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# TRANSMITTALof OMAHA LEAD SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAID : 2067 0 Date : 12/26/200 8 A \ 

## Address : 295 5 HARRIS StabilizationContractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S e

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Video of propert y (DVD ) 0 Executive Sununar y 0 SignedAcces s Agreemen t fo r

subject propert y 1^ Painting Agreemen t D Settlemen t documents (i.e. , fo r

damag e or to replac e plants , etc. ) D Photograph s ^ Satisfactor y restoratio nsignedby Propert y Owne r D Propert y close-ou t chec k

lis t signedby EP A 0 Propert y informationfromDougla s Count y Assessor' s Office D D • 

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## Signatiue Dat e 4030798 7 

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### PROPERT Y SUMMAR Y Date : 12/29/0 8 LB PSTABILIZATIO NEP ACONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address ; 295 5 HARRI S SAID ; 2067 0 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered ; A. 2 Issue s Resolved : A. 3 Uniqu e Findings : NONE . A. 4Othe r Relevan t Information : Acces s Date ; 10/30/0 8 Wor k Began : 11/11/0 8 Closeou t Date ; 11/13/0 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

TECHNOLOCIES , INC .

### ENVIRONMENTA L& CONSTRUCTIO N SERVICE S 

# Property Statu s Form Address : p9 3 J ) MOLA.'VJ U 

## ^ ' Date : /7?/^f/c ^ 

# Phone: tilT Plant & Permanen t Landscaping T o Remai nInPlac e Iteai # Desdriptio nan dLocatio n O

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Pre-Existing Conditio nof Strocture s Doe s ^ou r Basement hav e ahistoi y of leaking ? Ye s —N o Iteni # Desc r ptio n& Locatio n OnMiq ) 54»' ' {7i^w\af ^ i c f^tc hFffA/DC . fV^ I 

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## Prop Brt y Owner Pradent Employe e Signhtwre ; A ZH^ruiAf/ i 

## Signature : J'&^t 

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# JC^u^nC ^ Piuden t Technologies , Inc . (Prudent ) i s unde r conttac t (Contrac t #EP-R7-08-07 ) wit htiie U . S . Environmental Protectio n . \genc y (EPA ) t o stabiliz e Lea dBase dPain t (LBP ) a t anumbe r ofpropertie s locate di nOmaha , Nebraslpa , includin g tiie property locate da t c3^St S /VCCA,'UJ- \5U . 

## Th e EP A request s you r peimissio n t o allo w Pruden t t o perfor mLB PStabilizatio na t thi s propeity . B y signin g thi s form , tiie propprt y owne r grant s permissio nt o Pruden t t o perfor mactivitie s relate dt o LB P Stabilizatio nincludin g g pain t an dpaintin g o f th e reference dproperty . Furtiier , th e owner/tenan t verifie s that the y hav e rec^ve d tiie LB Ppamphle t "Renovat e Right. " I f

yo u hav e an y question s kbou t tiie LB Pstabilizatio nplanne dfo r you r property , pleas e contac t Pruden f s Adminisrtnjtive Clerk fo r t

l e Lea dBase dPain t Stabilization , Mrs . Debora hAkerele-Johnson . at

(402 ) 504-1004 . Gene ni l question s abou t th e Omah aLea dSit e cleanu p ca nb e directe dt o th e EP A Publi c Informatio nCenter ^ a t (402 ) 731-304 5 (Souti i Omah aofBce ) o r (402 ) 991-958 3 (NorthOmah a office) . Property AccciiOnBMedBv : A 

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Jenrvuh O ^eas e Pri mName ) Propot y Owne r Signdura : 

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# Cooc-lAe\ i FfAAAd/ ^ Rente r RESIDENTADDRESS; . 

# '7^F5 ' llarr U 5^ . WRENTAL . PROPERT YOWNE D 

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# Carrie OWNER' S MAIUN O ADDRESS ; OWNER' S TELEPHON E NUMBE F 

## .HOME : jtoiiiHlf£2^W0RK ; >^/^ l ^^-X/^ 7 NUMBE R O F OCCUPANT S UND E R 7 YEAR S OL D 

### . NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER ; ^ NUMBE R OFOHILDRE N UNDE R rYEAR S OL D VW O PLA YI N TH E YAR D FO R 6 HOUR S O R MOR E PE R WEEK : y . (I. & DOGS , ENTR YQATES . ETC. ) COMMENT S O R SPECIA L IN8T R JCTIONS : 

# 7 ^ & AU1H0IUT Y FO RENVmONMEN IA L RESPONS EACnONS ; Theactivitieetobeinipleinentedb y BP Aunde r tU i agreemen t aiepiiman t t o Sectio n104 O

f CERCLA . 4 2 U.S. C 9604 . EPA' a Iigti t o f

aoce u t o th e propert y i s provide dfbr inSectio n104(e ) o f CERCLA , 4 2 U.S . C 960S(eXwiiic hprovide i entr y fbr

"detenniningth e nee d for retponsc , o r choosin g ortakin g an y respons e actio nunde r thi s title , o r ofierwis e enlbtcin g ftc provision s o f th e title. "

98 0 Wan l Paitany . 8i««40 9 250 5 N . 24 " Straet , Suit e 308 424 2 Medica l Drive . Suit e 4260 :anM*CHy . M O 6411 4 Omaha . Nebraak a 6811 0 Sa n Antonio . T X 7822 9 • hAM f ffilAI MAJlTi n• ^ 1 

# uurren i oampi e rie-ttpnovaiio n ror m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o fLea d Pa riphle t Q I hav e receive d a cop yo fth e pampt|ile t , RefTovate Righ t Importan t Lea d Hazan j Infonnatio n fo rFamilies , Chil d Car e Rnowctef s an d School s informin g m e o f th e potentia l risl < o f th e lea d hazan j wposur e fro m renovatio n activit yt o b e performe d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wor k began . 

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# ' Signatur e o f recipient ' / ' Self-Certificatio n Optio n (fo rtenant-occupie d dweiiing s only ) — I f th e lea d pamphle t wa s delivsna d bu t a tenan t signatur e wa s no t obtainable , yo u maychec k th e appropriat e bo xbejow . Q Refusa l t o sig n —I certifytha t I ha/ e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovat e R^t lmportar\t Leac yHazar d Informatio n fo rFamilies , Chil d Ca m Pmviders an d Schools , th e renta l dwellin g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t t i occupan t refuse d t o sig n th e confirmatio n o f receipt , i furthe rcertifytha t I hav e left a cop yo fth e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e —I certf y tha t I hav e mad e a goo d fait h effor t t o 

### Rigl t delive rth e pamphlet , Renovat e Hi i '; Importan t Lea d Hazar d Infomiatio n fo r Families , Chik i Car e provkier s an d Schools , t o th e renta l dwellin g uni t liste d belo wan d tha t th e occupan t wa s upavailabl e t o sig n th e confirmatio n o freceipt . I furthe rcertifytha t I hav e left a cop ^ o f th e pamphle t a t th e uni t b yslidin g i t unde rth e dogp ^ 

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### •/ s a n aitematlv e t o deliver yi n person , yo u ma ymai l th e lea d pamphle t t o th e owpe r and/o rtenant . Pamphle t mus t b e maile d a t leas t 7 day s befor e renovatio n (Doqumen t wit h a certificat e o fmailin g fro m th e pos t office) .

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## Dougla s Count y Accoun t ljntorM||tio n )ratt|i ( rag e i U i J 

### Dougla s County , Nebrask a Propert yRecor d - R091771000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-6 0 f t wes t ofSOt h S t - ViC W O n iVla p 

### informatio n i s vali d a s o f 20(18-9- 4 Treasurer' s TaxRepor t Ne wFeatur e -*->- * Aut o Sale s Searc h Owne r FLOY D COURTNE Y 295 5 HARRI S ST OMAH AN E 68105-000 0 Propert yInformatio n Ke yNumber : 1^7 1 000 0 0 9 Accoun t Type : Residentia l Parce l Number : 0^1771000 0 Parce l Address . 2!)5 5 HARRI S S T OMAH AN E 68105-000 0 Lega l Description : DEA N PLAC E LO T1 1 BLOC K0 E 4 0 F T4 0 X 10 0 Valu e Informatio n Lan d Improvemen t Tota l 200 8 i $5,1200,00 $94,300,0 0 $99,500.0 0 200 7 j $5,200.0 0 $94,300.0 0 $99,500.0 0 200 6 _ _

I $5,200.0 0 $74,800,0 0 $80,000.0 0 200 5 _I $5,1200.00 $74,800.0 0 $80,000.0 0 200 4 j $5J200.0 0 $74,800.0 0 $80,000.0 0 200 3 $5J200,0 0 $74,800.0 0 $80,000.0 0 Sale s Informatio n Sale s Date : 2005-03-2 5 Dee d Type : Vi/ D Book : 200 5 Page : 03777 8 Price : 585,000.0 0 Grantor : E rend a S Walen z Grante e Courtne yFloy d Valld/lnvalld : \jrali d Exclusio n Reaso n 

## Sale s Date : 1993-01-2 8 Dee d Type : 1 ) Book : 194 7 Page : 08 4 Price : ; 134,000.00 Grantor : 

## htt p ://douglasne.mapping-onlin e .com/DouglasCoNe/static/accountinf o . j sp?accountno=R09.. . 10/ 1 /20 0 8/v/ugju o v^uuiiLj ' rrv^cuuill . . lUUlIililLlUl l 

### Fag e 2 o t 3 Grantee : Valid/Invalid : Exclusio n Reason : Viili d

Acre s : S F 

### 0.0 9 400 C 

### 0 Improvement Informatio n Buildin g 1 Unit e 

### 1. 0 Dept h Widt h 

### 100. 0 40. 0



## 1 1/ 2 Stor yFi n Vacan t N o

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93 6 0 sc . 1

Squar e Footage : P54. 0 Percen t Complete : 

### 100.0 % Perimete r 0 Quality : Averag e Uni t Type : 

### Condition : Averag e

Buil t As : 1/ 2 Stor yFi n Cond o Squar e Footage : 0. 0 HVAC : Oentra l Ai rt o Ai r Rooms : 6, 0 Exterior : Frame ' Viny l Units : 

### 1. 0 interior : Crywal l Baths : 

### 2. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 

### 2. 0

Roo f Type : Gabl e Stories : 1, 5 Floorcover : Allowanc e Foundation : Bloc k Sprinitie rSquar e Footage : 0. 0 YearBuil t Y(>a r Rem i dele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 

### 191 5 0 % 

### 191 5 941 Detai l Typ e Deta/ 7 Descriptio n Unit s Ad d O n Fenc e Chai n Lin k 

### 1. 0 Applianc e Allowanc e 

### 1. 0 Basemen t Bsmn t Bloc k 8 f t 

### 936. 0 Fixtur e Bas e Fixture s 

### 1, 0 

## http://douglasne.mapping-(>nline.com/DouglasCoNe/static/accountinfo.jsp?accountno=R09. . . 10/1/200 8/wugiu j y^uuiii y rvctUUll l JlUOIlj^lO n 

### Pag e 3 of 3 Fixtur e Bat h Ful l 2. 0 Garag e i Detache d 216. 0 Porc h Sla b Roo fCei l 208. 0 Use r ML S UPDAT E 1. 0



## http://douglasne.niapping-or.line.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R09. . . 10/1/200 817"^.'^ ^ rr; ' 

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## Pruden t Propert yCiose-Ou t For m (Lead-Base d Pain t Stabiiization ) SMD:__?:^tZZ^—- — Propert yAddress : '^f ^

/4^/VAi - •^'7 ' Owner' s Name : 7!n{Jf^^AfA y<FkiA4'yf ^ 

## Performanc e Standards/close-Ou t Criteri a YE S IN 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 aress ? Thi s w/oul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x 

# 7 beams , columns , rails , an d exterio rsurface s o fgarages . 2 , Wa s al l scrapin g an d othe rpreparattio n wori ccomplete d satisfactorily ? 

# "7 3 .Wer e al l require d area s o fth e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 

# T 4 ,Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea rproduct/quality ? 

# z 5 , Ar e al l o f th e area s wher e contaminate d material s hav e bee n spille d thoroughi yvacuumed / cleaned ? 

# y 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 area s an d als o remov e 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 ? 9 , I s ther e an yevidenc e 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 ACiose-Out . 10 .Ar e ther e an ypropert yitem s tha t wer e temporatii yre-locate d b yth e contracto r 

# y tha t nee d t o b e move d bacl< ? 11 . Ar e ther e an y(Icnown ) lingerin g issue s wit h th e propert yowner{s ) tha t hav e bee n lef t unresolved ? 

# y ^

Othe rConsiderations?propert yOwne rDiscussions?Additiona ! Wor k tha t i s Require d 

## Pruden t Representativ e Signature : cJ^*''^^''^; ^ 

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# Dat e F7 ^ ^/ ^ /^/iic.^^^ ^ Propert yOwne rSignature : Date :