## TRANSMITTA Lo f

OMAHA LEA D SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAID# : 36 1 Date : Octobe r 2 9 Address : 200 3 Pinkne y St . Remediatio nContractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S [i

f Vide o o f propert y (DVD ) g

f Executiv e Summar y l?

f Signe dAcces s Agreemen t fo r subjec t propert y 

## 5 /

Painting Agreemen t D Settlemen t document s (i.e. , fo r

damage o r

to replac e plants , etc. ) D Photograph s [?

r Satisfactor y restoratio nsigne db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A w Propert y informatio nfromDougla s Count y Assessor' s Offic e D D D 

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### PROPERT Y SUMMAR Y Date : 9/4/0 8 LB PSTABILIZATIO NEP A CONTRA T EP-R7-08-0 7 Mont hof : Septembe r Propert y Address : 200 3 Pinkne y S t SAD) : 36 1 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : Non e

A. 2 Issue s Resolved : Non e

A. 3 Uniqu e Findings : Non e

122A. 4 Othe r Relevan t Informatio n Acces s Date : 8/21/0 8 Wor k Bega nDate : 9/04/0 8 Closeou t Date : 10/01/0 8

Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s For m 4 . Signe dAcces s Agreemen t 5 . Pre-Renovatio nFor m 6 . Pain t Matc hFor m 7 . Trackin g For m 8 . Dougla s Count y Assesso r Propert y Informatio nPag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio nAgreemen t

TECHNOLOGIES , INC .ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Propert y Statu s Eor m Address : ^ ^ fi^j^^. ^f ^ Date : Tj^/^p 

# Phone : ^^S^-'^^f ^BVID : S6/ ' Plant & Pennanent Landscaping T o RemainI nPlac e Item # DescriptionandLocatio n OnMa p

Pre-Existing Conditio no f Structure s Doe s you r

Basemen t hav e ahistor y o f leaking ? Ye s —N o — Item # Descriptio n & Location OnMa p 

# SdMi^ 

# pmfi ^ 1 / 

# l l u / / 

## I J 

# jifi ^ DM M W- Propert y Owne r Pruden t Em i Signature : 

## y.4^^,xyi/ ) cl)/>j//nJ ^ 808 0 War d Parkway , Suit e 40 j 250 5 N . 24* " Street . Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Fax : (816 ) 363-370 7

# 31^1

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

contrac t (Contract #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio nAgency (EPA) t o stabiliz e Lea dBasedPaint (LBPla t anumbe r

ofpropertie s locatedi nOmaha , Nebraska , includin g th e propert y locateda t R00 3 r l HkjVJ J ^ h• The EP A request s you r

permissio nt o allo w Pruden t t o perfor mLB PStabilizatio na t thi s property . B y signing thi s form , tiie propert y owne r

grant s permissio n to Pruden t t o perfor mactivitie s relate dto LB P Stabilizationincludin g scraping paint andpaintin g of th e referencedproperty . Ftirther , th e owner/tenan t verifie s tha t they hav e receive dti\e LB Ppamphle t "Renovat e Right. " If

you have an y question s about th e LB Pstabilizatio nplannedfo r

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

fo r

th e Lea dBase dPaint Stabilization , Ms . Debora hAkerele-Johnson . a

t (402 ) S04-1004 . Crenera l question s about th e OmahaLea dSit e cleanup ca n b e directe dt o th e EP A Publi c InformationCenter s a t (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nort hOmaha office) . Propert y Acces s GrantedBv : A ^ ^ O M , \dJ-^U . U'~ ^

7 (Signaturey ' 7 1 (Date) PROPERTY INFORMATIO N f (T o b e Cfiifiplete db y natdefl t and/o r propertyjgvn^^i^eas e print ) 

## RESIDEHTNAN E f^A{\ftl\^ \ H^tJk J I 1^° ^ Rente r RESIDEN TADDRESS : 

# , : 5 # I F RENTAL , PROPERT YOWNE D BY : OWNER' S MAILIN G ADDRESS ; ^nMC ' OWNER' S TELEPHON E NUMBER-HOME : < 1HS^^ ' I d ^PwORK : 

## 1 L NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : U NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : _j_ 

# / f NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PU YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES , ETC. ) 

# /^ m

AUTHOIUT Y FO RENVIRONMENTA LRESPONSEACTIONS ; Th e activitie s to be implemente dby EP A unde r thi s agreemen t ai e pursua mto Sectio n10 4 o f

CERCLA . 4 2 U.S.C . 9604 . EPA' s righ t o f

acces s t o the propert y i s providedfb r i

nSectio n 104(e) o f CERCLA . 4 2 U.S . C 960S(e) , ivhicf aprovide s entr y for "determining the need for response , o r choosing ortaking an y respons e actio nunde r Ihi s title , o r otfierwise enforcing tfie provision s o f Ita

e tide. "

:080 War d Parkway , Suit e 40 5 250 5 N . 24" * Street , Suit e 308 424 2 Medica l Drive , Suit e 425 0 '.ansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 hone : (816 ) 363-3703 Phone : (402 ) S04.inru i

# Curren t Sampl e Pi#-Renovatio n For m Effectiv e unti l Apri l 2010 . Confinmatlo n of Receip t of Lea d Pamphle t ^

I hav e receive d a cop yof th e pamphlet , Renovat e Right : Importan t Lea d Hazar d Intormatio n torFamilies , Chil d Car e Provider s an d School s Infomnin g me of th e potentia l ris k of th e lea d hazar d exposur e fro m renovatio n activit y to be performe d in mydwellin g unit . 1 receive d thi s pamphle t befor e th e wor k began . Printednam e o f recipien recipien t ^,,, ^ Dat e

>yy ^

# 'A ir e of recipien t Printe d nam ^^--r ?

Self-Certificatio 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 xbeiow . 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 , Renovat e Righ t Importan t Lea d Hazar d Intormatio n fo rFamilies , Chil d Car e Provider s an d Schools , to th e renta l dwellin g uni t liste d belo w at 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 t at 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 elTor t to delive rth e pamphlet , Renovat e Right : Importan t Lea d Hazar d Intormatio n fo r Families , Chil d Car e provide s an d Sdiools , to th e renta l dwellin g uni t liste d beio wan d tha t th e occupan t wa s unavailabl e to sig n th e confirmatio n of receipt . I fyrljie rcertifytha t I hav e left a cop y of th e pamphle t at th e uni t byslidin g it 

# f/ m 3^^-^ FS'S M Printe d perso n oaiifyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver y Signatur e of pftBo n certifyin g lea d pamphle t deliver y 

# ^^^ 3 PJ^jf^l ^ 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 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) .

# pain t matc h for m Pain t matchin g form : propert yaddress : ^^ J h/^m ^ ^ BVID : 5/ / 7 Area : M^/ ^ /^^^ ^ Color : (^ ^

^/^'pf e Explanation : ^--^m ^ Area : ^ Pom\f^^^f,- ^ 6 ^ ^ ^ ^^ ^ Explanation : S^kl0 6 Area : Color : Explanation : Area : Color : Explanation : I agre e t o thes e color s a s listed , onc e paintin g start s I ca n no t chang e thes e selecte d colors . Homeowne rsijgnature : Pag e 1

# Acces s INFORUATK M TRACfON GSHEE T PROPBRT Y 

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CLIC KT O ENLARG E IMAG E 

# D CLIC KT O ENLARG E IMAG E 

### Squar e Footage : 1750. 0 Percen t Complete : 

### 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Fai r

Buil t As : 2 Stor y Cond o Squar e Footage : 0. 0 HVAC : Force d Ai r Rooms : 7. 0 

### Exterior : Fram e Sidin g Units : 1. 0 

### Interior : Drywal l Baths : 1. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 3. 0

Roo f Type : Hi p Stories : 2. 0 Floorcover : Allowanc e Foundation : i Bloc k Sprinlde rSquar e Footage : ! 0. 0 yea r Percen t Adjuste d Yea r Yea rBuil t Physica l Ag e Remodele d Remodele d Buil t 

### 9 9 "1909 0 % 

### 190 9 Detai l Typ e ! Detai l Descriptio n Unit s Applianc e • Allowanc e 

## ~i. o Basemen t Bsmn t Bloc k 8 f t 872J 0 Fixtur e i Bas e Fixture s 

## "i o Fixtur e Bat h Ful l 1. 0 Porc h : En d Soli d Wal l 52. 0 Porc h Tinc l Soli d Wal l 140. 0



### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R15. . . 8/19/200 8

## Page 1 of 2 Dougla s County , Nebrask a Propert yRecor d - Rl52889000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabi e Q scal e 0-5 0 ft wes t o T90t h S t - Vie W O n Ma p Informatio n i s vali d a s o f 2008-7-1 4 Treasurer' s Ta xRepor t Ne wFeatur e -»-»- > Aut o Sale s Searc h Owne r BRUN TNAOM I V 200 3 PINKNE YS T OMAH AN E 68110-000 0 Propert yInformatio n Ke yNumber : \ 288 9 OOO O 1 5 Accoun t Type : Residentia l Parce l Number : 152889000 0 Parce l Address : ; 200 3 PINKNE YS T i OMAH AN E 68110-000 0 Lega l Description : \ KOUNTZ E PLAC E LO T1 BLOC K3 3 N 1/ 2 6 2 X 7 4 Valu e Informatio n Lan d Improvemen t Tota l 200 8 $500.0 0 

## j;i4,oob.o o $ 14,500.0 0 200 7 $5~00.0 0 $ 15,200.6 0 $ 15,700.0 0 200 6 $500.0 0 $15,200.0 0 

## ^isjoo-oo " 200 5 $500.0 0 $15,200.0 0 $ 15,700.0 0 200 4 $500.0 0 $ 22,900.0 0 $ 23,400.0 0 200 3 $500.0 0 $ 22,900.0 0 $ 23,400.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widti i Vacan t 0.1 1 4792. 0 1. 0 0. 0 0. 0 I N o Lan d Attribute s Attribut e Attribut e Descriptio n Negativ e Influenc e Traffi c1 Improvemen t Informatio n Buildin g 1



## http://douglasne.mapping-online.coni/D(iuglasCoNe/static/accotmtinfo.jsp?accountno=R15.. . 8/19/200 8, —Qvw.^/v'xix v.^iuuiv < x.>iiv\./i.vjij f /A.aaiM<iiiv; c 

### Pag e 1 of 2 

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## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) SAID : 3CP I 

## ^ / ) ' b ^ L PropertyAddress : fk O Q .2 > n</I L kkJi ^

^ Owner' s Name : '(\ l ifp'V^' ^ IDhjJyA ^ 

## Performanc e Standards/ciose-Ou t Criteri a YE S N 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 , af l trim , porches , box 

### / 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 ? 3 .Wer e al l require d areas o f th e 5tructure(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 ? 

### / • SAre ai l o f th e areas wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? 6 .

Di 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 , roadways , alleyways , publi cacces s areas an d also 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 .Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? 

## X . . y I s ther e anyevidence o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . 

# i^" ­ 10 .Ar e 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? 

## X ^ II .

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 rConsiderations?propertyOwne rDiscusslons?Addit!ona l Wor k tha t i s Require d 

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