## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID : 3689 6 Date : 12/26/200 8 Address : 222 3 OGDE N Remediation Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S a ' Video of propert y (DVD ) \ ^ Executive Summar y WSignedAcces s Agreemen t fo r

subject propert y mPainting Agreemen t D Settlemen t documents (i.e. , fo r

damage o r

to replac e plants , etc. ) D Photograph s 0 Satisfactor y restoratio n signedby Propert y Owne r D Propert y close-out chec k

lis t signedby EP A M Propert y infonnatio n fro mDougla s Count y Assessor' s Ofific e D D D 

## ignature > Dat e

4030984 8 

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### 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 : 222 3 OGDEN SAID : 3689 6 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 : 10/31/0 8 Wor k Began : 11/04/0 8 Closeou t Date : 11/05/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . Signe dAcces s Agreemen t 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 . EPA 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 : 

# D^l-^- ^ Phone: ^5 5 '/^C g BVID : '3>ai.b7 U Plan t & Pennaneii t Landscapin g T o Remtu nI nPlac e Iteiii # 

## Lptio nan dLocatio n O nMa p 

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Pre'^dstin g Conditio n o f Structure s Doe s ybu r Basemen t hav e ahistor y o f leaking ? Ye s — N o Itein # Descri i tio n& Locatio n OnMi ^ 

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Prope r y O^ne r Pruden t Emplo ; Signatir e Signature : 808 0 Wki d Parkwiy , Siit t 40 5 260 8 N . 24 * Straet , suit e 30 8 424 2 Medica l Ditvt , Suit * 428 0 AM Aiil«inla.TX 7822 9

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Pruden t Technologies , Inc l (Prudent) i s under contrac t (Contrac t #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agenc y (EPA) t o stabiliz e Lea dBasedPaint (LBP ) a t anumbe r

ofpropertie s locatedi n Omaha, Nebrasla , includin g th e propert y locateda t ^3^ 3 QC' v Af t Y ^ S 1 . The EP A request s your p e missio n t o allo w Pruden t t o perfor mLB PStabilizatio n atHhi s property . B y signing thi s form, tiie prop srt y owne r

grant s pennissio n t o Pruden t t o perfor mactivitie s relatedt o LB P Stabilization includin g sc r iping pain t andpaintin g ofth e referencedproperty . Further , th e owner/tenan t verifie s tha t they hav e receive dtiie LB Ppamphlet "Renovat e Right. " I f

you have an y question s about th e LB P stabilizatio n plannedfo r

your property , pleas e contact Prudent' s AriministTfltiv e Cler k

fo r

ti e LeadBasedPain t Stabilization , Mrs . Debora hAkerele^ohnson . a

t (402 ) 504-1004 . Gener aI question s about th e OmahaLea dSit e cleanup ca n b e directedto tiie EP A Publi c Infonnation Centen a t (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nort hOmaha office) . Property Acoei s Giante dBy : /yj ^ / / C jCyj^l^ S (Pleas e Prin t Name ) Propeit y Owne r Signature ; 

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— (^ignature ) PROPERT Y INFORMATIO N CIiLfee complete db y miden t and/o r propert y owne r - pleas e print ) RESIOENTNAME : 

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# ^/z S RESIDENTADDRESS : 

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# v3 0/fl^4 } I F RENTAL , PROPERT Y OWNE D B^ : 

# :_^ki £ OWNER' S MAIUN G ADDRESS ; 

# S ^ OWNER' S TELEPHON E NUMBER. HOME : f4 ^

></c5S~ yTc^j^HK ! 1462^-^^ ^ S ^ J^^S S Li > NUMBE R O F OCCUPANT S UNDE R ' 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 Y EAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : O COMMENT S O R SPECIA L INSTRU C TIONS : (I.E . DOGS . ENTR YGATES , ETC. )

AUTHORir Y FO RENVIRONMENTA LUBSFONS EACTIONS ; Th e activitie s t o b e implemente db y EP A unde r di s agreemen t ar e pursuan t t o Sectio n10 4 o f

CERCLA . 4 2 U.S.C . 9604 . EPA' s right o f

acces s t o d w propert y isprovide dfor i nSectio n104(e ) o f CERCLA . 4 2 U.S . C 960S(eX whic hprovide s entr y for''determinin g th e nee d fiw response , o r loosin g ortaldn g in y respons e actio nunde r thi s title, o r otfierwis e eiilbicin ^

i08 0 War d Paitavay . Suit s 40 5 250 $ N . 24* ^ StTMt . SUH B 30 8 424 2 Medica l Drive , SuK a 425 0 lansa s City , M O 6411 4 Omaha , Nebraska 6811 0 Sa n Antonio , T X 7822 9 'hon0:(816)36M7O 3 Phone : (402)504-100 4 Phone : (210)822-958 8 «v . /e4« \ «A 9 vt m

# Curren t Sampt e P re^enovatio n For m Effectiv e unti l Apri l 2010 . Confimiatio n of Receip t of Lea d P4niphle t I hav e receive d a cop y of th e pamibhiet , , /^novat e fl^f ; Importan t Lea d Hazar d Informatio n fi xfamilies . Chil d Ca n > Provider s an d School s irrformin g me of th e potentia l ris k of th e lea d hazarq i exposur e fro m renovatio n acttvity to be performe d in mydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . 

# A/t//^lo/7e S /C Is /lb 5r Printe d riam e of recipien t Dat e ^ * * 3 ^ 

# JQ^U- Signatur e of recipien t Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — If th e lea d pamphle t wa s deitvere d I bi t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e appropriat e bo x tielow . Q Refusa l to sig n —I ceilif ytiia t I tjav e mad e a goo d M h effort to delive rth e pamphlet , /^novat e /%/if : Importifn t Lea d Hazan j Infonnatio n fo rFamSes , CNI d Car e Providers an d School s to th e renta l dwellin g uni t liste d belo wat th e dat e an d tim e indicate d an d tha t ti e occupan t refuse d to sig n tii e confirmatio n of receipt . I furthe rcertif ytha t II ha re lef t a cop y of th e pamphle t at th e uni t wit h th e occupant , Q Unavailabl e fo rsignatur e —I cetif y tha t I hav e mad e a goo d feuth effor t to delive rth e pamphlet , Ftenovat e Importan t Lea d Haar d infonnatio n fo r f^mitHes , ChB d Car e pnyvider s an cSchools , to th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e to sig n th e confinnatio n of receipt , 1 turthercertif ytha t I hav e left a of th e pamphle tat th e uni t byslidin g it 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 in certifyin g lea d p imphle t deliver y 

# ^ ^ /O^J^T W UnltAddres s Not e Regardin g Mailin g Optio n — As an altemativ e to deliver yin person , yo u ma ymai l th e lea d pamphle t to th e owne r arxj/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 pos t office) .

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### Pag e 1 of 2 Dougla s County , Nebnsk a Propert yRecor d - R183884000 0 Prin t Repor t NE

W Featur e - Parce l Dimensions availabl e @ scal e 0-5 0 i i wes t o

f 90t h S t - Vie W O h Ma p Informatio n i s vali d a s o f 20 ( i8-9- 4 Treasurer' s Ta xRepor t Ne wFeatur e ->-*- > Aut o Sale s Searc h Owne r JONE S JESS E ETA L 222 3 OGDEr i S T OMAHAN E 68110-000 0 Propert yInformatio n Ke yNumber : [ 38* 4 000 0 1 8 Accoun t Type : Re ; Mdentia l Parce l Number : 18:884000 0 Parce l Address : 22 : 3 OGDE N S T

, ON/AHAN E 68110-000 0 Lega l Description : \ N E WTO N AD D LO T 8 BLOC K3 5 0 X 140. 8 Valu e Informatio n Lan d Improvemen t Tota l 200 8 .. . $2.7(0.0 0 $5'3,200.0 0 $55,900.0 0 200 7 $2,7 C 6.0 0 $55,000.0 0 $57,700.0 0 200 6 $2,7C0.0 0 _$55.000.0 0 "$57,70b.6 0 200 5 $2~7C0 M 

### isi.ooo.o o $'57700.0 0 200 4 $2,700.0 0 $33,56(j.'0 0 $36,200.0 0 200 3 I $2,7 0 D.O O $33,500.0 0 $36,200.0 0 Lan d Informatio n Acre s • S F Unit a i Dept h Widt h Vacan t 

### 0.1 6 : 7000, 0 

## 1. 0 l 

## 140 F 50. 0 

## N o Improvemen t Informatio n Buildin g 1



### http://douglasne.mapping-on ' ine.com/DouglasCoNe/static/accountinf o . j sp?accountno=R l 8.. . 10/1/200 8

## Pag e 2 of 2

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••« 3 C < o r 2 ?; 2 STOR Y UNFI N

CLIC KTO ENUtRGEIMApg ' Squar e Footage : : 1:67. 0 Percen t Complete : 100.0 % Perimete r1 0 . Quality : ] Averag e Uni t Type : | Condition : : Averag e

BuiitAs : ! 2 ft/2 Stor yUnfi n Cond o Squar e Footage : ; 0. 0 HVAC : j F cree d Ai r Rooms : . 6. 0 Exterior : \ Fram e Viny l Units : ': 1. 0 Interior : i Dr/wal l Baths^ i 1. 0 Roo f Cover : i C cmpositio n Shingl e Bedrooms : ; 3. 0 Roo f Type : ; G J bl e Stories : ': 2. 5 Floorcover : -, Albwanc e Foundation : Bloc k 1 Sprinkle rSquar e Footage : 0. 0

Ad d O n Yet r Percen t j Adjuste d Yea r YearBuil t Physica l Ag e Remo i 'ele d Remodele d \ Buil t 191 0 

# 0 % r 191 0 " " 9 9 Detai l Typ e : Detai l Descriptio n 

### Unit s Applianc e Basemen t Fixtur e Fixtur e Garag e Porc h Porc h Porc h ' • Unfinishe d Atti cW/floo r ' Allowanc e i Bsmn t Bloc k 8 ft ] Bas e Fixture s • Bat h Ful l ; Detache d ; En d Soii d Wal l

En d Soli d Wal l Sla b Roo f Cei l 

### 264, 0 "i. o 

### 624. 0 1 ^ 1. 0 308. 0 112. 0 

### 192. 0 40.o '



## http://douglasne.mapping-on ine.com/DouglasCoNe/static/accountinf o .jsp?accountno=R l 8.. . 10/ 1 /200 8

## Pruden t PropertyClose-Ou t For m (Lead-Base d Pain t Stabilization ) PropertyAririn»« i ^ A 9^ 3 (X^dpjr ) C:>dr ^ _ 

## owier-swnmi. . n^/j . , Uh^ & / Je.^S / ^ J J^ne S Performance Standards/close-Ou t Criteri a YE S IN 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 woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x 

# K biearre , 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 ? 

# X 3 .

Vie n 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 ? 

# I T 4 .Wja s th e pain t product s utilize d equivalert t t o a 3 0 yea rproduct/quality ? A[ e al l ofth e area s wher e contaminate d material s hav e bee n spiiie d thjoroughl yvacuumed / cleaned ? 6 .Ol 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 , 

## V ^ rokdways , alleyways , publi cacces s areas an d als o remove 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 ? ^ . 8 .

Are ai l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et c properl yremoved ? < 9 .

I s tiier e anyevidence o f propert ydamag e tha t wa s don e byth e contractor ? An ypropert ydamag e ne^st o b e complete d prio rt o th e EP ACiose-Out . 10 . Ar e ther e an ypropert yitem s tha t wer e temporatii yre-locate d b yth e contracto r i ^ thq t nee d t o b e move d back? 11 .Areithere any(known ) lingerin g issues wit h th e propertyowner{s ) tha t hav e bee n lef t unresolved ? i Gthle rConsiderations?propert yOwne rDiscusslons?Addltiona l Wor k tha t i s Require d



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