## TRANSMITTA Lo f

OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID : 2382 0 Date : 12/27/200 8 Address : 34 7 N 3 5 S T Remediatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 4 • Vide o o f propert y (DVD ) 1 ^ Executiv e Summary S ISigne dAcces s Agreemen t for subjec t property aPaintin g Agreemen t D Settlemen t document s (i.e. , for damag e o r t o replac e plants , etc. ) D Photograph s 0 Satisfactory restoratio n signe db y Property Owne r D Property close-ou t chec k lis t signe db y EP A [FProperty informatio n fromDougla s County Assessor' s Offic e D D D


### Signatur ^ Dat e

4031042 3 

# iMilHIi l Superfun d

### PROPERT Y SUMMAR Y Date : 12/27/0 8 LB PSTABILIZATIO N EP A CONTRA T EP-R7-08-0 7 Mont hof : Decembe r Propert y Address : 34 7 N 3 5 S T I SAID : 2382 0 A . EXECUTIV ESUMMAR 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 : 11/13/200 8 Wor k Began : 11/15/200 8 Closeou t Date : 12/9/200 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

TECHNOLOGIES . INC .ENVIRONMENTA L& CONSTRUCTIO N 

### TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address : -3^ ^ ^ ) 3S ~ S f Date : M- ] T-^ f 

## Phone : J? / - g^^" ^ BVID : -Z^fe O Plan t & Pennanen t Landscapin g T o Remai n I n Plac e 

## Item # Descriptio n an dLocatio n 

## OnM ^ 

# tOo r ^



## e

Pre-Existin g Conditio n o f Structure s Doe s you r Basemen t hav e ahistor y o f leaking ? Ye s — 

## Item # Descriptio n& Locatio n O n Map

Propert y Owne r Pruden t Employe e Signatm c SignaturcyO^—^<^2'^-^ ^ ' 808 0 VMr d PaikMny , Suit e 40 8 250 5 N . 2»7;;^lleet , Suit s 30 8 424 2 Medica l Drive , Suit s 426 0 Kansa s City , M O 6411 4 Omaha , Nebrasic a 6811 0 Sa n Antonio , T X 7822 9 Phona : (81« t 863-370 3

# 23f32 ) Pruden t Technologies , Inc . (Prudent) i s unde r

contrac t (Contract #EP-R7-08-07 ) wit hth e U . S . Environmenta l Protectio n Agenc y (EPA ) t o stabiliz e Lea dBase dPain t (LBP ^ a t anumbe r

o f propertie s locatedin Omaha , Nebraska , includin g tiie propert y locateda t ^Q ^ / O f ^ .S/~ The EP A request s you r

permissio n t o allo w Pruden t t o perfor mLB PStabilizatio n a t thi s property . B y signing tiiis form, ttie propert y owne r

grant s permissio n to Pruden t t o perfor mactivitie s relate dto LB P Stabilization including scraping paint andpaintin g o f th e referencedproperty . Further , tiie owner/tenan t verifie s tha t they hav e receive dth e LB Ppamphlet "Renovat e Right. " Ifyo u have an y question s about th e LB Pstabilizatio 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 abouttiie OmahaLea dSit e cleanup canb e directe dt o th e EP A Publi c Information Center s a t (402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nortii Omaha office) . Propert y Acces s GrantedBy : fiSl^/i)/^ 0 // dB t C I "^ ^ f i Propeit y Owne r Signature : 

# j/-/3-d r (Date ) PROPERTY iNFORMATIO N CT

o li e complete dby residen t and/o r property owner - pleas e print ) RESIDEN TMAME : C^A - T M K l H ^ ^H^l^b< i Ownerf^ ^ RESIDEN TADDRESS : 3^ 7 /i J 6 '' ^ 5~ " S / ' I F RENTAI. , PROPERT YOWNE D BY : ^-^/ ? 7 vA rQ ^ A ) C T/ [ /"^-^/ ^ OVWNER'SMAIUN G ADDRESS ; / ^ I 7 A J /- ^ / < 3 6 5 / OWNER' S TELEPHON E NUMBER-HOME : 1^^ ^

.^'^A/'^^WORK : f \ ' NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : O NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : __2 > NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA YI N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : O COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES . ETC. ) / - - x

AUTHORir Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e impletneotedby EP A unde r thi s agreemen t ar

e pursuan t t o Sectio n 10 4 o f

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

acces s t o (h e propert y i s providedfor i n Sectio n104(e ) o f CERCLA . 4 2 U.S . C 9605(e) . whichprovide s entr y for "determining the need for response , o r choosing ortaldn g an y respons e aclio n unde r thi s title, or otherwis e enforcing fce provisicn s of the title. "

250 5 N . 24* ^ Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 08 0 War d Parkway , Suit e 40 5 Omaha , Nebrask a 6811 0 Sa n Antonio , T X 7822 9 ".ansa s City , M O 6411 4 Phone : (402 ) 504-1004 Phone : (210)822-958 8 hone : (816 ) 363-3703 Fax : (402)504-100 5 Fax : (210) 579-6577 ax : (816 ) 363-3707Effectiv e urrti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pampliis t ^

hav e receive d a cop yo fth e pampiilet , flenovate Right : Importan t Lea d Hazard Informatio n fo rFanfftes , t^il d Car a F>ro\riders an d Sc^wol s informin g m e o f •• tJi e potentia l ri8l< o f th e lea d hazar d exposur e from renovatio n activit yt o b e perfbrme d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wori < began . Printe d nam e o f recipieri t ^ , ^ Dat e Signatur e o f recipien t / ^ Seif-Certlficatio n Optio n (fb rtenant-occupie d dwelling s onl ^ — i fth e lea d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychac k th e appropriat e bo xbelow . •Refusa l t o sig n — I certif ytha t I hav e mad e a goo d fait h effor t t o delive rth o paniphlSt , /%/V)v<at9 R^ h Importan t Lea d Hazar d Infonnatio n fo rFamilies , Chil d Car e Provider s an d Schools , t o th e tenta i dwellin g uni t liste d belo wa t th e dat e an d tim e indicate d an d tha t th e occupan t refuse d t o sig n th e confirmatio n o frec^pt . I furthe rcertif ytha t 1 hav e lef t a cop yo fth e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e —1 certif ytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet . Renovat e Ftiglh t Importan t Lea d Ham d Informatio n for FamiSes , C/wto fCa e pmwder s an d Schods , t o th e renta l dwellin g uni t liste d belo wan d thiat th e occupan t wa s unavailabl e t o sig n th e confirmatio n o f receipt . I ^irthe rcertif ytiia t I hav e lef t a cop yo f th e pamphle t a t tli e uni t b yslidin g i t underthedoor . 

## Get-oAi ) QulA^x vI f- i 3 "O S oS% 0 Printe d nam e o fperso n certifyin g Attempte d deliver y dat e en d tim e lea d pamphle t delivery 

# HuiJrx-y- — Signatur e o f perso n certifyin g lea d pamphle t deliver y



## rJrv-o->vo«^ J^ g c=>^i ^ I UnitAddres s Not e Regardin g Mailin g Optio n —A s a n altemativ e t o deliveryi n person , yo u ma ymal l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d a t leas t 7 day s befor e renovatio n (Documen t wit h a certificat e o f maifin g fro m th e postoffice) .Vvjc y 

# pain t matc h form - Pain t maitchin g form " Propert yaddress : 3^f 7 JO - 3S^^ ^ 5f_ BVID : p^^^ o Area:^o*"*^^ ? ^'=^'^'^ ^

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CUC KTO ENU\RG^ ^ IMAG E Squar e Footage : ; 1156. 0 Perimete r; 0. 0 Uni t Type : '

Buil t As : I 1 1/ 2 Stor yUnfi n HVAC : ! Centra l Ai rt o Ai r Exterior : ! Fram e Sidin g interior : ! Drywal l Roo f Cover : [ Compositio n Shingl e

Roo f Type : j Gabl e Floorcover : j Allowanc e 1 Yea rBuil t 

### 192 5 ,,..4. . Yea r Remodele d Percen t Remodele d " 0 % Detai l Typ e ; Detai l Descriptio n Applianc e \ Allowanc e Basemen t i Bsmn t Bloc k 8 ft Fixtur e ' Bas e Fixture s Fixtur e 

### fBat h Ful l Garag e ! Detache d Porc h ! En d Scree n Porc h ; Sla b Roo f Cei l Porc h i Woo d Dec k Use r ! Atti c1/ 2 Finis h 1 1/ 2 Stor yUnfi n 34 7 N 3 5 S t Mij^rv ; ttifWBlMkei t i rifs t F)r.o r i < 155, 0 » B R ,

Percen t Complete : ; 100.0 % Quality : ; Averag e Condition : ; Averag e Cond o Squar e Footage : i 0. 0 Rooms : : 7. 0

Unite : 1. 0 TM Baths^lj. O Bedrooms : ] 3. 0 Stories : 1. 5 Foundation : i Bloc k Sprinkle rSquar e Footage : \ 0. 0 Adjuste d Yea r Physica l Ag e Buil t 192 5 8 3 Unit s 1. 0 1156. 0



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## http://douglasne.mapping-onlme.com/DouglasCoNe/static/accountinfo.jsp?accouiitno=R13.. . 9/24/200 8

## Page 1 of 1 

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## Catherin e M Shield s SPCt<SOH-i D • ; :NK ? Looku p Bacltorour.'t t Inf o fo rCatherine ­ 34 7 N 35t h S t Houseliold : Tyrone , Joh n Siiields . Omaha , N E 68131-240 3 Se a Wha : Cathr.riri B Siirglds' s Hcnx > i s Wor h (402 ) 344-304 1 Firtd Schoo i Informatio n o n Catherin e Shielas Listin g Detail s lot ;v\fvu;r, s Se s Wha rCalheiin s Snields' s Horn s i s Wori h Mak e I t eas yfo rpeopl e t o contac t yo u o n WhitePages.co m Lear n 'not e 

## Joh n Shield s Looku p Backgroun d Inf o fo rJoii n Shieids . 34 7 N 35t h St hiouseiioid : Catherine , Tyron e Se3 W.ha t Jol m ShieSd s s Ho^i e i s VVoft h Omaha , N E 68131-240 3 Pin d Schoo : Ipformatio n o n Joh n Shieid s (402 ) 344-804 1 

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## Tyron e Shield s \ r>,>l<;^i p Ry^fcnfpun d Irif o fo rTyron e Shields . hiousehoid : Catherine , 34 7 N 35t h St Sft G Wha t fvrori e SI'ieids' s Hoir.e . ia Wnrt h Joh n Omaha , N E 68131-240 3 Fin d Scfico l irfotmatio n o n Tyron e Shield a (402 ) 344-804 1 iicriNrVviXT^ V Listin g Detail s SeeWalTyron e Shieios' s riorre i s Worli ^

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## .coinysearch/ReverseAddress?street=347+n+35+st&city_zip=omah.. . 9/25/200 8 http://www.whitepage s

## Page 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R130454000 0 Prin t Repor t Informatio n I s vali d a s o f 2008-9- 4 *'^* ' ''*'*"'* " P^f^ ' Dimension s availabl e @ seal s 0-5 0 f l wes t o

f 90t h S t - Vie wo n Ma p ' Treasurer' s Ta xRepor t ! Ne wFeatur e - ^ - ^ - > Aut o Sale s Searc h Owne r SKRADETA L 181 7 N 10 0 S T OMAH AN E 68114-000 0 Propert yInformatio n Ke yNumber : 045 4 00001 3 Accoun t Type : i Residentia l Parce l Number : ' 130454000 0 Parce l Address : j 34 7 N 3 5 S T ; OMAH AN E 68131-000 0 Lega l Description : ' HAWTHORN E AD D LO T2 8 BLOC K3 N 4 0 W 9 0 F TLT2 7 & S 5 W 9 0 F T4 5 X 9 0 Valu e Informatio n I Lan d ; Improvemen t ' Tota l 200 8 I $5,300.0 0 I $64,700.0 0 $70,000.0 0 200 7 I $5,300.0 0 $51,66o.OO ' 556,900.0 0 200 6 i $5,306.0 6 i $51,600.0 0 \ $56,900.0 0 200 5 ' $5,300.0 0 ' $51,600.0 0 $56,900.0 0 200 4 ! $5,300.0 0 ; $51,600.0 0 $56,900.0 0 200 3 I $5,300.0 0 \ $36,300.0 0 $41,600.0 0 Lan d Informatio n Acre s ] S F i Unit s i Dept h \ Widt h '• Vacan t 0.0 9 ; 4050. 0 i 1. 0 ; 90. 0 j 45. 0 N o Improvement Informatio n Buildin g 1



## http://douglasne.mapping-online.coni/DouglasCoNe/static/accountinfo.jsp?accountno=R13.. . 9/24/200 8

## Pruddn t PropertyClose-Ou t For m ( Lead-Based Pain t Stabilization ) SAID : :23fA 6 ^ PropertyAddress : ^^" ^

P ^- T 5 ^ Owner' s Name : HS^Wl^JP . ^ly^ff ^ 

## Perfor^manc e Standards/close-Ou t Criteri a 1 .

Wasth e entir e structure(s ) painte d wit h th e exceptio n o f th e stated , exclude d areas ? Thi s woul d includ e paintin g of othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x bearws , columns , rails , an d exterio rsurface s o f garages . 2 .Wa s al l scrapin g an d othe rpreparattio n wor k complete d satisfactorily ? 3 .

Wereial l require d area s 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 pain t product s utilize d equivalen t t o a 30 yea rproduct/quality ? 5 .

Ar e al l of th e area s where contaminate d material s hav e bee n spille d thordughl yvacuumed/ cleaned ? 6 .

Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chips o n th e entir e property , roacvyays , alleyways , publi cacces s areas an d also remov e anyothe rgenerate d debris ? 7 .

I s theigras s area tha t surround s th e structure(s ) i n reasonabl ygood condition ? 8 .

Ar e al l item s such a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e etc . properl yremoved ? I s ther e anyevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need i t o b e complete d prio rt o th e EP AClose-Out . 10 . Are ther e anypropertyitem s tha t wer e temporatil yre-locate d b yth e contracto r tha t riee d t o be move d back ? 11 . Ar e ther e any(known ) lingerin g issues wit h th e propertyowner(s ) tha t hav e bee n left unresolved ? Othe rConsiderations?propert yOwne rDiscussions?Additiona l Work tha t i s Require d 

## Pruden t Representative Signature : 

# Dat e f^'<:^'aS ' Property/Owne rSignature : J^/i^Mt/yA ^ I 

# Date : i/J-f-^ ? YES 

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