TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 2125 Date: 12/26/2008 

Address: 640 N 42 ST 

Stabilization Contractor: Prudent Technologies Year: 2008 

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PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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Video of property (DVD) 'J_ 

Executive Summary 

Signed Access Agreement for subject property 

Painting Agreement 

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

Photographs 

Satisfactory restoration signed by Property Owner 

Property close-out check list signed by EPA 

Property information from Douglas County Assessor's Office 

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Superfund 
PROPERTY SUMMARY 

Date: 12/29/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address; 640 N 42 ST SAID; 2125 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered; NONE. 

A.2 Issues Resolved; NONE. 

A.3 Unique Findings: NONE. 

A.4 Other Relevant Information: 

Access Date; 09/15/08 

Work Began: 09/30/08 

Closeout Date: 10/01/08 

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 

TECHNOLOCIES. INC. 
TECHNOLOGIES, INC. 

ENVIRONMENTAL & 

CONSTRUCTION 

SERVICES 

Property Status Form 

Address: ^i(^ fJ^H^^ ^ Date: f~/^-^^ 

Phone: ^63 - ^iZS ^ BVID: QiaF 

Item# 

OnM^ 

Plaat & Permanent Landscaping To Remain In Place 

Description and Location 

6^i^M " Off<]m :Z[4m6 m^-mi ii 

Pre-Existing Condition of Structures 

Does your Basement have a history of leaking? Yes — No — 

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OnMap 

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^HkT^ l^j^^^ c LA 

8080 Vferd Parkway, Suiio 40S 

Kans2B City. MO 64114 

Phone: (SIS) 363-3703 

Fax: (816) 363-3707 

2309 N. 24'" Street. Suite 303 

Omaita, Nebtaska 6811C 

Plione: (402) 504-1004 

Fax: (402) SGi-inr-a 

Prudent Employee 

Signature: (/f/^i ^ /yU 

S&42 Mediedica l Drive, Suite 4250 

San Antonio, TX 76229 

Phone: (210} 822-«58S 
?FFD 

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

Enviromnental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a number ofproperties 

located in Omaha, Nebraska, including the property located at (r/4t^ k ) .. Q-ZF^ ^ j , 

The EPA requests your permission to allow Prudent to perfonn LBP Stabilization at this property. By 

signing Ms form, ihe property owner grants peimission to Prudent to perform activities related to LBP 

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

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

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

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

at (402) 504-1004. General questions about tiie 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). . . 

Fropei^ Access Gnnted By: L^nnis LZ)di<.^ 

PropSTQ' Owner Signature: _ 

RESIOENTNAME: 

(Please Print Name) 

(Signature)" (Date) 

PROPERTY INFORMATION 

(To i>e completed liy resident and/or property owBcr — piease print) 

RESIDENT ADDRESS: i^F// M yy^-^ ^ 

Renter 

IF RENTAL. PROPERTY OWNEO BY: 

OWNER'S MAiLING ADDRESS; 

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OWNER'S TELEPHONE NUMBER • HOME 

NUMBER OF OCCUPANTS UNDER 7 YEARS OIJ); < ^ NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: ~ ^ 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: <S? 

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

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AUTHORITY FOR ENVIRONMENTAL RESPONSE ACnONS: The activities to be implemented by EPA under tins agroemeot are puisuani to Section 104 

of CERCLA. 42 U.S.C. 9604. EPA's riglii of access to the property isprovided for in Section !04<e) of CERCLA. 42 U.S. C 960S(e). wbidi provides entry 

for-ddecminingthe need for response, or eioosing ortaking any response action under this title, or ofl^ ^ 

iO Ward Parkway, Suits 405 

:iS3S City, MO 64114 

sne: (816) 363-3703 

:: (816) 363-3707 

2505 N. 24* Street, Suite 308 

Omaha, Nebraska 68110 

Piione: (402)504-1004 

Fax: r402\ 5Qi-in0S 

4242 Medical Drive, Suite 4250 

San Antonio, TX 78229 

Plione: (210)822-9688 
Current Sample#re-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

Q; I have received a copy of the pamphlet, Ftenovate Right Important Lead Hazard 

•' Infonnation for Fairwlies, Child Care Provid&rs and Schools infomiing me cf 

the potential risk of the lead hazanj ©qposure froTi renovation activity to be 

performed in my dwelling unit. 1 received this pamphlet before the work began. 

Printed n^ e of recipiem^ /j Jj 'l3ate 

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Signature of recipient 

Setf-CertificatiQn Option (for tenant-occupied dweiiings only) — 

If the lead pamphlet was delivered but a tenant signature was not obtainable, 

you may chectc the appropriate box below. • 

Q Refusal to sign — I certify that 1 have made a good faith effort to deliver the 

pamphlet, f?enovate fl/ght; Important Lead Hazard Infonnation for FamMes, 

Child Care Provkiers and Schools, to the rental dwelling unit listed below at the 

date and time indicated and that the occupant refused to sign the confinnation 

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, RerxjvatB Rght Important Lead Ha^rd Information for 

Families, Chiki Care provkiers and Schools, to the rental dwelling unit listed 

below and that the occupant was unavailable to sign the confimnation of receipt. 

I further certify tfiat 1 have left a copy of the pamphlet at the unit by sliding it 

und^ihedoor- / ^ ^, ^ 

Printed name of pet^op certifying Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of pirson (4rttfying lead pamphlet delivery 

(^¥d 7y ^^ ^ ^ 

Unit Address 

Note Regarding Mailing Option — As an aitematlve to delivery in person, you 

may msal the lead pamphlet to tt» owner and/or tenant. Pamphlet must be mailed 

at least 7 days before renovation (IDocument with a certificate of maling from the 

post office). 
a ^M^77ori^ cifHi p577m mm// / 

P;»Tni- moi-^i,-: ^ P^"""^ '"^•^ch form Paint matching form: 

Property^,,.ess:^,^..,,^ ^ ^^ ^ 

Area: Fh^MCf i <A F * ^fol^/ ^ ^"^ ^'^'^ f f''' ^ > • 

ffi»^po/c^<F(iht^,^^Zs^,^ f^^^^ioy^ ^1 ' 

A''ea: Color: 

Explanation: 

Area: ^^^^^5-^ ^ 4 , color: ^^,/ , ^,^ ^ ^ ^ 

Explanation 

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Explanation: 

5-7 M/^A^r 

Area: Color: 

Explanati on: 

Page 1 
Access lAfFORMMTTON TRAOmiG SHBET 

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Page 1 of 

I Dougia s County , Nebrask a Propert y Recor d - R2016S3000 0 

Print Report 

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InTorTiaiion IS valid as OT zuCc-;'-:4 " _ .^ _ _ • ' 

Treasurer s i ax Repon 

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DGvVD DENNiS D 

S40 N 42 ST ^ 

0?v'iAHA NE 68131-GOOC 

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Property Information 

Key Number: 1S89 0000 20 

Account Type: 

Parcel Number: 

Parcel Acfdrfiss; 

Legal Description: 

Residential 

: 2016S80000 

640 N 42 ST 

OMAHA NE 58131-0000 

POPPLETON PARK LOT 1 BLOCK 5 N 40 F~ 4C X 128 

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Valu e Informatio n 

Land 

\ 2008 

2007 

Improvement Total 

S5,700.0G $66,800.00 

$5,700.00 S61.300.00 

$72,500.00 

S57.600.00 

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1 

2006 $5,700.00 361.900.00 SS7.600.00 

2005 $5,700.00 S51.S00.0C $67,500.00 

2004 $5,700.00 358,500.00 S64.200.00 

2003 35,700.00 S58.500.00 $54,200.00 

Sales Informatio n 

Sales Date: 13S4-03-2; 

Deed Type: D Book: 1988 Page: 142 

Price: $54,900.00 

Grantor: 

Grantee: --i 

Valid/Invalid: Vaiid 

Exclusion Reason: 

Sales Date: 1SS2-02-11 

Deed Type: D Soo.Jc; 192' Page: 

Price: S42.000.00 

Grantor: 

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i^age 2. 01 

Grantee: 

Valid/Invalid: vaiid 

Exclusion Reason: 

Lan d Informatio n 

Acres SF Units Depth Width Vacant 

0.11 5120.0 1.U 128.0 4n G No 

Imorovement Information 

Building 1 

1 wo Step.'' S4-0 N 42 S I 

CL-iCKTC Eivi. CLiCK TO ENLARGE I1V5AGE 

Square Footage: 1398.0 

Perimeter 0.0 

Unit Type: 

Percent Complete: 100.0% 

Quality: Average 

Condition: Fair 

Built As: 2 Story Condo Square Footage: 0.0 

HV.AC: Centra! .Air to Air Rooms: 6.0 

Exterior: . Frame Siding Units: i.O 

interior: Drywaii Baths: 1.5 

Roof Cover: Composition Siiingie Bedrooms: 3.0 

—I 

rRcofType: Gabie Stones: 2.0 

Floorcover: Allowance Foundation: Block 

Sprin.kler Square Footage: 0.0 

YearBuilt Year 

Remodeled 

1918 

Percent 

Remodeled 

0% 

Adjusted Year 

Sunt 

1918 

Physical Age 

90 -F 

Detail Type 

.Add On 

Detail Description 

Fence Ciiain L;ni< 

Units 

Aooiiance Aliowance 1.0 1 

Basement Bsmnt Block 8 ft 

MXture Base Fixtures 

707.0 

-ixiure Bath Fui! 

1.0 

1.0 

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

I Garage 

I Porch 

Bath Half 

Detsclied 

Slab .Roof • 

1.0 

216.0 

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128.0 ' 

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Prurient PrOOerty Ciose-Out Form (Lead-Based Paint StabiUzation) 

ProoertvAddrass: /Jk J J ^ 9 /^W ^ 

Owner's Name; JOAWVAJ ^ U&tjS A 

Performance Standards/ciose-Out Criteria 

Was the entire structure(s) painted with the exception of the stated, excluded areas? This would 

Include painting of other associated features including fascia, saves, siding, a!i trim, porches, box 

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

2. Was all scraping and other preparation work completed satisfactoriiy? 

3. Were oil required areas of the structure(s} primgd as needed and painted with two top coats? 

4. Was the paint products utilized equivalent to a 30 year product/quality? 

Are all of the areas where contaminated mEterials have been spilled 

thoroughly vacuumed/ cleaned? ^ 

Did the contractor collect/vacuum all failing and scraped paint chips cn the entire property, 

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

Is the grass area that surrounds the structure{s) in reasonably good condition? 

Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape etc. 

properly removed? 

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

needs to be comoieted prior to the EPA Ciose-Out. 

Are there any property items that were temporatiiy 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? 

Other Considerattons?property Owner Discussions?Additionai Work that is Required 

Py0fi^^4yL. C]C.w^Ji.qt^h^r^ ^ 

Pru Prucfen c t ReJeffesentative U 

Date 

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