## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID : 212 5 Date : 12/26/200 8 Address : 640 N 4 2 S T Stabilizatio n Contractor : Pruden t Technologie s Year : 200 8



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# y D D D 

## PAIN T STABILIZATIO N

PROPERT Y FIL EFOLDE RDOCUMENT S



## r Video of propert y (DVD ) 'J

_ Executive Summar

y SignedAcces s Agreemen

t fo r subject propert y Painting Agreemen

t Settlemen t documents (i.e. , fo

r damage or

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

A Propert y information fromDougla s Count y Assessor' s Offic

e

Signatuji e suJai/a x at e
4030798 5 

# ini n Superfun d

### PROPERT Y SUMMAR Y Date : 12/29/0 8 LB PSTABILIZATIO N EPA CONTRAT EP-R7-08-0 7 Monthof : Decembe r Propert y Address ; 64 0 N 42 S T SAID ; 212 5 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 : Acces s Date ; 09/15/0 8 Work Began : 09/30/0 8 Closeout Date : 10/01/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . SignedAcces 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 . EP A Propert y Closeout for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES . INC .

### TECHNOLOGIES , INC . ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Propert y Statu s For m Address : ^i( ^ fJ^H^^ ^ Date : f~/^-^ ^ Phone : ^63 - ^iZS ^ BVID : 

# Qia F Item # OnM ^ Plaat & Permanen

t Landscaping To Remain I n Plac e Descriptio n andLocatio n



# 6^i^ M " Off<] m:Z[4m 6 m^-m i i i Pre-Existin g Conditio n o f

Structure s Doe s your Basemen t hav e ahistor

y o f leaking ? Ye s —

N o — 

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^ Item # OnMap / I 

## i i F ^HkT^ l^j^^ ^ c L A

808 0 Vfer dParkway , Suii o 40 S Kans2 B City . M

O 6411 4 Phone : (SIS ) 363-370 3 Fax : (816 ) 363-370 7 230 9 N . 24' " Street . Suit e 30 3 Omaita , Nebtask a 6811 C Plione : (402 ) 504-1004 Fax : (402 ) SGi-inr- a 

## Prudent

Employe e Signature : (/f/^i ^ /y U

S&4 2 Medi edica l Drive , Suit e 425 0 Sa n Antonio , T

X 7622 9 Phone : (210 } 822-«58 S

# ?FF D Pruden t Technologies , Inc . (Prudent) i s unde r contrac t (Contract #EP-R7-08-07 ) wit

hth e U . S . Enviromnenta

l Protectio n Agenc y (EPA) t o stabiliz e Lea dBase dPaint

(LBP) at anumbe r ofpropertie s locatedin Omaha, Nebraska , includin g th e propert y locateda

t (r/4t ^ k ) . . Q-ZF ^ ^ j , Th e EP A request s you

r permissio n t o allo w Pruden t t o perfonn LB PStabilizatio n a t thi s property . B y signing M s form, ih e propert y owner grant s peimissio n t o Prudent t o perfor mactivitie s relate dt o LB P Stabilization including scrapin g paint andpaintin g o f

th e referencedproperty . Further , th e owner/tenan t verifie s tiiat

they hav e receive dtiie LB Ppamphle t "Renovat e Right. " I f yo u have an y question s about

th e LB Pstabilizatio n plaimedfo r you r property , pleas e contact

Prudent' s Administrative Cler

k fo r th e Lea dBase dPaint

Stabilization , Mrs . Debora hAkerele-TnlimMwi ^ a t (402) 504-1004 . Genera

l question s about

tiie Omah aLea

dSit e cleanu p ca n b e directe dt o th e EP

A Public Information Center s a t (402 ) 731-304 5 (Sout

hOmahaoffice) or

(402 ) 991-958 3 (Nort

hOmaha office) . . .



# L^nni s LZ)di<. ^ Fropei ^ Acces s Gnnte dBy : PropSTQ' Owne r

Signature : _

RESIOENTNAME : (Pleas e Prin t Name ) (Signature ) " (Date )

PROPERT Y INFORMATIO N (T o i> e complete dliy residen t and/o r propert y owBc r

—pieas e print ) RESIDEN TADDRESS : 

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/ M yy^-^ ^ Rente r

I F RENTAL . PROPERT YOWNE O BY : OWNER' S MAiLIN G ADDRESS ; 

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y OWNER' S TELEPHON E NUMBE R • HOM E NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OIJ) ; < ^ 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 OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : 

# <S ? COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. )



# A k

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACnONS : Th e activitie s t o b e implemente db y EP A unde r tins agroemeo t

ar e puisuan i t o Sectio n 104 o f CERCLA . 4 2 U.S.C . 9604 . EPA' s riglii o f acces s t o th e propert y isprovide dfor i n Sectio n !04<e ) o f

CERCLA . 4 2 U.S . C 960S(e) . wbid i provide s entr y for-ddecminingthe nee dfor response , o r

eioosin g ortakin g an y response actio n unde r this title , o r

ofl^ ^

i O War d Parkway , Suit s 40 5 :iS3 S City , M O 6411 4 sne : (816 ) 363-370 3 : : (816 ) 363-370 7 250 5 N . 24 * Street , Suit e 30 8 Omaha , Nebrask a 6811 0 Piione : (402)504-100 4 Fax : r402 \

5Qi-in0 S 424 2 Medica l Drive , Suit e 425 0 Sa n Antonio , T X 7822 9 Plione : (210)822-968 8

# Curren t Sample#re-Renovatio n For m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t Q ; I have receive d a cop yo f th e pamphlet , Ftenovat e Righ t Importan t Lea d Hazar d • ' Infonnatio n fo rFairwlies , Chil d Car e Provid&rs an d School s infomiin g m e c f th e potentia l risk

o f th e lea d hazan j ©qposure froT i renovation activit yt o b e performe d i n m ydwellin g unit . 1 received thi s pamphle t befor e th e wor k began . Printe d n^ e of recipiem

^ / j J j 'l3at e 

# ^W-/- ^ '^^^" ' Signature of recipien t Setf-CertificatiQ n Optio n (fo rtenant-occupie d dweiiing s only ) — I f th e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u maychectcth e appropriat e bo xbelow . • Q Refusa l t o sig n —I certifytha t 1 hav e mad e a goo d fait h effort t o delive rth e pamphlet , f?enovat e fl/ght; Importan t Lea d Hazar d Infonnatio n fo rFamMes , Chil d Care Provkiers an d Schools , t o th e rental dwellin g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t th e occupan t refuse d t o sig n th e confinnatio n o f receipt . I furthe rcertifytha t I hav e left a cop yo f th e pamphle t a t 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 t o delive rth e pamphlet , Rerxjvat B Rgh t Importan t Lea d Ha^r d Informatio n fo r Families , Chik i Care provkier s an d Schools , t o th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n th e confimnatio n o f receipt . I furthe rcertif

ytfia t 1 hav e left a cop yo f th e pamphle t a t th e uni t b yslidin g i t und^ihedoor - /

^ ^, ^ Printe d nam e o f pet^o p certifyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver

y Signature of pirso n (4rttfyin g lea d pamphle t deliver y 

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# ^ Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n aitematlv e t o deliver yi n person , yo u maymsa l th e lea d pamphle t t o tt » owne rand/o rtenant . Pamphle t mus t b e maile d a t least 7 days before renovatio n (IDocumen t wit h a certificat e o f malin g fro m th e pos t office) .

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### Pag e 1 o f

I Dougia s County , Nebrask a Propert yRecor d - R2016S3000 0 Prin t Repor t .J:^ „ ,:^ ^

- ^ ,,^i: ^ „ ^ ^io-.P R - "-' . r.=V\'=22trjre-=a-;e;0;~s-.i;o.- j = - = :;= : egscf.i s 0-5 0 ft wes t O f 90 rSt-Vie w o n MZ O InTorTiaiio n IS vali d a s O TzuCc-;'-: 4 " _. ^ __• ' Treasure rs i a xRepo n i Ne wrs^-LliT B - ^ -* • - ? Aut o Sale s Searc h j —— • 

### i Owne r DGvV D DENNi S D S4 0 N 4 2 S T^ 0?v'iAH AN E 68131-GOO C 

# r^. F Propert y Informatio n

Ke yNumber : 1S8 9 000 0 2 0 Accoun t Type : Parce l Number : Parce l Acfdrfiss ; Lega l Description : Residentia l : 2016S8000 0 64 0 N 4 2 S T OMAH AN E 58131-000 0 POPPLETO N PAR KLO T1 BLOC K5 N 4 0 F ~ 4C X 12 8 j

' " — 1 i 

### i Valu e Informatio n

Lan d \ 200 8 200 7 Improvemen t Tota l S5,700.0 G $66,800.0 0 $5,700.0 0 S61.300.0 0 $72,500.0 0 S57.600.0 0 1

i 1 200 6 $5,700.0 0 361.900.0 0 SS7.600.0 0 200 5 $5,700.0 0 S51.S00.0 C $67,500.0 0 200 4 $5,700.0 0 358,500.0 0 S64.200.0 0 200 3 35,700.0 0 S58.500.0 0 $54,200.0 0 Sale s Informatio n

Sale s Date : 13S4-03-2 ; Dee d Type : D Book : 198 8 Page : 14 2 Price : $54,900.0 0 Grantor : Grantee : 

# -- i Valid/Invalid : Vaii d Exclusio n Reason : Sale s Date : 1SS2-02-1 1 Dee d Type : D Soo.Jc ; 192 ' Page : Price : S42.000.0 0 Grantor : 

### hTtp:.//douglasne.mapping-oriline.com/DoiigIasCoNe.'static/accouritinfo.isD?accoimt^^ ^ 8/26''200 S

### i^ag e 2 . 0 1 Grantee : Valid/Invalid : vaii d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 1 5120. 0 1. U 

### 128. 0 4 n G 

### N o Imorovemen t

Informatio n Buildin g 1 1 w o Step.' ' S4- 0 N 4 2 S I

CL-iCKT C Eivi . CLiC KT O ENLARG E I1V5AG E Squar e Footage : 1398. 0 Perimete r0. 0 Uni t Type : Percen t Complete : 100.0 % Quality : Averag e 

### Condition : Fai

r Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0 HV.AC : Centra ! .Ai rt o Ai r Rooms : 6. 0 Exterior : . Fram e Sidin g 

### Units : i. O interior : Drywai i Baths : 1. 5 Roo f Cover : Compositio n Siiingi e Bedrooms : 3. 0 — I 

## r RcofType : Gabi e Stones : 2. 0

Floorcover : Allowanc e 

### Foundation : Bloc k Sprin.kle rSquar e Footage : 0. 0 YearBuil t Yea r

Remodele d 191 8 Percen t Remodele d 0 % Adjuste d Yea r Sun t 191 8 Physica l Ag e 9 0 

# - F Detai l Typ e .Ad dO n Detai l Descriptio n Fenc e Ciiai n L;ni < Unit s Aooiianc e 

### Aliowanc e 1.0 1 Basemen t Bsmn t Bloc k 8 f t MXtur e Bas e Fixture s 707. 0 

### -ixiur e Bat hFui ! 1. 0 1. 0 

### http://douglasne.mapping-oniine.coxr7DouglasCoNe/static/accoimtinfo.isD?acr.niiriTrin=Po n Q n c'•)r^p, c

### Pag e 3 of 3

i Fixtur e I Garag e I Porc h Bat h Hal f Detsclie d Sla b .Roo f • 1. 0 216. 0

. . ] 128. 0 '



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# Jffi j

Prurien t PrOOert

yCiose-Ou t For m (Lead-Base d Pain t StabiUzation ) ProoertvAddrass : /Jk J J ^ 9 /^W ^ Owner' s Name ; JOAWVAJ ^ 

### U&tjS A 

## Performanc e Standards/ciose-Ou t Criteri a 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 , saves , siding , a! i trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 2 . Wa s al l scrapin g an d othe rpreparatio n wor k complete d satisfactoriiy ? 3 . Were oi l require d areas o f th e structure(s } primg 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 ? Ar e al l o f th e areas wher e contaminate d mEterial s hav e bee n spille d thoroughl yvacuumed /

cleaned ? ^ Di d th e contracto rcollect/vacuu m al l failin g an d scrape d pain t chip s c n th e entir e property , roadways , alleyways , publi cacces s areas an d als o remov e an yothe rgenerate d debris ? I s th e gras

s are a tha t surround s th e structure{s ) i n reasonabl ygoo d condition ? Ar e al l item s suc h a

s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? I s ther e an yevidence o f propert ydamag e tha t was don e b yth e contractor ? An ypropert ydamag e need s t o b e comoiete d prio rt o th e EP ACiose-Out . Are ther e an ypropert yitem s tha t wer e temporatii yre-locate d b yth e contracto r tha 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 propert yowner(s ) tha t have bee n lef t unresolved ? Othe rConsiderattons?propert yOwne rDiscussions?Additiona i Wor k tha t i s Require d 

## Py0fi^^4yL . C]C.w^Ji.qt^h^r^ ^ Prucfen t ReJeffesentative U Pru c Dat e 

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