TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: ^J^/DO-J P Date: ^t^^ - rTC ^ " ^^^ ^ 

Address: i.TjT^ ^ A J ^1 ^ ^91^ -

LBP Stabilization Contractor: PRUDEN T TECHNOLOGIES , INC. Year: 2009 

PAIN T STABILIZATIO N 

PROPERT Y FIL E FOLDE R DOCUMENT S 

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

y Executive Summary 

[r Signed Access Agreement Form 

y Advance Notice Form 

m Pre-Stabilization Video Agreement Form 

y Access Tracking Form 

y Property Access Assessment Form 

Lf Neighbor Access Agreement Form 

» Paint Match Form 

¥ Pre-Stabilization Property Safety Assessment Form 

/ Work-Site Hazards Analysis Checklist 

Lr Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

W Douglas County Assessor Property information 

r/ Property Completion Agreement Form Signed by Property Owne r 

LJ Property Close-Out Check List Signed By EPA 

Pruden t Technologies, Inc . Signatur e / < Dat e 

4/1/10 

Dat e 

30054958 

nni 

Superfund 
IKSINOIJOGIBS, INC 

Property Summary 

Date: 9^^2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: Sep 

Property Address: 3156 N 47 Av. SAID #: 49989 

A. Executive Summarv; 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 7/20/2009 

ii. Work Began: 8/04/2009 

iii. Close-Out Date: 9/04/2009 

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 
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 (LBP) ata number of properties located in Omaha, 

Nebraska, including the property located at ?>\*yk \J M rTV-^^ . 

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 includii^ 

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/Office 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 (402) 731-3045 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Property Access Granted By: 

(Please Print Name) 

Property Owner Signature: -c R. (Signature) P^ (Date) 

PROPERTY INFORMATION 

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

RESIDENT NAME: Matt Owner ! Renter 

< $ 

RESIOENT ADDRESS:. 

IF RENTAL. PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE; I NUMBER - HOME: ( H^^H "^'^ i ~ ^ WORK: J L 

I' NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: ii 

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.) 

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 ofaccess 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 taking any response action under this title, or otherwise enforcing die provisions ofthe title." 

( 

8080 Ward Parkway, Suite 405 

Kansas City, MO 64114 

2605 N. 24'" Street, Suite 308 

Omaha, Nebraska 68110 

4242 Medical Drive, Suite 4250 

San Antonio, TX 78229 

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

Pav (R1fil 1(57.1707 
HOMEOWNERS SIGNATURE: 

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 of yard 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? 

Notice needed: V A ^ 

Number to call to give notice: ^ ^ v - 9 "^s ^ 

Whom we are giving notice to: ^o,v ^^"^ 

Home Owner's Signature 
PRE-STABILIZATION VIDEO FORM 

IUNDERSTAND THAT PRUDENT TECHNOLOGIES WlLL 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 WlLL ALSO BE SHOT PRIOR TO 

COMPLETION OF STABILIZATION. 

OWNERSNAME: ~~(iihe~) 

HOMEOWNERS SIGNATURE: -th& 

J 

PRUDENT 

ANY CONDITIONS'NEED TO BEAWAREOF BEFORE SHOOTING VIDEO: 

(I.E. PETS, NOTICE NEEDED): *kL 
Me3 Phew Nc's: Hone: 'flzk 

- Celi: rax: 

Please writs legibv! 
Access Assessment Form: (Must be completed for every property. Information 

must be obtained from a property walk thru, not given by owner) 

Is the property stucco or asbestos? 

v 0( d 

If yes, is any of the stucco or asbestos damaged or cracked? 

If yes, stop as we can't stabilize this property. It requires special preparation 

techniques. It will be returned 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? 

N 

Does I this property have any significant structural damage? 

If yes, describe location of garage. 1 

Does this property have aluminum siding? 


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? 

Are there any low hanging power lines? 

m 
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. 

fa 

TECHNOLOGIBS. INC. 

PAINT MATCHING FORM: tWc 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: 2,^ 5 0:' K^ M*7 f\\J ^ 

BVID: ^SOM ^ 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: 

Sv^^ 

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

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9588 

Fax: (210) 579-6577 

Cs^Wt'k P ^-2- ^ P ^ c^ a ^^o^,•CtV^ KeS ^ yo\6?C<; 
TBCHNOLOGIBS,! 

PAINT MATCHING FORM: 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: 2>^E>Q} t\i ^ H (\ ^ ^ 

BVID: 2>SOM9> 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature 

VNAV C^IV ft OQi^f^tv, / ^ (XjJ 

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

Kansas City, MO 64114 Oniaha, 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 

PAINT MATCHING FORM: 

TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: 3\5& 1\! 7 C\\I e 

BWD: ssqg 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: 

8080 Ward Parkway, Suite 405 --

2505 N. ~ XIhStreet. Suite -~ ~~~ 308 .~ 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 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 
PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 3 15 6 rJ 7 E3t\re 

PRUDENT REPRESENTATIVE DOING ASSESSMENT: 

&7.r4Ulw 

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

TO KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A 

CREWISUB. 

REPRESENTATIVE REMARKSIFINDINGS (POWER-LINE 

PROXIMITY TO HOUSE, SCAFFOLDINGLADDERSLIFT 

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

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 
— 

TECHNOLOGIES.] 

Checklist for the Worksite Hazard Analysis 

Address •.S\^L U.H-f^ /U ^ 

Crew: Date: 

Item lazard Corrective Action 

Overhead Lines 

b(uL<'; te:g%­

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines ^^ ^ yjjt,* C)^r<j>-Vfc^>'^^

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property W<^CSL-V<? 

Ai^yJ^Wy^^Q^^^^vv ^Ag3^ry.^^-A+ifc>N ^^^^ ^ 

j^c^^^^M,-.^ l^^^-s±.:kp ^ 

Neighbor Access Required 

High ^ Traffic Area 

Garage 

Structures 

:sluS ^ ^ 

Driveway ^ ^5 Sidewalk 

•~ ^^^^g ^ Ai? 

tfZXIP" Foundation 

Retaining Walls 

Fences 

^ Trees 

Foliage 

General Condition of yard 

<^<3UJQJV_ Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

Crew Site Safety Officer 

8080 Ward ParkwJiy,^tr405 2505 N. 24'" Street, Suite 308 4242 Medical Drive, Suite 4250 

Kansas City, MO 64114 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-Renovatlo > ^ < n Form 

Eflecthro until April 2010. 

Conflrmation of Receipt of Lead Pamphlet 

STl have received a copy of the pamphlet, Renovate FSght: Important Lead Hazard 

Informsilon lor f^n^lles, Child Care Providers and Schools Informing me of 

the potential ii8i< of ttie ISEKI hazard exposure iKxn renovation actlvify to be 

pevfonmed In my dwefling unit. I received this pamphlet Isefbre the worl< began. 

naiiM of recipient /"'T X Date^ 

signature of recipient 

Setf-CettmcaHon Option (for tenant-occupied dwellings only) — 

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

you may dieck the appropriate tx>x below. 

• Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, renovate /%/7t: Important Lead Hazard Infonnation fbr Fairies, 

ChBd Care Providers and Schools, to the rental dwelling unit listed below at the 

date and time Indicated and that the occupant refused to sign the confirmation 

of receipt I further certify that I have left a copy of the pamphlet at the unit with 

ttie occupant. 

Q'Unavallable fbr signature — I certify that I have made a good M h effort to 

defivor the pamphlet, Renovate fV^ t Important Lead Hazard Infonnation for 

FamlBeB, Cfiffcf Care provlldsrsarKySc/xxjIls, to the rental dwelling unit listed 

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

I further certify that I have left a copy of the pamphlet at the mIt by sliding It 

under the door. 

FWitedViame of person certifying /) Attemiked ddilvery 

date and time 

lead pamphlet delivery 

Signature of person 

UnitAddress 

Note Regarding Mailing Option — As an altemative to delivery In person, you 

may mall the leed pamphlet to the owner and/or tenaiit. Pamphlet must be mailed 

at least 7 days befors renovation (Document with a certificate of mailing finom the 

postofHoe). 
Douglas County Account InfoHB|tion Page 1 of3 

Douglas County, Nebraska Property Record - R2414680000 

Print Report 

NEW Feature - Paxel Dimensions available @ scale 0-50 ft west of S2nd St - VlOW OH IViap Information is valid as of 2009-6-16 Treasurer's Tax Report 

New Feature -*-*- * Auto Sales Search 

Owner < 

LOWE MATTHEW 

ETAL 

3156 N 47 AVE 

OMAHA NE 68104-0000 0 ^ 

\ - j 

Property Informatio n 

Key Number: 1468 0000 24 

Account Type: Residential 

Parcel Number: 2414680000 

Parcel Address: 3156 N 47 AV 

1 OMAHA NE 68104-0000 

Legal Description: 1 WAVERLY PARK LOT 2 BLOCK 3 40 X 125 

Value Informatio n 

Land /mproi^ement Total 

2009 $5,700.00 $50,200.00 $55,900.00 

2008 $5,700.00 $53,500.00 $59,200.00 

2007 $5,700.00 $53,500.00 $59,200.00 

2006 $5,700.00 $53,500.00 $59,200.00 

2005 $5,700.00 $38,600.00 $44,300.00 

2004 $5,700.00 $35,100.00 $40,800.00 

Sales Informatio n 

Sales Date: 2003-06-06 

Deed Type: WD Book: 2003 Page: 112978 

Price: $83,350.00 

Grantor: TANYA MULLER ETAL 

Grantee: MATTHEW LOWE ETAL 

Valid/Invalid: valid 

Exclusion Reason: i 

Sales Date: \ 1992-08-27 

Deed Type: D Book: 1932 Page: 166 

Price: $29,500.00 

Grantor: 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R24... 6/19/2009 
:;.;'<i:..'T"..-)i w---W- i i-'i.iv»-Wfyw-V*TMn,i.-*l**^,( - •:•>-;••''•*' .•*".•• :''-> h ? 

Douglas County Account Infonaation Page 2 of 3 

Grantee: 

Valid/Invalid: Valid 

Exclusion Reason: 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.11 5000.0 1.0 125.0 40.0 No 

Improvemen t Informatio n 

Building 1 

r.M.Wi;i.t.*.i.iiMt,HM.iii!iiWM.Haaa; 

CLICK TO iNLARGEIMAOE CLICK TO ENLARGE IMAGE 

Square Footage: 1000.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Average 

Built As: 1 1/2 Story Fin Condo Square Footage: 0.0 

HVAC: Central Air to Air Rooms: 5.0 

Exterior: Frame Aluminum Units: 1.0 

Interior: Drywall Baths: ' 2.5 

Roof Cover: Composition Shingle Bedrooms: 2.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinlder Square Footage: i 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1922 0 0% 1922 87 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 624.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 2.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R24... 6/19/2009 

-••^-iC ^ Secsnif Fkioi 

1 1.C STORY 

•rtr 

Fitsi Ptoor 

= 1' 

352.0 »a «, 

a: 

•if' 

;*!.' •or. 

i; ^ 

E-art-4 E*x». a t 

6; * j . q •< S»V 

ap- U>J t a 

?»=• . . i 
Douglas County Account Info|a|tion Page 3 of3 

Fixture 

Garage 

Porch 

Porch 

Porch 

Porch 

Bath Half 

Detached 

End Screen 

End Screen 

Slab Roof Ceil 

Slab Roof Ceil 

1.0 

352.0 

64.0 

16.0 

64.0 

144.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R24... 6/19/2009 
Prudent Property Close-Out Form (Lead-Based Paint Stabilization) 

SAID: 850^ g 

Property Address: 3(5* 6 N M V Av e 

Owner's Name: M^ H Lou/e 

S.NO 

Performance Standards/close-Out Criteria 

Was the entire structure(8) painted with the exception of the stated, 

excluded areas? This would include painting of other associated 

features including fascia, eaves, siding, all trim, porches^^ box 

beams, columns, rails, and exterior surfaces of garages. 

Was all scraping and other preparation work completed 

satisfactorily? 

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

painted with two top coats? 

Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

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? 

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

condition? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

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

cones, barrier tape etc property removed? 

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

contractor? Any property damage needs to be completed prior to 

the EPA Close-Out. 

10 Are there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

11 Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? 

12 Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Prudent Representative Signature 

Date: 

Property Owner Signature 

y. Date 

8080 Ward Parkway, Suite 405 

Kansas city, MO 64114 

Phone: (816) 363-3703 

Fax: (816) 363-3707 

1AW-

Yes NO 

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2505 N. 24*^ Street, Suite 308 4242 Medical Drive, Suite 4250 

Omaha, Nebraska 66110 San Antonio, TX 78229 

Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (402)504-1005 Fax: (210) 579-6577