## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL E FOLDE R SAID# : 73 3 Date : Oct . 7 Address : 261 7 Poppleto n Ave . Remediation Contractor : Pruden t Technologie s Inc . Year : 200 8 PAINT STABILIZATIO N PROPERT Y FIL E FOLDE RDOCUMENT S \ / Video of

propert y (DVD ) Q ' Executive Summar

y 0 ' SignedAcces s Agreemen t fo r subjec t propert y a ' Painting Agreemen

t D Settlemen

t documents (i.e. , fo

r damage o r to replac e plants , etc. ) D Photograph s \ y Satisfactor

y restoratio n signedb

y Propert y Owne r D ' Propert

y close-out

chec k lis t signedby EP

A 0 ^ Propert

y information firomDougla s Count y Assessor' s Offic

e D D D 

## Signatur&

Z Dat e

### Date : 9/02/0 8 PROPERT Y SUMMAR Y LB P STABILIZATIO N EP A CONTRAT EP-R7-08-0 7 Monthof : Septembe r Propert y Address : 261 7 Poppleto n Ave . SAID : 73 3 A . EXECUTIV E SUMMAR Y A. 1 Issue s Encountered : P.O . called& saidthe cre w ha dbroke n he r gutter . A. 2 Issue s Resolved : Corrected9/02/0 8

A. 3 Uniqu e Findings : None 122A. 4 Othe r

Relevan t Infomiation : None Acces s Date : 8/21/0 8 Wor k Began Date : 8/28/0 8 Closeou t Date : 9/18/0 8

Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 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 County Assessor Propert y Informatio n Pag e 9 . EP A Propert y Closeou t for m 10 . Propert y Completio n Agreemen t

TECHNOLOCIES . INC .

## TECHNOLOGIES , INC . ENVIRONMENTA L & CONSTRUCTIO N SERVICE S 

# / ) Propert y Statu s For m ^hnHfpm^ mDate : fhi/fi f Phone:^ /

;M-/>5V 7 

## BVID : ,^^ ^ Address :

Item # O n Ma p Plant

& Permanen

t Landscaping T o Remain I n Plac e Descriptio n andLocatio n 

# 0if f lllifMI - H^^('



# Vr^- ^7-^ y

Pre-Existin g Conditio n o f

Structure s Doe s you r Basemen t hav e ahistor

y of leaking ? Ye s — N o — Item # O n Ma p Descriptio n & Locatio n

808 0 War d Parkway , Suit e 40 5 Kansa s City , M O 6411 4 Phons : (816 ) 363-3703 Fax:(816)363-370 7 Omaha , Nebraska 6811 0 Phone : (402)604-100 4 Fax : (402)504-100 5 424 2 Medica l Drive . Suit e 425 0 Sa n Antonio , T

X 7822 9 Phone : (210)822-958 8 Pax : (210 ) 579-6577

# 73 ^

Pruden t Technologies , Inc . (Pnident) i s unde r contrac t (Contract #EP-R7-08-07 ) wit

hth e U . S . Enviromnenta

l Protectio n Agency (EPA ) t o stabiliz e Lea dBasedPaint

(LBP\At anuuAer ofpropertie s locatedi n Omaha , Nebraska , includin g th e propert y locate da

t ^hl'7 ' rPppiCJp/ l /\u^ ' The EP A request s you

r permissio n t o allo w Pruden t t o perfonn LB P Stabilizatio n at thi s property . By " signing thi s form, tiie propert y owne r grant s pennissio n t o Pruden t t o perfor mactivitie s relate dt o LB P Stabilizatio n including scrapin g paint andpaintin g of

th e referencedproperty . Further , th e owner/tenan t verifie s tha

t they hav e receive dth e LB P pamphle t "Renovat e Right. " Ifyo u have an

y question s about

th e LB P stabilizatio n plannedfo r you r property , pleas e contact

Prudent' s Administrative Cler

k fo r th e LeadBase dPaint

Stabilization , Ms . Debora hAkerele-Jnhngnw^ a t (402 ) 504-1004 . Genera

l question s about

th e Oinah aLea

dSit e cleanup can b e directe dt o th e EP A Publi c Infonnatio n Center s at (402 ) 731-304 5 (Soutli Omahaoffice) or (402 ) 991-958 3 (Nort

hOmah a office) . )OV"or h PropetorAcoessGrantedBy : ^^^O^^'^n V J \^V ^ l^ - I (ndasePrimNdne) Propeity Owne r

Signature : ^ ^ (^ignadre ) 7 \(Date ) PROPERT Y INFORMATIO N (T o b e comnlcte db y reddcn t and/o r propert y owne r

- pleas e print ) RESIDEN T NAME : jP/ 9 rork y'^Ar^/'g - (^^^ ) Rente r RESIDEN T ADDRESS : ji/( ? / 7 FcJ-fep/^fo wrr^ C I F RENTAL , PROPERT

Y OWNE D BY ; OWNER' S MAILIN G ADDRESS ; OWNER' S TELEPHON E 

# Sc \

# in^ ^

NUMBER.HOME

: «/to?5^-jfoi /

^'^^ U ^^ O "05^^ 7 NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : ^ NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : ^ NUMBE R O F CHILDRE N UNDE R 7 YEAR S OL D WH O PLA Y I N TH E YAR D FO R 5 HOUR S O R MOR E PE R WEEK : ^ COMMENT

S O R SPECIA L INSTRUCTIONS : (LE . DOGS , ENTR Y GATES . ETC. ) .

AUTHORIT Y FO RENVIRO>tMENTALRESPONS EACTIONS ; Tb e activicie s t o b e implemente db y EP A unde r thi s agreemen t

ar e pursuan t

t o Sectio n10 4 o f CERCLA . 4 2 U.SC . 9604 . EPA' s righ t o f acces s t o tfie propert y i s provide dfor i i Sectio n104(e ) o f

CERCLA , 4 2 U.S . C 9tiOS(e) , whic hprovide s entry fisr "deteimiaingtt K

nee dfor response , o r

choosin g ortakin g an y respons e actio nunde r dii s title , o r

otherwis e enforcis ^ tb e provision s o f dw title. "

i08 0 War dPartcway . Suit s 40 5 260 5 N . 24 " Street , Suit e 30 8 424 2 Medica l Drive , Suit s 425 0 lansa s City . M O 6411 4 Omaha , Nebrask a6811 0 Sa n Antonio , TX 7822 9 •hone'(816 ) 363-^70 3 Phone : (402)504-100 4 Phone : (210)822-858 8 ax - (816 ) 363-370 7 Fax : (402 ) 604-100 5 Fax : (210 J 579-857 7

# d,hl J PoppM .

Pruden t Technologies , Inc . (Prudent ) i s unde r contrac t (Contrac t #EP-R7-08-07 ) wit

hth e U . S . Environmenta

l Protectio n Agenc y (EPA) t o stabiliz e Lea dBasedPaint

(LBP) a t anumbCT_o

f pro] locatedi n Omaha , Nebraska , includin g th e propert y locate da

t /c^/C^ f

^^ ^ " The EP A request s you

r pennissio n t o allo w Prudent to perfor mLB P Stabilizatio n a

t thi s property . B y signing thi s form , tiie propert y owne r grant s permissio n t o Pruden t t o perfonn activitie s relate dt o LB P Stabilizatio n including scraping paint andpaintin g o f

th e referencedproperty . Further , th e owner/tenan t verifie s tha

t they hav e receive dth e LB P pamphlet "Renovat e Right " Ifyo u hav e an

y question s about

th e LB P stabilizatio n plannedfo r your property , pleas e contac t

Prudent' s Administrativ e Cler

k fo r th e Lea dBase dPaint

Stabilization , Mrs . Debora hAkerele-Jnlinignn ^ a t (402 ) 504-1004 . Genera

l question s about

th e Omah aLea

dSit e cleanu p ca n b e directe dt o th e EP

A Publi c Infonnatio n Center s a t (402 ) 731-304 5 (Soutii Omahaoffice) or (402 ) 991-958 3 (Nort

hOmaha office) . Property Acces s Grante dBy : Propeit y Owne r

Signature :

RESIDEN T NAME : pleas e Prin t Name ) (Date ) PROPERT Y INFORMATIO N (T o b e complete db y residen t and/o r propert y owne r

- pleas e print ) Owne rRente r RESIDEN T ADDRESS : I F RENTAL . PROPERT

Y OWNE D BY : OWNER' S MAIUN G ADDRESS ; OWNER' S TELEPHON E NUMBER-HOME : J L .WORK : J L NUMBE R O F OCCUPANT S UNDE R 7 YEAR S OLD : NUMBE R O F OCCUPANT S 7 YEAR S OL D AN D OLDER : NUMBE R O F CHILDRE N UNDE R 7 YEAR S OLO WH O PLA Y I N TH E YAR D FO R 5 HOURS O R MOR E PE R WEEK : COMMENT

S O R SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR Y GATES , ETC. )

AUTHORIT Y FO RENVIRONMENTA LRESPONS EACTIONS ; Th e activitie s t o b e in^lementiedb y EP A unde r thi s agreemen t

ar e puisuan t

t o Secdo n104 o f CERCLA , 4 2 U.S.C . 9604 . EPA' s right o f acces s t o th e property i s provide dfor inSectio n104(e ) o f

CERCLA . 4 2 U.S . C 9605(e) . whid i provide s entry fo r "determinin g th e nee dfor

response, o r

choosin g ortakin g any response actio nunde r thi s title , o r

otherwis e enforcin g th e provision s ofth e title. "

08 0 War d Parkway , Suit e 40 5 ansa s City . M O 6411 4 hone : (816) 363-3703 ax : (816 ) 363-3707 250 6 N . 24 * Street . Suit e 30 8 Omaha , Nebrask

a 6811 0 Phone : (402)504-100 4 Fax : (402)504-100 5 4242 Medica l Drive , Suit e 425 0 Sa nAntonio , T X 7822 9 Phone : (210)822-958 8 Fax : (210 ) 579-6577

# Curren t Sampl e Pre^enovatlp n For m

Effectiv e unti l Apri l 2010 . Confirmatio n o f Receip t o f Lea d Pamphle t p rI hav e received a cop yo f th e pamphlet , Ftermvat e Right : Importan t Lea d Hazar d Informatio n fo rFamilies , Chil d Car e Provider s an d School s infomnin g m e o f th e potentia l risl< o f th e lea d hazar d exposur e fro m renovatio n activit yt o b e perfomie d i n m ydwellin g unit . I receive d thi s pamphle t befor e th e wort< began . P^rtee^^am e o f reofojan t ./ y, Dat e Signatur e o f recipien t I / / Self-Certificatio n Optio n (fo rtenant-occupie d dwelling s onl ^ — I f th e lea d pamphle t wa 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 effort t o delive rth e pamphlet , Ftenavat B Fiight : Importan t Lea d Hazar d informatio n fo rFamilies , Chil d Car e f^vlder s an d Schools , t o 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 th e 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 f th e pamphle t a t th e uni t wit h th e occupant . Q Unavailabl e fo rsignatur e —I certii ytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet , Renovat e Righ t importan t Lea d Ha^u d infomiatio n for Families , Chil d Car e provider s an d Sdioois , t o th e rental 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 confimnatio n o f receipt . I furth ^ certif ytha t I hav e left a cop yo f th e pamphle t a t th e uni t b yslidin g I t Printe d nam e o f perBo n certifyin g 

# m^/?o/ e Attempte d deliver y dat e an d tim e lea d pamphle t deliver

y Signatur e o f penso n certifyin g lea d pamphle t deliver y 

# 3//7 f^nff/rtnJl ^ Uni t Addres s Not e Regardin g Mailin g Optio n —A s a n altemativ e t o deliver yi n person , yo u ma ymai 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 mailin g fiom th e pos t ofiice) .

# pain t matc hfor m Pain t matchin g form : . propertyaddress : ^/ 1 f^^j ^ ^ ^ ^ ^ BVID : 73^ 5 Area : ^a/ht f jH&f&y-^'X/zf/WoTor- . % , i l Explanation : Area : color : 

# Explanation : ^ , i . r i , ^ Area : Colo r Explanation : Area : Colo r Explanation : I agre e t o thes e color s a s listed , onc e paintin g start s I ca n no t chang e thes e selecte d colors . Homeowne r signatur e 

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### http://douglasne.mapping-online.com/DouglasCoNe/static/accountinf o .jsp?accountno=R22.. . 8/19/200 8^^vrvUXb T J L XVW\JlUX t XI U 

## Pag e 1 ot 2 Dougla s County , Nebrask a Propert yRecor d - R221873000 0 Infonnatio n i s vali d a s o f 2008-7-1 4 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-S O ft wes t o f 90t h S t - Vle W O H Ma p Treasurer' s Ta xRepor t Ne wFeatur e -*->- > Aut o Sale s Searc h Owne r KARGL E ROBER T L ETA L 261 7 POPPLETO N AV E OIMAHAN E 68105-000 0 Propert yInformatio n Ke yNumbe r\

187 3 000 0 2 2 Accoun t Type : I Residentia l Parce l Numbe ri 221873000 0 Parce l Address : i 261 7 POPPLETO N A V

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### N

o Improvemen t Informatio n Buildin g 1



## http://douglasne.mapping-online.com/DougIasCoNe/static/accoimtinfo.jsp?accountno=R22.. . 8/19/200 8

# ^EP k Jun e 26,200 8 (latM t miitoo ) 

# EP APropert y CloseOu t

For m(Lead-Base dPain t

Stabilization ) VMkn dVcMchPiqpartj mNmbm .



# jl^) ! Po/>jy.^ . 116 6 OlHMI^IinMt , 

# Perfermanc e Standards/gose-On t Criteri aj2 » 1 . ViifI»catbestrootan(8)paiiMwtttOM«(cep( ^ TUiwoo U iiKtadepdntfai g o f

othe r iMsoctaiedfbato miDchidin

g fbcia , earns , 8 ^ bMM.o6liinBii>ndls.and<actwiorwiftoc8ofeBMM . 1 Wai«nsonpin8iiidofhflrpiti»ntioniffQikoQ09l ^ 3 . W< w lf l wquiwdaioMoflhBflnict«o(»)primBd M neededan dpd ^ 4* Walliepafttp(odaet8iitiUxedeqaivalenttoi30yearproduct/quality ? 9 . itavdloftb e ana s wher e cooninlnBtedmataiat o have bee ns^ ^ dDidihBecntiactorcoliect/vacaimanBflMngandKrBpedpaIrt wrtwpi.dleyww8.iiia>Hpaece3sawa8aai«l»oitinovoawotfa w 7 . b1l»9«ssarealh8t8amniid8lhe8inictiira(i)innasoiiablygDodeoD^ ^ i ite«nil8miiidi88poIye%1«nedieetiii8,ladden,paintbrQahM.^ ^ WBMved ? OilS^iqfevideQc^ ^ novedback ? _____ 11 . An(hao«r90nown)Ihigeriog{ssaeswi(b1heimpettyomer(s)1luaba w O&e r OonsidefatioDfl/Piopert y Owne r Discussioos/Additiona l Wor k tha t i s Requhre d

o ^ ^k t 4*f0tk» J i^t^fitj p»ttm ^

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## Prudent

Property Close-Ou t

For m(Lead-Base dPain t

Stabilization ) 

# o,^^^^ . p^ n hpoietiff

^ m e owner' s itom « /}^/£V^ Y /^^^^/ ^ 

## Performanc e Standards/close-Ou t Criteri a YE S N O 1 . Wa s th e entir e $tructure(s ) painte dwit hth e exceptio no f th e stated , exclude dareas ? Thi s woul d indud e paintin g o f

othe r associate dfeature s includin g fescia, eaves , siding , al l trim , porches , bo x beams , columns , rails , an dexterio r surface s o f

garages . / 

### 2 . Wa s all scrapin g an dothe r preparattio nwor k

complete dsatisfactorily ? 3 . Wer e all require darea s o f th e structure(s ) prime da s neede dan dpainte dwit htw o to p coats ? 

# 7



# t 4 . Wa s th e pain t

product s utilize dequivalen t t o a3 0 yea r

product/quality ? 5 . Are all ofth e area s wher e contaminate dmaterial s hav e bee nspitte d thoroughl y vacuumed /

cleaned ? 6 . Di dth e contracto r

collect/vacuu mal l fallin g an dscrape dpain t chip s o nth e entir e property , roadvimys, alleyways , publi c acces s area s an dals o remov e an y othe r generate ddebris ? 7 . I s th e gras s are atha t

surround s th e structure{s ) I nreasonabl y goo dcondition ? 8 . Ar e al l Item s suc ha s polyethyien e sheeting , ladders , pain t brushes , cones , barrie r

tap e etc . property removed ? _ ^ ^ ) 

# J 

# J 9 . I s ther e an y evidenc e o f propert y damag e tha t

wa s don e b y th e contractor ? An y propert y damag e need s t o b e complete dprio r t o th e EP A aose-Out . 10 . Are ther e an y propert y item s tha t wer e temporatii y re-locate db y th e contracto r tha t nee dt o b e move dback ? 11 . Ar e ther e an y (known ) lingerin g issue s wit hth e propert y owner(s ] tha t hav e bee nlef

t unresolved ? Othe r Conslderatlons?propert y Owne r Dlscusslons?Addltlona l Wor k tha t I s Require d



## Pruden t R < Date ^^^ 2 ' ^ P

resentathr e ^ ( y y ^ ' 

# ^ n \r7y^J ^ ^ 

# i J