### 0 

## TRANSMITTA Lo f

OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID : 2364 9 Date : 01/12/200 9 Address : 417 0 CHICAG O Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S 0 ' Vide o o f propert y (DVD ) Executiv e Summary \ FSigne dAcces s Agreemen t for subjec t property o

r Paintin g Agreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D Photograph s M Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A E

f Property informatio n fromDougla s County Assessor' s Offic e D D D


### Signatur e 7 Dat e

4030797 7 

# Hil l Superfun d

### PROPERT Y SUMMAR Y Date : 01/12/200 9 LB PSTABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address ; 4170CinCAG O SAID : 2364 9 A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : Non e
A. 2 Issue s Resolved : Non e

A. 3 Uniqu e Findings : Non e
A. 4 Othe r Relevan t Information : Non e Acces s Date : 10/08/0 8 Wor k Began : 11/12/0 8 Closeou t Date : 11/14/0 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 n For m 6 . Pain t Matc hFor m 7 . Trackin g For m 8 . Dougla s Count y Assesso r Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES , INC .ENVIRONMENTA LA CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : ^/? 0 CkUcO mS f Date : /^^c^-^ F Phone: FF^^^^F S BVID : Z3(^^ 9 Plan t & Pennanen t Landscapin g T o Remai nI nPlac e Descriptio nan dLocatio n O nMa p



# 67^nfi7ji - i7tt \I)0fk 6 7)rl l fi7^/j/^S it ^ Pre-Existin g 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& Locatio n OnN^ ) 

# I I 

# 6o7hl - ^ ' n Propert y Owne r Pruden t Employe e Signature : Signature : 808 0 VAu d Partcway , Siit e 40 9 260 6 N . 24 * Sti»«««"«»
- • — Kansa s City , M O 6411 4

## • TSC/pli ^ Pruden t Technologies , hic . (Prudent ) i s unde r

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 dBase dPaint (LBP ) a t aniimbe r

o f propertie s locatedi n Omaha , Nebraska , includin g tiie propert y locateda t Ql' ^ Q.W.iQJ3i(X( ^ ? T • The EP A request s you r

pennissio n t o allo w Pruden t to perfor mLB P Stabilizatio n ai/thi s property . B y signing thi s form, th e propert y owne r

grant s permissio n t o Pruden t t o perfor mactivitie s relate dt o LB P Stabilization including scraping paint andpaintin g o f th e referencedproperty . Further , th e owner/tenan t verifie s tha t they hav e receive d tihe LB P pamphle t "Renovat e Right " If

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

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

fo r

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

t (402 ) 504-1004 . Genera l question s about th e OmahaLea dSit e cleanup can b e directe dt o th e EP A Publi c Information Center s at (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nort hOmaha office) . I Piopeit yAcces s Grante d By : TNAAv\i>aV?>' \ VC \ \ xfi i J lf\ : L X ^ Property Owne r Sigiudure : (Sigoioire ; "^^^^^^^ V PROPERT Y INFORMATIO N j (T o b e coBip{.eted.b y rctidcn t and/o r propert y owne r (TobecoBip{.eted.byrCHdcnta : - pleai e print ) RESIDEN T NAME ; ^ J rOwner A Rente r RESIDEN T ADDRES S C L 

# Q I F RENTAL , PROPERT Y OWNE O BY : \ \ 3 / Mr - OWNER' S MAIUN G ADDRESS ; ' S liM ^ OWNER' S TELEPHON E NUMBER-HOME : (^<J04.^$ ^ 4HH^W0RK : f403 4 0^1: > ^1 i ) NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : M NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : .3 . NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y I N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : 

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

# r AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activate s t o b e implemente db y EP A unde r Ha s agreemen t ar e puisuan t t o Sectio n10 4 o f

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

acces s t o ih e property i s provide dfo r i

nSectio n104(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s enti y for

"determinin g th e nee dfo r response, o r choosin g ortakiit g any response actio nunde r thi s title , o r otherwis e enforcin g th e provision s o f tte title. "

0 War d Parkway , Suit a 40 5 2505 N . 24* ^ Street , Suit e 30 8 4242 Medica l Drive , Suit e 425 0 sa s Oily , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 ne : (816) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 (816 ) 363-370 7 Fax : (402)504-100 5

# ^...,,^iv ^

I I«7-ric;iluvciiio n roi m Effec^ e unti l Apri l 2010 . f P Confirmatio n o f Receip t o f Lea d Pampiile t • ^jZC l hav e received a copyo f th e pampiilet , Renovat e Righ t Importan t Lea d Hazard LInfonnatio n fo rFamilies , Chik i Car e Provkier s an d S^nol s informin g m e o f th e potentia l r1 ^ o

f th e lead hazar d exposur e fro m renovatio n activit yt o b e performe d i n mydwellin g unit . I receive d thi s pamphlet befor e th e wori < began .

Signatur e o f recipient ^ ^ O ' Self-Certificatio n Optio n (fo rtenant-occupie d dwelling 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 olstainable , yo u ma ycheci < th e appropriate bo xbelow . Q Refusa l t o sig n —i certif ytiiat i hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovat e Ri^ t Importan t Lea d Hazar d Infonnatio n fo rFamSes , Chik i Car e Prowder s an d Sc/ioo/s , t o th e renta l dwellin g uni t liste d belo wat th e dat e an d tim e indicate d an d that th e oocupan t refuse d t o sig n tfv e confirmatio n o

f receipt , i fuithe rcertil ythat I hav e lef t a copyo f th e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e — I certif ythat I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , fienovat e Righ t Importan t Lea d Hazan i Informatio n fo r Famttes , (M d Car e prcwder s an d Schoois , t o th e renta l dwellin g uni t liste d b^o wan d tha t th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I furthereertif ytha t I hav e lef t a copyof th e pampi^et at tti e uni t t> yslidin g i t underilWdoor . / j ,* / 

# §QIC f

CSm S 70^^-o S '7-77 7 Printe d nam e o f perso n certifying ^

Attempte d deliver y dat e an d tim e lead |3amphle t deliver y Signatur e o f perso n 64rtifyin g lea d pamphlet deliver y 

# V/7i ? M'/!AG< m Uni t Addres s Not e Regardin g Mailin g Optio n —As a n alternativ e t o deliver yi n person , yo u ma ymai l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e mailed a

t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e o f mailin g fro m th e post office) .

# 0HI7( ^ 

# /Bo i y 4 pAiFiiA a, • yL/F ) ^si-'^ m</fidd-ji^j FmtFjF Pain t matchin g form : i/.c^/ilfil O ^M S propert yaddress : y/7 ^ (^Is m ^ " Area:y^/^^/A^^^A'^'^Color : 7^C/^ioo J f m fi ^ ^^' ^

^//<^iy^y ^ I / jA)r 7 

# Area : i^ U ' . . Color:;^^//^ ^ / AKJ/^IU^ ^ 

# m Exptanation T^ rilf^H<^ m\'^^ ^ Sf>oKe ^

d/ n feiATtm4 - Area : Color : P£i7f/^ £ /^^/T^/t S Al ^ '' ^ Explanation : Area ; Color : Explanat i on : Area : Color : Explanation : Pag e 1tSU m 

# Acces s MPOf^HATiortTRAGIWGSI^S r MB . 

# ^^v f _^F^^_jino_6i m r. -d^lm i FldOf/t ^

OnvOoiMK K Home ; 

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### Pag e 1 of 2 Dougla s Count y Accomjllnformatio n m^l i Dougla s County , Nebrask a Propert yRecor d -J^'^^^FI^— Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t of SOt h S t - Vje W O n Ma P Informatio n i s vali d a s o f 2008-9- 4 Treasiirer' s Ta xRep^or t Ne wFeatur e -*— > - ^ Aut o SiiLes_Searc h Owne r KILCOYN E JAME S M ETA L 

# > , U 

# 7 ? 417 0 CHICAG O S T OMAH AN E 68131-000 0 Propert yInformatio n Ke yNumber : 192 3 000 0 2 0 Accoun t Type : Residentia l Parce l Number : 201923000 0 Parce l Address : 417 0 CHICAG O S T OMAH AN E 68131-000 0 Lega l Description : POPPLETO N PAR KLOT 1 6 BLOC K1 7 5 0 X 12 8 Valu e Informatio n I Lan d Improvemen t Tota l 200 8 ! $6,400.0 0 $128,900.0 0 $135,300.0 0 200 7 $6,400.0 0 $105,500.0 0 $111,900.0 0 200 6 ^ _\ $6,400.0 0 $105,500.0 0 $111,900.0 0 200 5 F $6,400.0 0 $105,500.0 0 $111,900.0 0 200 4 $6,400.0 0 $45,900.0 0 $52,300.0 0 200 3 $6,400.0 0 $45,900.0 0 $52,300.0 0 Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 

### 0.1 4 6400. 0 1. 0 128. 0 50. 0 N o Improvemen t Informatio n Buildin g 1



### http://douglasne.mapping-online.com/Dn n o I a^ r r^•^T, =Pag e 2 o f 2 Dougla s Count y Accouj^nformatio n uj^ r

MJJj^l'J:l^^^'*!['!W?'»M.^^!l!:•.^r'-!.•^!.•!^:• ^ CLIC KT O ENLARGE.I|yiAG E Squar e Footage : 2534. 0 Perimete r 0. 0 Uni t Type :

Buil t As : 2 1/ 2 Stor yFi n HVAC : Force d Ai r Exterior : Fram e Sidin g Interior : Drywal l Roo f Cover : Compositio n Shingl e

Roo f Type : Hi p Floorcover : Allowanc e YearBuil t Yea r Remodele d Percen t Remodele d 189 5 0 0 % Detai l Typ e Detai l Descriptio n Ad d O n I Fenc e Woo d Applianc e Allowanc e Applianc e Fireplac e Masonr y Basemen t Bsmn t Bloc k 8 ft Fixtur e Additiona l Fixture s Fixtur e Bas e Fixture s Fixture Bat h Ful l Fixtur e Bat h Hal f Garag e Detache d Porc h Sla b Roo f Cei l Porc h Sla b Roo f Cei l •'H» » •"•" « , J • .>-.' « 2 i ^ter ,
CLIC KT O ENLARG E JMAG E Percen t Complete : 100.0 % Quality : Good Condition : Averag e Cond o Squar e Footage : 

### "o o Rooms : 10. 0

Units : 1.0 Baths : 1. 5 Bedrooms : 4. 0 Stories : 2. 5 Foundation : Bloc k Sprinkle rSquar e Footage : O.o' " Adjuste d Yea r Physica l Ag e Buil t 189 5 11 3 Unit s 1, 0 1. 0 1. 0 1050, 0 1.0 1. 0 1.0 1. 0 312. 0

98. 0 135. 0

http://douglasne.mapping-online.r,nm/nrM .

## Pruden t Pfopert ydose-Ou t Forrt i (Lead-B^s6 d Paifi t Stabiliieitloh } Propert y '^^'ir^^^-
- ^ Fy C <l->^/^/^9/ 0 Owner' s NamP i ((7/Fk^.^A) . j{ i l(>^lfjAi F• ' 

## Performanc e Siahdafds/ciose^Ou t Criteri a YE S N O Wa s tri e entir e structure(s ) painte d wit h th e exceptio n o f th e ststed , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s inciudin g fascia , eaves , siding j al l trim , porches , b6x 

## r .be3rns,ci>lumns , rails , an d exterio rsurface s o f garages . , . ... . _...y.,,.,....,;, , •^,,._ , 2 .Wa s al l scrapin g ah d cithe rpreparattio n wori ccoriiplete d satisfactbrity ? j , ^ 3 .

Wer e al l requinad areas o f th e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 .Wa s th e p^in t product s utilize d equivalen t t o a 5 0 yea rproduct/qusliiv ? Ar

e al ! o f th e area s wher e contaminate d material s hav e bee n spille d 

## y thoroughl yvacuumed/deahed ? Di d th e cbntractb rcollect/vacuu m al l fallin g an d scrape d pairi t chip s or i thi s ehtiri e f)r6p6rty ^ \ A rbadways j allg^ys , publi cacces s ariea s ari d alsib,.remdv e an yothe rgen&rafga.disb'ris? , ... , I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygood cohdition ? Arf

e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et c prope'ri yremoved ? S . I s ther e anyevidenir e o f propert ydamag e tha t was don e byth e contractor ? An ypropert ydaitiag s needst o b e complie d prioi'to,th e EP AaoseOut . ^ ^ _, 

# u .

# X 10 . Ar e ther e anypropert yitem s tha t wer e temporatii yre-locate d b vth e contrsctc r ths t need t b b e move d back? ( / 

# y 11 . Ar e there any(known ) lingerin g issues wit h th e propertyowner(s ) tha t hav e bee n lef t unresolved ? 

# y X Othe rCbnsideratiohs?prbpert yOwne rDiscussions?Add!tione l VVor k

tha t JsRequii-ied, . .. , 

# m m ^ .(y.t.yyW-r^a!^M(-^^- . ,^^j|^,'^ l \b8£ ^ UJ7 . Pruden t Re^eisehtativ e 

# f