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## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO NFIL EFOLDE R SAID# : 2505 0 Date : Oct . 2 7 Address : 121 5 N3 5 St . Remediatio nContractor : Prudent Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S 7 V i de c o f property (DVD ) 0 Executiv e Summary 0 Signe dAcces s Agreemen t fo r subjec t property B Paintin g Agreemen t D Settlemen t document s (i.e. , fo r damag e o r l o replac e plants , etc. ) D Photograph s ffl Salisiaclor y restoratio n signe db y Propert y Owne r D Propert y close-ou l chec k lis t signe db y EP A 11

1 Propert y informatio n fro mDougla s Count y Assessor' s Offic e 

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### PROPERT Y SUMiVIAR Y Date : 9/9/0 8 LB PSTABILIZATIO NEP A CONTRA T EP-R7-08-0 7 Mont hof : Septembe r Propert y Address : 121 5 N . 3 5 St . SAID : 2505 0 A . EXECUTIV ESUMMAR Y A. l Issue s Encountered : Non e

A. 2 Issue s Resolved : Non e

A. 3 Uniqu e Findings : Non e

122A. 4 Othe r Relevan t Informatio n Acces s Date : 8/11/0 8 Wor k BeganDate : 8/20/0 8 Cioseou t Date : 8/25/0 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 . Tracldn g For m 8 . Dougla s Count y Assesso r Propert y Informatio nPag e 9 . EP A Propert y Cioseou t form(no t required ) 10 . Propert y Completio nAgreemen t

TECHNOLOGIES , INC .ENVIRONMENTA L& CONSTRUCTIO N 

## TECHNOLOGIES , INC . SERVICE S 

# Propert y Statu s For m Address: /^/5 " /t/ ! 55"^-^/ - Date : ^'(^^^ ^ 

## Phone: *'70^-'^f O ^7i/ l ^^^^' - d^y^F^ ^ Plan t & Permanen t Landscaping T o RemainI nPlac e Item# Descriptio nan dLocation O

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# M 808 0 War d Parkway , Suit e 40 5 250 5 N . 24* ^ street , Suit e 30 8 424 2 IMedica l Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrasic a 6811 0 Sa n Antonio , TX 7822 9 Pliona : f402 ) 504-100 4 Phone : f210 ) 822-958 8

# Z505 0

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

contract (Contract #EP-R7-08-07 ) wit hthe U . S . Environmenta l Protection Agency (EPA) t o stabiliz e Lea dBase dPain t (LBf ) a t anumbe r

of OTOperties locatedinOmaha, Nebraska , including the propert y locateda t /v,/.* ^ N ' .y ^ OTT " Th e EP A request s you r

pennissio nto allow Pruden t to perfor mLB PStabilizatio na t thi s property . B y signing thi s form, the propert y owne r

grant s pennissio nto Pruden t t

o perfor mactivitie s relatedt o LB P Stabilizationincluding scraping paint an dpainting o f

th e referencedproperty . Further , th e owner/tenan t verifie s tha t the y have receive dthe LB Ppamphle t "Renovat e Right. " I f

yo u have an y question s about th e LB Pstabilizationplannedfo r

you r

property , pleas e contact Prudent' s Administrative Cler k

fo r

th e Lea dBasedPain t Stabilization , Mrs . DeborahAkerele-Johnson . a

t (402 ) 504-1004 . Genera l question s abou t the OmahaLea dSit e cleanu p ca nb e directe dto the EP A Public InfonnationCenter s a t (402 ) 731-304 5 (Sout hOmahaoffice) or (402 ) 991-958 3 (Nort hOmaha office) . iBv : / ^'SJM ^<^^^- ^ T^^O^b£ryv ^ C^^v^'ic- ^ Property Owner Signature PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r - pleas e print ) RESIDEN TNAME : C-^H^ l I lA/9/iA.D^Olr i ( Owne r^ Rente r RESIDEN TADDRESS : I F RENTAL , PROPERTYOWNE D BY : 

# s^m c OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHONE NUMBE R - HOME : [Kf^\^^'T'ii i WORK : 

### i 1 

# n NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : C > NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : 

# a NUMBE R O F CHILDRE NUNDE R 7 YEAR S OL D WH O PLA Y I NTH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : _ COMMENT S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORrr Y FO RENVIRONMENTA LRESPONS EACTIONS : Th e activitie s t o b e implemente db y 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 th e property i s provide d forh Sectio nI(M(e ) o f CERCLA , 4 2 U.S . C 9605(e) , whic hprovide s entr y ib r

"decenninin g th e nee dfor response , o r choosin g ortakin g an y respons e actio nunde r thi s title , o r oiherwis e enforcin g ih e provision s o f th e title. "

tlS O War d Partcway , Suit e 40 5 250 5 N . 24* ^ Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 iansa s City , M O 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 «. ­ .^n-. . cn^.^nn ^ Phone : (210)822-958 8

# Curren t Sampl e PrijPenovatio n For m Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamplile t " Q I have receive d a cop yof th e pamphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Care Provider s an d School s informin g m e of th e potentia l risk of th e lea d hazard exposur e fro m renovatio n activityt 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 .

SigrWre.''«5 f rlci^en t srti f Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) — I f th e lea d pamphle t w/a s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ychec k th e appropriat e bo xbelow . Q Refusa l t o sig n —I certifytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet . Renovat e Right : importan t Lea d Hazar d informatio n fo rFamilies , Chil d Car e Providers an d Schools , 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 tha t th e occupan t refuse d t o sig n th e confirmatio n of receipt . I furthe rcertifytha t I hav e lef t a cop yo f th e pamphle t at th e uni t wit h th e occupant . •Unavailabl e fo rsignatur e —I certifytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovat e Right : Importan t Lea d Hazar d Informatio n fo r Families , Chil d Care provider 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 unavailabl e t o sig n th e confirmatio n of receipt . I furthe rcertifytha t I hav e left a cop yo l th e pamphle t at th e uni t b yslidin g i t unde rth e door , - n 

# /^r^ - •e/e^ s Printe d nam e of personj:ertifyin g Attempte d deliver y dat e an d tim e lea d pamphle t deliver y 

# jMaMje^^T' — Signatur e of perso n celtifyin g lea d pamphle t deliver y 

# 7:xl S M IB ' iV ^ C>/)/^ceh^ ^ A^ ^ Uni t Addres s Not e Regardin g Mailin g Optio n — A s a n alternativ e t o deliver yi n person , yo u maymai l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d at leas t 7 day s before renovatio n (Documen t wit h a certificat e of mailin g fro m th e pos t office) .

# pain t matc h for m ,fj ^ , 2 Pain t matchin g form : . _ Propert yaddress : /^/f /i 7 3i ^ BVID : 7^ ^

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### Dougla s Count y Accoun t In|Mjrnatio n Pag e 1 o f 3 • Dougla s County , Nebrask a Propert yRecor d - R060812000 4 Prin t Repor t NE W Featur e - Paice l Dimension s availabl e @ scal e 0-5 0 f t wes t o f 90l h S t - VJe W O n Ma p Informatio n i s vali d a s o f 2008-6-1 9 Treasurer' s Ta xRepor t Ne wFeatur e ->->- * Aut o Sale s Searc h Owne r THOMPSO N ERI C M ETA L 121 5 N 35 S T OMAH AN E 68131-000 0 Propert yInformatio n Ke yNumber : 

### 081 2 000 4 06 Accoun t Type : Residentia l Parce l Number : 060812000 4 Parce l Address : 121 5 N 3 5 S T OMAH AN E 68131-000 0 Lega l Description : BEMI S PAR KLO T7 BLOC K5 -E X N 9 5 FT - L T7 5 2 X 52. 5 Valu e Informatio n Lan d Improvemen t Tota l 200 8 $ 1,700.0 0 $56,100.0 0 $57,800.0 0 200 7 $ 1,700.0 0 $56,10 0 0 0 $57,800.0 0 

### 2006 $1,700.0 0 $56,100.0 0 $57,800.0 0 200 5 $1,700.0 0 $56,100.0 0 $57,800.0 0 200 4 $1,700.0 0 $38,700.0 0 $40,400.0 0 200 3 $1,700.0 0 $38,700.0 0 $40,400.0 0 Sale s Informatio n Sale s Date : 2002-09-2 0 Dee d Type : W D Book : i 222 3 Page : 33 8 Price : $62,000.0 0 Grantor : Grantee : Valid/Invalid : vali d Exclusio n Reason : Sale s Date : 1998-10-2 3 Dee d Type : Book : 211 1 Page : 183 Price : $ 46,000.0 0 Grantor :

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### Dougla s Count y Accoun t Inimnatio n Pag e 2 o f 3 Grantee : Valid/Invalid : Exclusio n Reason : Vali d Sale s Date : Dee d Type : Price : Grantor : 1997-08-0 6 $35,00 0 0 0 Book : I 207 3 Page : \ 25 0

Grantee : Valid/Invalid : Exclusio n Reason : Vali d Lan d Informatio n Acre s 0.0 6 S F 2756. 0 Unit s 1. 0 Dept h 53. 0 Widt h 52. 0 Vacan t N o Improvemen t Buildin g 1 Informatio n

TW O STOR Y 121 5 N 3 5 S T

F(rs t Floo r 65 0 Os q ft . Secon d Floo r 550. 0 sq . a

Bvai t Slac k a I I 6& D D «q . II . CLIC KTO ENtJ»RGE,IMAG ^ Squar e Footage : 1300. 0 Perimete r 0. 0 Uni t Type :

Buil t As : 2 Stor y 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 : Gambre l Floorcover : Allowanc e CtJC.K.ICLENLA8gjEJ.Ma& E Percen t Complete : 100.0 % Quality . , Averag e Condition : j Averag e Cond o Squar e Footage : | 0. 0 Rooms : ; 6. 0

Units : i 1. 0 Baths : 1. 0 Bedrooms : > 3. 0 Stories : 2. 0 Foundation :

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### Dougla s Count y Accoun t InfiMjiatio n Pag e 3 o f 3

1 

### 1 \ Sprinkle rSquar e Footage : j 0. 0 yea r6u(7 t Yea r Remodele d Percen t Remodele d Adjuste d Yea r

Buil t i oh„^i^= i A^ ^ Physica l Ag e 192 4 0 0 % 192 4 ; 8 4 Detai l Typ e Detai l Descriptio n Unit s Applianc e j Allowanc e 1. 0 Basemen t ! Bsmn t Bloc k 8 f t 650. 0 Fixtur e Bas e Fixture s 1. 0 Fixtur e Bat h Ful l 1. 0 Porc h Sla b Roof Cei l 1 120. 0



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## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) SAID: 7S"Oh" n ^, , / Propert yAddress : L ^ 1 ^

A J S S .3f Owner' s Name : 

## ^/n//i j linr.nin'yi n 

# i Performanc e Standards/close-Ou t Criteri a YE S 

### N 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 areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x / beams , columns , rails , an d exterio rsurface s o f garages . 2 .Wa s al l scrapin g an d othe rpreparattio n worl < complete d satisfactorily ? / 3 .Were al 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 3 0 yea rproduct/quality ? 

# Z ' b .Ar e al l o f th e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? 

# y 5 .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 also remove an yothe rgenerate d debris ? / I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 

# r 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 anyevidence 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 AClose-Out . / 10 . Are ther e an ypropert yitem s tha t wer e te.mporatil yre-locate d byth e contracto r

tha t nee d t o b e 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 lef t unresolved ? Othe rConsiderations?propert yOwne rDiscussions?Additiona l Wor k tha t i s Require d / '



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