TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: ^^?y^> ^ Date: 7|cS3|n2fiQ^ 

Address: /^ / 5)- fvJ ."^U ^^T 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

 Executive Summary 

 Signed Access Agreement Form 

 Advance Notice Form 

 Pre-Stabilization Video Agreement Form 

 Access Tracking Form 

 Property Access Assessment Form 

 Neighbor Access Agreement Form 

 Paint Match Form 

 Pre-Stabilization Property Safety Assessment Form 

 Work-Site Hazards Analysis Checklist 

 Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

 Douglas County Assessor Property infonnation 

 Property Completion Agreement Form Signed by Property Owner 

 Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature Date 

y^^ c J ^ ^ Date" 

30055374 

HHniii 

Superfund 
TECHNOLOGIBS, INC 

Property Summary 

Date; 7/23/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: July 

Property Address: 1412 N 34 ST SAID #: 25585 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 6/24/2009 

u. Work Began: 7/01/2009 

iii. Close-Out Date: 7/15/2009 

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 
^SfS ' 

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

Protection Agency (EPA) to stabilize Lead Based Paint (LBF) at a number ofproperties located in Omaha, 

Nebraska, including the property located at /^/o l N - 3 j ^Y^^ 

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

form, the property owner grants permission to Prudent to perform activities related to LBP Stabilization includir^ 

scraping paint and painting ofthe referenced property. Further, the owner/tenant verifies that they have received 

the LBP pamphlet "Renovate Right." By signing this document I agree to allow an EPA contractor to conduct a 

soil cleanup at my property following completion of lead-based paint stabilization. I understand that the 

stabilization contractor cannot provide assurances that the soil cleanup contractor will be bound to. I further 

understand that the soil cleanup contractor will make all reasonable efforts to address concems that I, as the 

property owner, may have regarding soil cleanup at my property. 

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

Relations/OfTice Manager for the Lead Based Paint Stabilization, Mrs. Shannon Holt, at (402) 504-1004 or 

(402)812-0223. General questions about the Omaha Lead Site cleanup can be directed to the EPA Public 

Information Centers at (402X211-3^5 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Property Access Granted By: 

Property Owner Signature: 

(Date) \ 

PROPERTY INFORMATION 

(To be completed by resident and/or property owner - please print) 

RESIOENTNAME: //$^ / Owner Renter 

RESIDENT ADDRESS: /^/.^ 7j ^/ K 

IF RENTAL, PROPERTY OWNED BY 

OWNER'S MAILING ADDRESS; — J . jf ^ 

OWNER'S TELEPHONE NUMBER HOME: i^^L^l^lpiU^y^: ^^ ( TA^ -jf^Cf 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD : C J NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: ^^l l 

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

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

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AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement are pursuant to Sectioi 104 

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

for "'determining the need for response, or choosing or talcing any response action under this title, or otherwise enforcing the provisions ofthe title." 

aibso Ward Parkway, Suite 405 

Kansas City, MO 64114 

2505 N. 24'" Street, Suite 308 

Omaha, Nebraslca 68110 

4242 IVIedical Drive, Suite 4250 

San Antonio, TX 78229 

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

Pav /fl1fi) 7fi?-:^7n7 Pav //inoi <;n/i.inric 
Advanced notice needed. 

After signing the access you allow Prudent to begin Lead 

Based Paint Stabilization. All 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 ofyard 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? \j^c, 

Notice needed: ^ y ^"^^ 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owner's Signature 

TKISrrCONDrTTONST^tU ru blTAWWKtor BtruKt iTiuu IIINV3 viutu;­

(I.E. PETS, NOTICE NEEDED): 
i 

PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENTTECHNOLOGIES WILL BE COMING OUT 

TO SHOOT A PRE-STABILIZATION 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. 

OWNERS NAME

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PROPERTYADDRESS: .// M n '^(f ^ P 

BVID/SAID: ^^S^ ^ 

HOMEOWNERS SIGNATURE: 

PRUDENTREPRESENTATIVE SIGNATURE: 

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k m CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING VIDEO: 

(I.E. PETS, NOTICE NEEDED): 
ACCESS INFORMATION TRACKING SHEET 

PROPERTY 

BVID :^5T ^ ADDRESS /9/^ /j-srs T 

. 

Property Owned By: ^e^^sl int({6i 

(If new DToperty owner 

Owners Phone No's: Home : (,11'Hoai Work, 

^»: tif^-nsn-fi^ Fax; 

Access Contractor. ASW FDA MES FE Other 

fOWe One; 

DATE TIME Accessor COMTACT DETAIL 

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Comments: 

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Please write leglblyl 
Access Assessment Form: (Must be completed for every property. Information 

must be obtained from a property walk thru, hot given by owner) 

Is the property stucco or asbestos? . 

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 retumed to EPA and they will assign at a later date. 

Does this property require lots of scrapping? / 

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? 

Does this property have any significant structural damage? 

If yes, EXPLAIN? 

Does this property have a garage? 

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If yes, describe location of garage. 
Does this property have aluminum siding? \J'^~^ -^Vk/^l \ /IM ^ 

UOod 

If yes, is it original factory 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/occupied^ 

Are there any pets at this property? 

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Are there any low hanging power lines? 

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Is there a neighboring property that needs to be accessed along with assigned 

property to complete stabilization process? 

If so, get a signed access from all necessary neighboring properties. 
TO BE FILLED OUT ONLY IF MATCHING COLOR ^^^ ^ 4'ldf^^ 

Paint matching form: ^ /— 7 

Property address: l^O - /»• J^5V v 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signatuTST^ 

IfAue M 6idiifj^ MonB psfi H/ci/Ji/ei 

Page 1 
PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTYADDRESS: I'^I'S^ tf' ^V ^ 

BVID/SAID ' ^^1> ^ 

PRUDENT REPRESENTATIVE DOING ASSESSMENT: 

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****IF SAFETY RISK PROPERTY MUST BE TURNED OVER 

TO KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A 

CREW/SUB. 

REPRESENTATIVE REMARKS/FINDINGS (POWER-LINE 

PROXIMITY TO HOUSE, SCAFFOLDING/LADDERS/LIFT 

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

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REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 
TECHNOLOGIES, INC 

Checklist for the Worksite Hazard Analysis 

Address: i^\i^ 

Crew: 

Item 

Overhead Lines 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required 

High Traffic Area 

Garage 

Structures 

Driveway 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Foliage 

General Condition ofyard 

Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

OK? 

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an/ Sub-Contractor 

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Date: (^.^^ t^"^ 

Corrective Action 

iPP\) ^Wi <^awvi>s4^7^ 

<vrv OA^ltSite Safety Officer 

Hazard -y^SZ^ 

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Cc*v^,OK «4~ 

PAA91rV> ^4nft 

8080 Ward Parkw^JSuite 405 2505 N. 24'" Street, Suite 308 4242 IMedical Drive, Suite 4250 

Kansas City, MO.OT114 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 




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Current Sample Pre-Renovation Form 

Effectivs until April 2010. 

Confinnation of Receipt of Lead Pamphlet 

d | I have teceived a copy of the pemphiet, Renovate Right: Important Lead Hazard 

^ InfonnaOonforRur^es,Chkl Care Provkiers and Schoote^p^xrt^ rne c^ 

the potential risk of the lead hazard eoqx)8ure (rem tQn]^ffittk]n acth% to t>e 

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

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recipient „//—r^ - Date 

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Signatui 

8etr>Ger1ffieatkm 6|jfion (for tenant-oocupled dwetllnge only) — 

if the lead pampMet was delivered but a tenant signature was not obtainable, 

you may check the appropriate box below. 

• Refusal to sign—I oeriify that I have made a good faith eflot to deliver the 

petmphlet./tenovala/%^t: Irnportanf Lead Hazartf Mvmaflbnferfii^

CVilcf cam ftovlblare and Sctoofe, to the rental dwellhg uiit Hsted below at ^ 

date and time indteated and that the occupant refused to sign the conflnnation 

of race^ . I Either certHy that I have left a oopy of the pamphlet at the unit with 

theoooupant. 

Q Unavailable fbr signature—I oertify that I have made a good felth effort to 

deTivar ths pamphlet, Aiarwvato nSof/it* Important Laad Hazard Information for 

fbrnAas; Chficf Care preWdsra and SChooils, to the rsrttaJ dweiling un^ 

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

i ftrther certify that I have left a oopy of the pamphlet at the unit by sliding it 

WMM/AJ/ ^ 

RrtntedIram

 namee of person osrtifying

Attempted delivery

data and time 

lead pamphiet delivery 

I certifying lead panphiet delivery 

UhltAdcbass 

Noto Regarding Mailing Option—As an altemative to delivery h person, you 

may maB the lead pamphlet to the owner and/a tenant. Pamphlet must be mailed 

at least 7 da ^ beltora re^G^«tlon (Pocument with a certificate of mailing liom the 

postoffloe). 

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Douglas County Account Infomiation http://douglasne.niaiming-online.com/DouglasCoNe/static/accountinfo. i.m^mii ,

Douglas County, Nebraska Property Record - R1642100000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJeW On Ma p Information is valid as of 2009-6-3 Treasurer's Tax Report 

New Feature -•-•- > Auto Sales Search 

Owner 

IVIEYER RODGER 

nr-fOC 

3648 U^FAYETTE AVE N E ^T\\I J /^7^ 0 ^ ^ 

; OIVIAHANE 68131-0000 " V • ", ^ j 

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Propert y Informatio n 

Key Number: 4210 OOOO 16 

Account Type: Residential 

Parcel Number: ' 1642100000 

Parcel Address: 1412 N 34 ST j 

OINAHA NE 68131-0000 ; 

Legal Description: LOWES ADD LOT 2 BLOCK U N 34.5 FT LOT 1 & E 20 N 34.5 FT 34.5 X 80 

Value Informatio n 

2009

[2008

2007

2006

2005

2004

Land

 ;

 !

 $1,700.00

 $1,700.00

 $1,700.00

 $1,700.00

 $1,700.00

 $1,700.00

 Improvement 

 $43,200.00 

 $43,200.00 

 $43,200.00 

 $43,200.00 

 $43,200.00 

 $16,900.00 

Total 

$44,900.00

$44,900.00 

$44,900.00

$44,900.00

$44,900.00 

$18,600.00

 i 

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Sales Informatio n 

Sales Date: 2006-09-11 

' Deed Type:

Price:

 WD j

 $34,500.00 

 SooAr: 2006 Page; ' 110262 

Grantor: i CENTEX HOME EQUITY COMPAI^ LLC j 

Grantee: I^EYER RODGER ETAL 

Valid/Invalid: Valid 

Exclusion Reason: 

Sales Date: 2005-12-07 

Deed Type; ; TRD Booir: ; 2005 Page: 155392 

i Price: [ $52,850.00 

Grantor: Eric H Lindquist 

Grantee: Centex Home Equity Company 

1 Valid/Invalid: \ invalid 

lof 2 6/8/2009 12:28 PM 
i (ouglas County Account Information ht^://douglasne.iTiaa|^ng-online.com/Doug] asCoNe/static/accounti nfo.. i.m^ljur 

Exclusion Reason: Sale to Mortgage - Banl< 

Land Informatio n 

Acres 

0.06 

SF 

2800.0 

Units 

1.0 

Depth 

80.0 

Width 

35.0 

Vacant 

No 

Improvemen t

Building 1 

 Informatio n 

Square Footage: 1117.0 

Perimeter 0.0 

Unit Type: 

Built As: 1 1/2 Story Fin 

HVAC: Central Air to Air 

Exterior: ; Frame Siding 

interior: ; Drywall 

Roof Cover: Composition Shingle 

Roof Type: Gable 

Floorcover: Allowance 

Year Built Year 

Remodeled 

Percent 

Remodeled 

1910 0% 

Deta/7 Type Deta/7 Description 

Appliance Allowance 

Basement Bsmnt Block 8 ft 

Fixture Base Fixtures 

Fixture Bath Full 

Porch EncI Screen 

User NEW ROOF 

CLICK TO ENLARGE IMAGE 'Z] 

Percent Complete: 100 0% 

Quality: Average 

Condition: Average 

Condo Square Footage: 0.0 

Rooms: 6.0 

Units: 1.0 

Baths: 1.0 

Bedrooms: 3.0 

Stories: 1.5 

Foundation: Blocl( 

Sprinkler Square Footage: 0.0 

Adjusted Year Physical Age Built 

1910 94 

Units 

1.0 

665.0 

1.0 

1.0 

154.0 

1.0 

2 of 2 6/8/2009 12:28 PM 
% 

TECHNOLOGIES, INC. 

Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: ;:?<rtr<2^.C 

Property Address: _ im9. -Kl. e^-^^ 51­

Owner's Name: l^QoJ ^ LLlSd fll j JC

S.N0 

Performance Standards/close-Out Criteria Yes NO 

1 

Was the entire structure(s) painted with the exception of the stated, 

excluded areas? This would include painting of other associated 

feature

beams,

s

 columns

 includin

,

g

 rails

 fascia

, an

, eaves

d exterio

, siding

r surface

, all trim

s of garages

, porches

. 

, box 

A

2 Was all scraping and other preparation work completed 

satisfactorily? X 

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

painted with two top coats? i<. 

4 Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? ^ 

5 

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

on the entire property, roadways, alleyways, public access areas 

and also remove any other generated debris? .X 

6 

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

condition? 

^ 7 Was the paint products utilized equivalent to a 30 year 

product/quality? 

8 Are all items such as polyethylene sheeting, ladders, paint brushes, 

cones, barrier tape etc properiy removed? X 

9 

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

contractor? Any property damage needs to be completed prior to 

10 

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e

 EP

 ther

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e

 Close-Out

 any propert

. 

y items that were temporarily re-located by the 

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contracto

e there an

r tha

y (known

t need to

) lingerin

 be move

g issue

d back

s wit

? 

h the property owner(s) 

Y

that have been left unresolved? 

X 

12 

Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

\ 

Prudent Representativee Signature Signature: ^J/^AJ^ ^^•>MJ\ 

Date: 

Property Owner Signature: 

Date: y-Z^-O f 

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

Kansas City, MO 64114 Omaha, Nebraslta 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