TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: 37^2 7 Date: 

Address: J257 ^ Ettf^O n A ^ 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

A Video of property (DVD): Pre-Stabilization & Post-Stabilization Videos 

y Executive Summary 

A Signed Access Agreement Form 

A Advance Notice Form 

A Pre-Stabilization Video Agreement Form 

A Access Tracking Form 

sK Property Access Assessment Form 

y Neighbor Access Agreement Form 

A Paint Match Form 

y Pre-Stabilization Property Safety Assessment Form 

A Work-Site Hazards Analysis Checklist 

B^ Photographs: Pre-Stabilization Property Hazard Assessment Photographs 

H Douglas County Assessor Property information 

e^ Property Completion Agreement Form Signed by Property Owner 

n Property Close-Out Check List Signed By EPA 

Pruden 'jrudent Technologies Tecnnologies, Inc. Siignatur : e Date 

30055309

•11 

Superfund 
TBOINaLOGIBS. INC 

Property Summary 

Date: 11/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov 

Property Address: 2574 Ellison Av. SAID #: 37627 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 10/14/2009 

ii. Work Began: 10/30/2009 

iil. Close-Out Date: 11/04/2009 

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 
NUMBER OF CHILDREN UNDER 7 YEARS OUD WHOM PLAY IN THE YARD FOR » HOURS OR MORE PER WEEK: 

sy 

Prudent Teeimolo&tes, tne. (PnidcM) is under contnct (Contnct # EP-RT-OS-O?) with the U. S. EnviiDiiinemal Protection 

Agency (EPA) to a^jijjze Lead Based Paint (LBP) at a niunbor of pitipenics located in Omaha, Nebraska, tncludine the 

property located at^M t ^'S? V SJAALUII^ ^ 

The EPA reqtiests your permission to allow Ahtdcnt to perform LBP Stabilization at this property. By signing this fonn, the 

property owner giants peimistio^ to Pmdent lo perform oetivities related to LBP Stabilization including scraping paim aqd 

painting ofthe refticnced propel^. Funher, the ownerAenant verifies that they have received the LBP pamphlet ''Renovate 

Right." 

By signing this dacwnent I agree (o allow an EPA contractor to conduct a soil cleanup at tny property following completion of 

lead-based paint stabiliation, jf the soil cleanup has not already bees performed. I understand that the stabilization contractor 

cannot provide assunnces of which oonttacior will bo twund to the soil cleanup. I fupher understand that the soil cleanup 

contractor will make atl reasooablo ofToits lo address concems thai 1, as the property owner, may have regarding soil 

cleanup at iny pKipcny. 

h] Yes, I havt read and uiukrsiand the pangiaph above. 

Siffiaaoc ofPrapeiiy 

/0~/Y- 0 

Date 

Ifyou have any questions about the LBP stabilization planned for your property, please contact Prudent's Cuaiomer 

Retotlonn/Office Mnnnaer for the Ua d Based Pamt Stabilization, Mri. Sha^n^ff Htft-at (4ffiZ) SM-IOIM or l401W134tt23. General questions about tbe Omalia Lead Site cleanup can be directed to the EPA Public Infonnation Centers at (402) 731 ­ 304S (South Omaha oOIce) or {fiiXL) 991-9583 (North Omaha office). 

l^perty Access Granted By: 

bojAAy.. ^. p^ri U -ZA 

(Picase Print Nane) 

Propetty Owner Signature 

' /^i^/^* ^ 

JbAV-o^ 

(DMe) 

80M Ward Parkway. Sulta 406 2S0S N. Hf^ StrMt. Suite SOS 43«2 Madtcal Driva^ Suite 4260 

Kaneaa City. MO 64114 Omaha, NtbraaJu SBIIO San Antonio, TX 70220 

Ptu>na:(ai«( 3134703 

Fai.(«16)M3'3707 

PHOOK (402)6041004 

Fas: {402)504.1005 

PDona: (2l0>822'«Stt 

FfDc: (210) 5704677 

OCT.15.2009 2:29PM N0.297,-,-J>.7/7 

Advanced notice needed. 

After signing the access you allow Prudent to begin Lead Based 

Paint Stabilization. Ali 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 of yard 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? 

Notice needed: 

1 ^ ^OO'^'f 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owners Signature ^ 

8080 want Parkway. Suiia 406 2S0» N. 24<* Straat, Sulta 306 4243 Madical Driva, Suitt 42S0 

KanaacCily, MO 64114 Omaha, MebraskaOSIIO Sao Antorrio, 7X78220 

Ptiora: (61^ 363-3701 

F«|:(0ia)363-3707 

PIMHM: (4O3)a04-ia04 

Pax: (4021 AM-tOOS 

Phone: (210) e22<458a 

nu : (210) $70-6677 
OCT.15.2009 2:29PM ^ ^'^ ^ '''J^^^^ 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL BE COMING 

OUT TO SHOOT A PRE-STABIUZATION 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. 

OWNERSNAME: U(Xnny £ ' /Lrf^^i^ J ^ 

PROPERTY ADDRESS: 2 5">^ C///JCn /fc'C 

BVID/SAH): ?> ' ^ ^ 

HOMEOWNERS SIGNATURE: 11^^,.,^/^^^^^t^i^i0 ^ 

PRUDENT REPRESENTATIVE SIGNATlflRE: 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETSr NOTICE NEEDED): 

P s ^ 

MOOWarUPannwiy, Suit* 405 2605 N. 24*" Straet Suite 308 4242 Madical Oriva^ SuKe 4290 

KantaaCity.M0M114 Omaha, Nabraaka 68110 San Antonio, TX7U20 

Pbopa: 1816) 303-3703 PtKme: (402)604-1004 Phone: (210)822.0688 

Fas: (816) 3634707 Fax: (403)504^005 Fax: (210) 6704S77 
TBC9INOLOGIES,] 

ACCESS INFORMATION TRACKING SHEET 

BVID: 3,7^7.7 PROPERTY ADDRESS: '^^l U t''^-^'^ 

Property Owned By: 

(If new property owner) 

Owners Phone No's: 

Home: Work: 

Cell: Fax: -

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACTDETAIL 

/^S*-t ^ A^JUule-CA^ i ^ l ^] ^ 

I 1 '^I' n t l 

/P U 

Comments: 

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

Kansas City, MO 64114 Omahia, Nebraslca 88110 San Antonio, TX 78229 

Phone: (816) 363-3703 Plione: (402)504-1004 Plione: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS,] 

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? 

H 

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? 

%nVi ^**^*^\A^ 

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

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

required? a 

Does this property have any significant structural damage? 

^^A> 

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 

Plione: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS,] 

Does this property have a garage? 

If yes, describe location of garage. 

Does this property have aluminum siding? 

If yes, is it original facto^ 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 or qjccupied? 

Are there any pets at this property? 

Are there any low hangin ingmgs p power lines? 

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

Kansas City, MO 64114 Oniaha, 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 
OCT. 15.2009« . 2:29PM,. 'NO.297 P,2''7 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

rROPERTVADDRJESS: _ 

BVID: '5?^77 

The following notes arc for the benefit of paint crew only. 

Paint Ye$ Paint No Location Paint Deseription 

Siding 

Alrr»\jn\orf> USoffit A^^V)OnlP'V^ 

xy^ 

Fascia '\|r>r^On^ Or^s 

Comer Trim 

frjruv^ioio*^^ J L ^ 

Window TYinis ^Imoo j J ^ " ^ t ^ 

Door Trims A ^<Y>Oi^» tJvvA. v^ 

Front Porch Ceiling •^/A C^^X^T 

Front Porch Ceiling Beams Ar^*viOwsOw^ \ ^ 

Front Porch Floor 

Front Porch Railings 

Front Porch Steps 

.Siding Baseboards P\\mO, ^ jvw L / 

Foundation S^cK^ (*iof-pVo-A-cJ ^ 

looo^ ^nnafch /A e €y/ihM) 6l^ \

, ^fcf4. ^ 

UUJ^OAUJ I^HUOLJ tvty, t>^c»<»^ r^tXJAj 

fifent Jgar H)<rtA,L(riJ UJ^A (^'\Jlci^C{^ ) 

I UNDERSTAND SHERWIN WILLIAMS WILL MA/CH MY CURRENT COLORS, 

Homeowno-signature: /[l^>i^>y^ f ^ ^ i..^- A>-Af-^'f 

BOIQ Ulhrd Ptitmny, Suit* 406 2fiOSN. 24'*Sti«ft. Suft* 308 4342 Modlcai OHv^ Sute 4260 

KancMCity,M0a«114 Om4>V.N«lnata 66110 S>nAnn>nip^ 7X76220 

Pftom: (816)363.3703 P)ioi)«: (402)504.1004 pxon*: (210)82^Mn Fax: (816) 3n-3707 Fw; (402) 60«-100S Pac (210) 6704677 
TECHNOLOGIES,] 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

NO 

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

^J0 

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 
TECHNOLOGIBS.] .& 

« 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 

BVID/SAID: '3>7^^ ^ 

PRUDENT ASSESSMENT REPERSENTATIVE: 

^ ^ At^fy 

REPERSENTATIVE REMARKS/FINDINGS: 

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

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

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 
TECHNCnX3GIIS, INC 

Checklist for the Worksite Hazard Analysis 

Address: 2>S7V FAUSnM ^ - ?'^* ^ " 

Crew: Date: |o|\«i|2 ^» ^ 

Item OK? Hazard Corrective Action 

Overhead Lines 

_pCUii«^ U>YC\ «W ~tW N.^*^ '>'>^« <4^'*^—tbbiUL pfli»*> cwu . In-transit Vehicle Clearance 

Levels around high wires ^ r^rp ^ 

Vehicle Clearance around 

high wires when working VIIV 

Phone lines fiQ-4 pl>p>>l. lu»M. Hft^rUQ fAHajJln,—A<>><\Oif|/ , 

Cable lines 

-Ufe^ 

Gas Line J^JL 

Water Line _HA. Sewer Line ^Hk. Septic Tank JUL 

Propane/Butane JiO- Access to/on Property JOJL 

Neighbor Access Required AUL 

High Traffic Area JiA. Garage j ^ lUa . V> 3^W S ^ lofts *»''t^4 ^*><V ^«^ 

Structures -hU^ 

Driveway .fclA. •MuA "te bl ni»»6VH H*HA^^k'K'o i ^ ^ Sidewalk -MJL. 

Foundation J4A- Retaining Walls M K 

Fences 

M K 

Trees 

-*it. Foliage 

General Condition of yard 

Daniaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

3-3>fay) JinV^). 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

Crew Foreman/ Sub-Contractor Site Safety Officer 

/ ^ J-^O-^dffix ^hU^^z^ " 

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 
i.m *»yi«iT 

^?pp 
NO.297 P. 3/7 OCT.1$.2809 2:29PM 

Current Sample Pre-Renovation Form 

I 

{

I 

Effective ur?lii April aoiQ. 

confirmation of Receipt cf Lend Pamphlet 

Q) I have received a copy of the pamphlet, Ficnovate fVght: Important Lead Hasad 

r Intonnation for Fomifies, Ctuld Care Providors and Schools informing me of 

the potential risk of the lead hazard exposure from renovation activity to be 

perfonrned In my dweiling unit. I rpc^h/ed this pamphlet before the work began. 

CAAA ^ 

h^N­ ^ 

L 

Printed name q f recipient Date 

 Signature of lecipiont 

Self-Certification Option 9or tenant-occupied dweWnoe only) — 

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

you may check the appropriate box below. 

a ftefusal to sign — I certi^ that I have made a good faith eifort to deliver the 

pamphlet, FWiovate plgtit: Important Lead Hazard Inforwation for Famriffes. 

C^iTd Care Pro\rider$ jn d SOiools, to the mntal dwelling unit listed below at the 

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

Qi receipt. I funher certify that I have left a copy of the pamphlet at the unit with 

tho oocupant. 

Q4Jnavailabla fbr signature — I certify that I have made a good faith effort to 

deliver tho pamphlet, Renovate Right: Important Lead Hazard (nfbrmatior) for 

FamHias. CNid Core providers and Schools, to the rental dv\«lling unit listed 

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

I further certif/ that I have left a copy of the pamphlet at the unit by sliding it 

under the door. . . 

l^nted^fame of person certifying 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person cortliying lead pamphlet delivery 

UnttAddress 

Note flegaidino Mailing Option — As an altemative to delivery in person, you 

may mail the load pamphlet to the owver and^or tenant. Pamphlet must be mailed 

at least 7 days before renovation Pocument with a certificate of mailing from the 

post off ice). 
Douglas County Account Infonnation http://douglasne.n]affljing-online.conVDougiasCoNe/static/accountinfo.. i.n^mi 

Douglas County, Nebraska Propert y Record - R l 134780000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft v«st of 52nd St - VieW On Ma p Information is valid as of 2009-9-29 Treasurer's Tax Report 

New Feature -^ r)* <r^ Auto Sales Search 

Owner 

PARRISH DANNY 

15112 MARTIN AVE w / * *^ ^ 1 

OMAHA NE 68116-0000 

Propert y Informatio n 

Key Number 3478 0000 11 

Account Type: Residential 

Parcel Number 1134780000 

Parcel Address: 2574 ELLISON AV 

OMAHA NE 68111-0000 

Legal Description: FORT VIEW ADD LOT 7 BLOCK 0 50 X 133.7 

Value Informatio n 

Land Improvement Totai 

2009 $2,600.00 $29,900.00 $32,500.00 

2008 $2,600.00 $29,900.00 $32,500.00 

2007 $2,600.00 $23,100.00 $25,700.00 

2006 $2,600.00 $23,100.00 $25,700.00 

2005 $2,600.00 $23,100.00 $25,700.00 

2004 $2,600.00 $10,200.00 $12,800.00 

Sales Informatio n 

Sales Date: 2006-12-01 

Deed Type: QCM Book: 2007 Page: 014657 

Price: $0.00 

Grantor PARRISH DANNY ETAL 

Grantee: PARRISH DANNY ETAL 

Valid/invalid: Invalid 

Exclusion Reason: Multiple Parcel Sale 

Sales Date: 2006-10-20 

Deed Type: WDM Book: 2006 Page: 121720 

Price: $36,000.00 

Grantor Bayer Helen G Estate of 

Grantee: Parrish Danny etal 

Vaiid/invaiid: Invalid 

lof 3 10/9/2009 10:05 AM 
Douglas County Account Information http://douglasne.manning-online.coni/DouglasCoNe/static/accountinfo.. 

Exclusion Reason: Multiple Parcel Sale 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.15 6650.0 1.0 133.0 50.0 No 

Improvemen t Informatio n 

Building 1 

2874ELUSONAV 

OHIKUM fl«rao» lEnd Sdu v>wi 

Jilt , t ! HBOKH I 

|Br«3Se««W4» ,_ ' 

RANCH 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 960.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Fair 

Built As: Ranch Condo Square Footage: 0.0 

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Vinyl Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Hip Stories: 1.0 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Buiit 

1907 0 0% 1907 101 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 960.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 216.0 

Porch EncI Solid Wall 120.0 

2 of 3 10/9/2009 10:05 AM 
Douglas County Account Information http://douglasne.manDing-online.com/DouglasCoNe/static/accoiintinfo. :.m^|)ll .

Porch EncI Solid Wall 165.0 

3 of 3 10/9/2009 10:05 AM 
Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: 'hIGiy j 

Property Address: p.- S J ^ ^ f L i cQ// [ f\y~ C 

Owner's Name: d/<^ v CvMV^ 

j S.NO 

1 1 

1 2 

: 3 

i 

i4 

! 5 

1 

1 

i 6 

17 1 

1 8 

1 9 

; 10 

1 

111 

j 

; •'2 

Performance Standards/close-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, eaves, siding, ail trim, porches, box 

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

Was all scraping and other preparation work completed 

satisfactorily? 

Were ali required areas of the structure(s) primed as needed and 

painted with two top coats? 

Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

Did the contractor collect/vacuum ali falling and scraped paint chips 

on 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? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

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 completed prior to 

the EPA Close-Out. 

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

contractor that need to be moved back? 

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

that have been left unresolved? 

Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Yes NO 

y 

c y 

y 

y ^ 

y^ 

' ^ ' l y 

t.' ^ 

^^ 

l y 

y A 

y 

Prudent Representative Signature: / ^ 

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: 1816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577