREAU BENJAMIN S 

Z303) 

3317 BURT ST #1 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number: 2356 OOOO 14 

Account Type: Residential 

Parcel Number: 1423560000 

Parcel Address: 111 S38ST 

OMAHA NE 68131-0000 

Legal Description: ! JEROME PARK LOT 3 BLOCK 10 45 X 167 1 

Vaiue Informatio n 

Land Improvement Total 

2009 $13,100.00 $134,800.00 $147,900.00 

2008 $13,100.00 $134,800.00 1 $147,900.00 

2007 $13,100.00 $134,800.00 $147,900.00 

2006 $13,100.00 $81,500.00 $94,600.00 

2005 $13,100.00 $81,500.00 $94,600.00 

2004 $13,100.00 $81,500.00 $94,600.00 

Sales Informatio n 

Sales Date: 2004-05-10 

Deed Type: WD Book: 2004 Page: 131294 

Price: $120,000.00 

Grantor: Thomas VanBelle Etal 

Grantee: Benjamin Gaudreau 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 1996-01-26 

Deed Type: D Book: 2025 Page: 215 

Price: $76,000.00 

Grantor: 

http://douglasne.mapping-online.eom/DouglasCoNe/static/accountinfo.j sp?accountno=Rl 42... 7/7/2009 
"i*», •••">'''* ••f?r^ " ^ ' ..^•'tfttttf-l.- -'i..', .i,.»n;,(t;. •• I a j,.1^j- " * • •• •.f-V^-V^'ni.*.' •i'r-JKl'i^. 

Douglas County Account Infi^aation Page 2 of 3 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Lan d Informatio n 

Acres SF (/n/ts Depth W/dfAi Vacant 

0.17 7515.0 1.0 167.0 45.0 No 

Improvemen t Informatio n 

Building 1 

2 1 2 Sl^l^^ liiiishcd 

• ;.pr 

" i toi­ 1*1 

. J'" It..* I*".'­

tl / 

.ti l i<i> 

JW. iL»f.-j,a:j, 

'Tit"" I K ' 

(•ll>M*4« > 

Fin EHW N(* (ncl In I iv Arieii « i .i| li 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 2250.0 Percent Complete: 100.0% 

Perimeter , 0.0 Quality: Good 

Unit Type: Condition: Average 

Built As: 2 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: I Forced Air Rooms: 15.0 

Exterior: 

•^ -

Frame Siding Units: 1.0 

Interior: Drywall Baths: 3.0 

Roof Cover: Composition Shingle Bedrooms: 5.0_ 

Roof Type: Stories: 2.5 

Floorcover: Allowance Foundation: Blocl< 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built I 

1905 0% 1905 102 

Detail Type Detail Description Units 

1.0 

Basement Bsmnt Blocl< 8 ft 

Appliance Allowance 

960.0 

Basement Finished 400.0 

Fixture Additional Fixtures 1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accoimtno=R142... 7/7/2009 
Douglas County Account In£^jiation ^ ^ Page 3 of 3 

Fixture 

Fixture 

Porch 

Porch 

User 

User 

User 

Base Fixtures 

Bath Full 

Slab Roof Ceil 

Slab Roof Ceil 

2nd floor 

Attic Full Finish 

window NC 

1.0 

3.0 

140.0 

16.0 

910.0 

356.0 

1.0 

http://douglasne.mapping-online.coni/DouglasCoNe/static/accoxmtinfo.jsp?accoimtno=R142... 7/7/2009 
PlUD] TECHNOLOGIES, INC. 

Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: ^OS f 

Property Address: /// ^. ,?p'5<r 

Owner's Name: ^ N 6^U/)I?CAL ( 

S.NO 

Performance Standards/close-Out Criteria 

1 

Was the entire structure(s) painted with the exception ofthe 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 Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

5 

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? 

6 Is the grass area that surrounds the structure(s) In reasonably good 

condition? 

7 Was the paint products utilized equivalent to a 30 year 

product/quality? 

8 Are ali 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 there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

11 Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? 

12 Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Prudent Representative Signature pif 

Date: 7-/^-^ f 

Property Owner Signature 

Date: 7 ^ // , , ^ ^ 

Yes NO 

K 

y> 

K 

X 

A 

A 

?^ 

A 

A 

X 

A 

/ 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, WIO 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