## TRANSMITTA Lo f

OMAHA LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAID : 3295 0 Date : 12/26/200 8 Address : 381 7 FLORENC EBLV D Stabilizatio n Contractor : Pruden t Technologie s Year : 200 8 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S g

f Vide o o f propert y (DVD ) g

f Executiv e Summar y I ZSigne dAcces s Agreemen t fo r subjec t propert y S Paintin g Agreemen t D Settlemen t document s (i.e. , fo r damag e o r t o replac e plants , etc. ) D Photograph s s l Satisfactor y restoratio n signe db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A WPropert y informatio n fro mDougla s Count y Assessor' s Offic e D D D

Signatur e i ^ Dat e

4031046 8 

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### PROPERT Y SUMMAR Y Date : 12/29/0 8 LB PSTABILIZATIO N EP A CONTRAT EP-R7-08-0 7 Monthof : Decembe r Propert y Address : 381 7 FLORENC EBLVD SAD) : 3295 0 A . EXECUTIV ESUMMAR Y A. 1 Issue s Encountered : NONE . A. 2 Issue s Resolved : NONE . A. 3 Uniqu e Findings : NONE . A. 4 Othe r Relevan t Information : Acces s Date : 10/21/0 8 Work Began : 10/28/0 8 Closeout Date : 10/29/0 8 Enclosures : 1 . Pre-Vide o 2 . Post-Vide o 3 . Propert y Statu s Form 4 . Signe dAcces s Agreement 5 . Pre-Renovatio n Form 6 . Pain t Matc hForm 7 . Tracldn g Form 8 . Dougla s Count y Assessor Propert y Informatio n Pag e 9 . EPA Propert y Closeout for m 10 . Propert y Completio n Agreement

TECHNOLOCIES , INC .ENVIRONIMENTAL A CONSTRUCnO M 

## TECHNOLOGIES , INC . SERVIC D 

# Propert y Statu s For m Address:'Sg^ n Flor-^n aKt > ^^' ' /d^U'-^ ^ BVID : 3pQ5 ^ 

# P*»«« ' (^/H-057 7 Plan t & Pemianen t Landscapin g T o Remai nI nPlac e Itciii # 

## Descriptio nan dLocatio n O nMap 

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Pre-Existin g Conditio no f Stroctuie s Doe s you r Basemen t hav e ahistor y o f leaking ? Ye s —N o Itan # Descriptio n& Locatio n O nMap

Propeit y O^woe r Pruden t Emp j Signature : Xr ^ \fhud U Signatur e

# 33^5 0 Pruden t Tedmologies , Inc . (Pnident ) is unde r contrac t (Contrac t #EP-R7-08-07 ) wit hth e U. S. Envitoiunental Protectio n Agenc y (EPA ) to stabiliz e Lea dBase dPain t (LBP ) at anumbe rof propertie s locate din Omaha , Nebraska , includin g th e property locate dat '^A 1 f\(j<-cr\c e "iMur / Th e EP A request s you r pennissio n to allo w Pruden t to performLB PStabilizatio n at thi s property . By signin g thi s form , tiie propert y owne r grant s permissio n to Pruden t to perfon n activitie s relate d to LB F Stabilizatio n includm g scrapin g pain t an dpaintiii ^ ofth e reference dproperty . Furtiier , th e owner/tensn t verifie s that the y hav e receive dtiie LB Ppamphle t "Renovat e Right. " Ifyo u hav e any question s abou t th e LB Pstabiiizatio n plamie dfo r you r property , pleas e contac t Prudent' s Adrt^inistfative Clerk fo r tiie Lea dBase dPain t Stabilization , Mrs . Debora hAkerelg-Jftlminn , at

(402 ) S04-1004 . Genera l question s abou t th e Omah aLcadSit e cleanu p ca n be directe d to th e EP A Publi c Infonnatio n Center s at (402 ) 731-304 5 (SouthOmah aofEice) or (402 ) 991-958 3 (Nort hOmah a office) . 

# Ro5< l 7. .A/ea L Propol yAecenOnnie d By : (Pleas e Prin t Name ) flJtte^ V (StSMture (Signature ) ) ^ate )

PROPERT YINFORMATIO N (T o be coaplete d byreiiden t aid/o rpropert yome r- picia e prln O 

### RESIDENTNAME : Ko^t AJeq,/ . ^_

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(SiJw ) nesmeiiTAPOREasi^Srt ? ploT^nc^ . Bil/(/ . IF REKTAL , PROPERT YOWNE D BY : Se^j-f OWNERT S HAIUN O ADDRESS ; 14/ ^

S£ L OWNERT S TELEPHON E NUMBE R •HOME i 

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08 0 WsnlPaiWny , Suit s 40 8 280 9 N. 24 * Straet , Suit o 30 8 424 2 Medlea l Driv* , Suit * 428 0 Isnt M City , MO 6411 4 Omaha , MebrwH * 8811 0 »»nant^ u r^'^"* ^ ihAMv/M M «a « ••'It *

# Curren t Sampl e Pre-Renovatio n For m Bteotlv s unt n Apr U aoiO . Conibrmtlo n of Rsoslp t of Loa d Pamphle t b(\\m9teoaiiietiBoopfalVnepBn<flt1ieit,FianavateRigM : Importan t Laa d Hea ^ Irfiarrnalkx t tor FamSaa , ChB d Car e Pixjvkler s an d School a intemiin g rn e 01 tt wpotentia l ris kofth e lea d hasar d CKpoeur e fronf ) renovatio n activit y to be performe d In mydwellin g uilt . I lecehw d tN s pami^ M befor e ti> e vvori < began . Printe d name d recipient Dat e 

# fkai. ^ • ignatur recipient Signatur e o r SelNCartHlcatioj n Optio n (lo rtenantoccuple d dweWng s only) — Ifth e iM d pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u ma ycheci < th e appropriat e bo xbeiow . Q Refusa l to sign— i certif ytha t I hav e mad e a goo d taithellbr t to delive rih e pamphlet , flenovate nigfit : tuportan t Lea d Itezar d Intonnatio n tor^mSea , Oiic fCar e AovibiBr s ant fScftoofs , to th e renta l dwellin g uni t 1 dat a an d tim e indicate d an d tha t th e oocupan t rstuse d to sig n th e confirmatio n ofreoelpL I furthe rcertif ytha t I hav e lef t a cop y ofth e pemphie t at th e uni t wit h tnaocoupeni , Q Unavallabi o fo rsignature' I certif ytha t I hav e mad e a goo d fait h efbt t to delh« rth e pamphlet , Asrioraf e n^ & Jhipcrtan t Z.eatf/ib ^ /^vnl99 ^ CMc l CSsr e pravMor s ffKfSc^x ^ beio wan d tlia t th e occupan t vva s unavallabi e to eig n th e corrfirmatio n ofreceipt . I furthe rcertifytiia t i iiav e lef t a cop y of th e pamphle t at tli e uni t byslidin g It AOemfAeddeXNer ^ dateandtim e lee d pamphle t delivery Signaiur e orpersoi^Certlfyin g lea d pamphie t deliver y

Uht t Addres s --•—------——--—---------—----— - Itot e Rogaidki g Mailin g Optio n •--A s an alleiTiatlv e to deRvei y in person , yo u ma yms D th e lea d pemphie t to th e owne rand^o rtenant . Pamphle t mus t be maile d at leas t 7 day s befor e renovation (Documen t wit h a certlticat e ofmailin g fro m th e poetoffloe) . ^

# pain t matcl i Jcaro .\ , , Paint matcliin g form : ~ - / K s-kl^ q Area : 5^^^:^ ^ 5-//^ ^ Color : 0(i^e. { 5l o ^// V Explanation : I^^I^^Mk ^ m^^P ' Area : ;^//// ^ T^'^" ^ ^ ^ /^^^^Col f fs^l /

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### Douglas Coimt y AccounlJ|tformatio n Page 1 of 2 Dougla s County , Nebrask a Propert yRecor d - R151253000 0 Prin t Repor t NE W Featur e - Parce l Dimension s availabl e @ scal e 0-5 0 f t wes t o f SOt h S t - Vle W O n Ma p Informatio n i s vali d a s o f 2008-9- 4 Treasurer' s Ta xRepor t Ne wFeatur e -•-*- > Aut o Sale s Searc h Owne r IMEA L ROS E 381 7 FLORENC E BLV D OMAH AN E 68110-000 0 Propert yInformatio n Ke yNumber : 125 3 000 0 1 5 Accoun t Type : . Residentia l Parce l Number : 151253000 0 Parce l Address . 381 7 FLORENC E B D OMAH AN E 68110-000 0 Lega l Description : KIRKWOO D AD D LO T4 BLOC K4 W 1/ 2 5 0 X 7 0 Valu e Informatio n I Lan d Improvemen t Tota l 200 8 j $1,900.0 0 $36,400.0 0 $38,300.0 0 200 7 ; $1,900.0 0 $36,400.0 0 $38,300.0 0 200 6 $1,900.0 0 $36,400.0 0 $38,300.0 0 200 5 $1,900.0 0 "' " $5700.00 ^ $7,660,0 0 200 4 i $1,900.0 0 $5,200.0 0 $7,100.0 0 200 3 $1,900.0 0 $5,200.0 0 $7,100.0 0 Lan d Informatio n Acre s '• • S F Unit e ! Dept h Widt h Vacan t 0.0 8 3500. 0 1. 0 1 ­ 70. 0 50. 0 N o Improvement Informatio n Buildin g 1

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### Dougla s Count y AccountjBformatio n Pag e 2 o f 2

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CLIC KT O ENLARG E (MAG E Squar e Footage : ' 1351. 0 Perimete r .• 0. 0 Uni t Type : •

BuiitAs : ; 1 1/ 2 Stor yFi n HVAC : I Force d Ai r Exterior : j Fram e Stucc o Interior : ' Drywal l Roo f Cover : Compositio n Shingl e

Roo f Type : i Gabl e Floorcover : : Allowanc e YearBuil t Yea r Remodele d Percen t Remodele d 190 5 0 % Detai l Typ e Detai l Descriptio n Applianc e Allowanc e Basemen t Bsmn t Bloc k 8 f t Fixtur e Bas e Fixture s Fixtur e Bat h Ful l Porc h Sla b Roo f Cei l Use r Atti cFul l Finis h ... . CyC KT O ENUj,RG g IMAGE _ Percen t Complete : 100.0 % Quality : Fai r Condition : ; Fai r Cond o Squar e Footage : '. 0. 0 Rooms : : 7. 0

Units : ; 1 0 Baths : 1. 0 Bedrooms : : 3. 0 Stories : 1. 5 Foundation : Bloc k Sprinkle rSquar e Footage : 0. 0 Adjuste d Yea r Physica l Ag e Buil t 190 5 10 4 Unit a 1 0 881. 0 __1. 0 

## i. o 160, 0 470, 0

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# AEF A lime26,200 8 (Istes t nivisffn ) 

# EP APropert y CloseOu t For m(Lead-Base dPain t Stabilizafion)

Performanc e Standard s /Close-Ont Criteri a ye s B D 1 .WsilliBeaiirBsliactiira(s)i«iiitodwiaiaeeroe|^ofthestatsdfcxchidid81 ^ TUswooI d iBctodeiniolIn g o f odM r associate dftatnres iochidbi s flneia, eave ^ 

# R buBMtfftK'T'w'SbiallsyaBdeixtBilflfsuiibocsflfgBnigw . 2 .WS Ia nscnptagiii dolbe r fnpanMioovraAooiDpbledsadsfiuiovOy ? 3 . Wemdlnqaindaie8Sofdisitnictue(s)iiriinBda8iioededandpaiiited ^ 

# K 4 . Wafli8i»liitiiiodiiGOiitflixedeqiifvaIenttoB30yearpto<}^ ^ 5 .Ar o a no f tte area s iwtier e oonwiinlnatBil laaterial s ha w beenspille dthorocgjil y vacttmned/cle«ned ? 

# K d .DidteeoatiBGtDroonectAneonmaUfUUa g an dscrape dpait t chip s O D tb e cotiRp^ ^ wadwuys , alhywayS i pobH c acces s aroa s aa dals o rcaov e sg y oflia r poueraic dddais ? 

# A 7 .b Iho glas s are atet snnoQnd s Q w 8lnicuut(8 ) i nroasonably goo dcondition ? > • 

### 8 .iteiniteni s sodi8 8 p(4yedQ'laiesbe0tin8;Iadden,paimlinB])es,coae8^ban ^ 

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### 9 .bAerevvcvidoaoeQfpiopoftydainflgiBtetwasdoiiobyAeciontnctor ? An y propat y damag e 

# A 10 . Aiete w an y laopottyiftem s tha t wer e teiuporarlly relocate dl y to contractor tt o novedbacK ? > < 

### 11 . AndMnanyCkaawn ) Bngeringlssimvrididiepropert y owners ) du ahav e bee nleftunre w 

# X Oflie r CoosidentioDa/Propat y Owne r Discussions/AdditiQna l Wor k tha t i s Requh« d

EP AGQR/Repceseatadv e 

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# AER A Jun e 26,200 8 (lates t revlstoD ) 

# EP APropert y Close-Ou t For m(Lead-Base dPain t Stabilization) Btac k an dVeatd i Frapert y I D Nooilwr: , 

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# Performanee Standard s /Oose-On t Criteri a IS L n o tadndo paintfn g o f otor assodate dtatDKS iaehidiD g fiacia, eawe8 > sidb ^ a ntrim , poidie ^ boaB8iy001innBSjndh,andflxlietiorsmftoesofBBa8e8 . y 2 > Was d l icnipin g an dciBiflf|iie|)iuatlonvwAcoiwptetedsatisflM<ority ? y 3 « Wttediniidio dana s ofd]9sinictnie(ji)priDa dI S neededan dpainte dvid i tw o to p ooats ? y 

### 4 Wttdiepaintpcodne(siitllizedeqidvalemtoa30year|m)dact/qQality ^ y 5 . Ai e diofdieaiea s wher e ootttaniinaiednurtBrialstuiv o bees spiDeddumiQ ^ vacuum i/ ^ 

### i , KddiBCCBtnwtoconect^vaciiama nMin g sn dscrtyedpsirtch^w i tii e entir e andals o renwv e any oflwrgBnenBeddebria ? y 

### 7 . bifcegBMS are adia l SMiuuiid s di e atroctaw(s ) i nteasonaibl y goo dcondition ? f/ ^ 

### 1 AieaBitemisoG ha s polyeiliykoosbeeting.!adden,paimtoiAes » cooes , baiTiert ^ WBOWtt ? • 

# y 9 .

blkieaiyenddeaoeofinnpettydanu^diaiwa s don e liy dMcwotraetot ? An y property toiage

floedilDbeooBipletedtrie r t o di e BP ACloae-Om . 

# y 10 . Aiedw e an y proiwityiteB B tt o wele^e^^lo^aril y relocate db y th e contmcto r tha t nee dt o b e 

# y novedback ? 11 . Aieda e an y (iaiown)nngeringbsaesivid i tte {nnpertyo«nar(s ) dia t bav e bee n1 ^ 

# y Ofiie r ConrideiatioDs/PiDpert y Owne r Discosaons/Additiona l Wor k iSui t i s Require d

BP ACCTH/Rqaoeiitalive . fifi ^ >a. ^ 

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