0

TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 23649 Date: 01/12/2009 

Address: 4170 CHICAGO 

Remediation Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

0' Video of property (DVD) 

 Executive Summary 

\F Signed Access Agreement for subject property 

or Painting Agreement 

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

D Photographs 

M Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

Ef Property information from Douglas County Assessor's Office 

D 

D 

D 

Signature 7 Date 

40307977 

Hill 

Superfund 
PROPERTY SUMMARY 

Date: 01/12/2009 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address; 4170CinCAGO SAID: 23649 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: None 

A.2 Issues Resolved: None 

A.3 Unique Findings: None 

A.4 Other Relevant Information: None 

Access Date: 10/08/08 

Work Began: 11/12/08 

Closeout Date: 11/14/08 

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. 
ENVIRONMENTAL A 

CONSTRUCTION 

TECHNOLOGIES, INC. SERVICES 

Property Status Form 

Address: ^/? 0 CkUcOm Sf Date: /^^c^-^ F 

Phone: FF^^^^F S BVID: Z3(^^ 9 

Plant & Pennanent Landscaping To Remain In Place 

Description and Location 

On Map 

67^nfi7ji - i7tt\ I)0fk6 7)rll fi7^/j/^S i t ^ 

Pre-Existing Condition of Structures 

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

Item# Description & Location 

OnN^) 

6o7hl- ^' II 

n 

Property Owner Prudent Employee 

Signature: Signature: 

8080 VAud Partcway, Siite 409 2606 N. 24* Sti»«««"«»- •— Kansas City, MO 64114 
•TSC/pli^ 

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

Environmental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a niimber of properties 

located in Omaha, Nebraska, includingtiie property located at Ql' ^ Q.W.iQJ3i(X(^ ?T • 

The EPA requests your pennission to allow Prudent to perform LBP Stabilization ai/this property. By 

signing this form, the property owner grants permission to Prudent to perform activities related to LBP 

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

verifies that they have receivedtihe LBP pamphlet "Renovate Right" 

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

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

at (402) 504-1004. General questions about the 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). I 

Piopeity Access Granted By: TNAAv\i>aV?>' \ VC \ \ x fi i J lf\L X: ^ 

Property Owner Sigiudure: 

(Sigoioire; "^^^^^^^V 

PROPERTY INFORMATION 

j (TobecoBip{.eted.byrCHdcnta (To be coBip{.eted.by rctidcnt and/o : r property owner - pleaie print) 

RESIDENT NAME; ^ J rOwnerA Renter 

RESIDENT ADDRESS C L 

Q 

IF RENTAL, PROPERTY OWNEO BY: \\ 3 / Mr -

OWNER'S MAIUNG ADDRESS; 'S liM ^ 

OWNER'S TELEPHONE NUMBER-HOME: (^<J04.^$^ 4HH^W0RK : f403 4 0^1:> ^1 i ) 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: M NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: .3 . 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 3^ 

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

r 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activates to be implemented by EPA under Has agreement are puisuant to Section 104 

of CERCLA, 42 U.S.C. 9604. EPA's right of access to ihe property is provided for in Section 104(e) of CERCLA, 42 U.S. C 9605(e), which provides entiy 

for "determining the need for response, or choosing ortakiitg any response action under this title, or otherwise enforcing the provisions of tte title." 

0 Ward Parkway, Suita 405 2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

sas Oily, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

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

(816) 363-3707 Fax: (402)504-1005 
^...,,^iv^ I I«7-ric;iluvciiion roi m 

Effec^e until April 2010. f P 

Confirmation of Receipt of Lead Pampiilet 

•^jZCl have received a copy of the pampiilet, Renovate Right Important Lead HazardL

 Infonnation for Families, Chiki Care Provkiers and S^nols informing me of 

the potential r1^ of the lead hazard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the wori< began. 

Signature of recipient ^ ^ O ' 

Self-Certification Option (for tenant-occupied dwellings only) — 

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

you may checi< the appropriate box below. 

Q Refusal to sign — i certify tiiat i have made a good faith effort to deliver the 

pamphlet, Renovate Ri^ t Important Lead Hazard Infonnation for FamSes, 

Chiki Care Prowders and Sc/ioo/s, to the rental dwelling unit listed below at the 

date and time indicated and that the oocupant refused to sign tfve confirmation 

of receipt, i fuither certily 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, fienovate Right Important Lead Hazani Information for 

Famttes, (Md Care prcwders and Schoois, to the rental dwelling unit listed 

b^ow and that the occupant was unavailable to sign the confirmation of receipt. 

I furthereertify that I have left a copy of the pampi^et at ttie unit t>y sliding it 

underilWdoor. / j ,* / 

§QICf CSm S 70^^-oS '7-777 

Printed name of person certifying^ Attempted delivery 

date and time 

lead |3amphlet delivery 

Signature of person 64rtifying lead pamphlet delivery 

V/7i? M'/!AG<m 

Unit Address 

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

may mail the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

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

post office). 
0HI7(^ /Boi y4 pAiFiiAa , • yL/F ) 

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Paint matching form: i/.c^/ilfilO ^M S 

property address: y/7^ (^Is m ^ " 

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ExptanationT ^ r ilf^H<^ m\'^^ ^ Sf>oKe^ d/n feiATtm4 -

Area: Color: P£i7f/^£ /^^/T^/tS Al^ '' ^ 

Explanation: 

Area; Color: 

Explanati on: 

Area: Color: 

Explanation: 

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Page 1 of2 

Douglas County Accomjllnformatio m^l n i 

Douglas County, Nebraska Property Record -J^'^^^FI^— 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of SOth St - Vje W O n Ma P 

Information is valid as of 2008-9-4 Treasiirer's Tax Rep^ort 

New Feature -*—> -^ Auto SiiLes_Search 

Owner 

KILCOYNE JAMES M 

ETAL 

> ,U 7? 

4170 CHICAGO ST 

OMAHA NE 68131-0000 

Property Information 

Key Number: 1923 0000 20 

Account Type: Residential 

Parcel Number: 2019230000 

Parcel Address: 4170 CHICAGO ST 

OMAHA NE 68131-0000 

Legal Description: POPPLETON PARK LOT 16 BLOCK 17 50 X 128 

Value Information 

I Land Improvement Total 

2008 ! $6,400.00 $128,900.00 $135,300.00 

2007 $6,400.00 $105,500.00 $111,900.00 

2006 ^ _ \ $6,400.00 $105,500.00 $111,900.00 

2005 F $6,400.00 $105,500.00 $111,900.00 

2004 $6,400.00 $45,900.00 $52,300.00 

2003 $6,400.00 $45,900.00 $52,300.00 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.14 6400.0 1.0 128.0 50.0 No 

Improvement Informatio n 

Building 1 

http://douglasne.mapping-online.com/Dnn oI a ^r r^•^T,= 
Page 2 of 2 

Douglas County Accouj^nformatio uj^ r n 

MJJj^l'J:l^^^'*!['!W?'»M.^^!l!:•.^r'-!.•^!.•!^:•^ 

CLIC K TO ENLARGE.I|yiAGE 

Square Footage: 2534.0 

Perimeter 0.0 

Unit Type: 

Built As: 2 1/2 Story Fin 

HVAC: Forced Air 

Exterior: Frame Siding 

Interior: Drywall 

Roof Cover: Composition Shingle 

Roof Type: Hip 

Floorcover: Allowance 

YearBuilt Year 

Remodeled 

Percent 

Remodeled 

1895 0 0% 

Detail Type Detail Description 

Add On I Fence Wood 

Appliance Allowance 

Appliance Fireplace Masonry 

Basement Bsmnt Block 8 ft 

Fixture Additional Fixtures 

Fixture Base Fixtures 

Fixture Bath Full 

Fixture Bath Half 

Garage Detached 

Porch Slab Roof Ceil 

Porch Slab Roof Ceil 

•'H»» •"•" « , J • 

.>-.'« 

2 i ^ter, 

CLICK TO ENLARGE JMAGE 

Percent Complete: 100.0% 

Quality: Good 

Condition: Average 

Condo Square Footage: "oo 

Rooms: 10.0 

Units: 1.0 

Baths: 1.5 

Bedrooms: 4.0 

Stories: 2.5 

Foundation: Block 

Sprinkler Square Footage: O.o' " 

Adjusted Year Physical Age Built 

1895 113 

Units 

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. 
Prudent Pfoperty dose-Out Forrti (Lead-B^s6d Paifit Stabiliieitloh} 

Property '^^'ir^^^-- ^ F y C <l->^/^/^9/ 0 

Owner's NamPi ((7/Fk^.^A). j{ i l(>^lfjAiF • ' 

Performance Siahdafds/ciose^Out Criteria 

YES NO 

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

include painting of other associated features inciuding fascia, eaves, sidingj all trim, porches, b6x 

r .be3rns,ci>lumns, rails, and exterior surfaces of garages. , . .... _ ...y.,,.,....,;,, •^,,._, 

2. Was all scraping ahd cither preparattion woric coriipleted satisfactbrity? j , ^ 

3. Were all requinad areas of the structure(s) primed as needed and painted with two top coats? 

4. Was the p^int products utilized equivalent to a 50 year product/qusliiv? 

Are al! of the areas where contaminated materials have been spilled 

y thoroughly vacuumed/deahed? 

Did the cbntractbr collect/vacuum all falling and scraped pairit chips ori this ehtirie f)r6p6rty^ 

\A rbadwaysj allg^ys, public access arieas arid alsib,.remdve any other gen&rafga.disb'ris?, ..., 

Is the grass area that surrounds the structure(s) in reasonably good cohdition? 

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

prope'riy removed? 

S. 

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

needsto be complied prioi'to,the EPA aoseOut. ^ ^ _ , u. X 

10. 

Are there any property items that were temporatiiy re-located bv the contrsctcr 

thst need tb be moved back? ( / 

y 11.

 Are there any (known) lingering issues with the property owner(s) that have been left unresolved? 

Other Cbnsideratiohs?prbperty Owner Discussions?Add!tionel VVork that JsRequii-ied,. .., yX 

mm ^ .(y.t.yyW-r^a!^M(-^^-. ,^^j|^,'^ l \b8£^ UJ7. 

Prudent Re^eisehtative f