TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID: 32950 Date: 12/26/2008 

Address: 3817 FLORENCE BLVD 

Stabilization Contractor: Prudent Technologies Year: 2008 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

gf Video of property (DVD) 

gf Executive Summary 

IZ Signed Access Agreement for subject property 

S Painting Agreement 

D Settlement documents (i.e., for damage or to replace plants, etc.) 

D Photographs 

s l Satisfactory restoration signed by Property Owner 

D Property close-out check list signed by EPA 

W Property information from Douglas County Assessor's Office 

D 

D 

D 

Signature i^ Date 

40310468 

inimi 

Superi'und 
PROPERTY SUMMARY 

Date: 12/29/08 LBP STABILIZATION EPA CONTRAT EP-R7-08-07 Month of: December 

Property Address: 3817 FLORENCE BLVD SAD): 32950 

A. EXECUTIVE SUMMARY 

A.1 Issues Encountered: NONE. 

A.2 Issues Resolved: NONE. 

A.3 Unique Findings: NONE. 

A.4 Other Relevant Information: 

Access Date: 10/21/08 

Work Began: 10/28/08 

Closeout Date: 10/29/08 

Enclosures: 

1. Pre-Video 

2. Post-Video 

3. Property Status Form 

4. Signed Access Agreement 

5. Pre-Renovation Form 

6. Paint Match Form 

7. Tracldng Form 

8. Douglas County Assessor Property Information Page 

9. EPA Property Closeout form 

10. Property Completion Agreement 

TECHNOLOCIES, INC. 
ENVIRONIMENTALA 

CONSTRUCnOM 

TECHNOLOGIES, INC. SERVICD 

Property Status Form 

Address:'Sg^n Flor-^na Kt > ^^' ' /d^U'-^^ 

BVID: 3pQ5 ^ P*»««' (^/H-0577 

Plant & Pemianent Landscaping To Remain In Place 

Itciii# 

Description and Location 

On Map 

^ou^ ^ hifi ioeJ^^em ( 9^^^ ip/pli^^ic. 

Pre-Existing Condition of Stroctuies 

Does your Basement have a history of leaking? Yes — No 

Itan# Description & Location 

On Map 

Propeity O^woer Prudent Empj 

Signature: Xr ^ \ fhud U Signature 
33^50 

Prudent Tedmologies, Inc. (Pnident) is under contract (Contract # EP-R7-08-07) with the U. S. 

Envitoiunental Protection Agency (EPA) to stabilize Lead Based Paint (LBP) at a number of properties 

located in Omaha, Nebraska, including the property located at '^A 1 f\(j<-cr\c e "iMur/ 

The EPA requests your pennission to allow Prudent to perform LBP Stabilization at this property. By 

signing this form, tiie property owner grants permission to Prudent to perfonn activities related to LBF 

Stabilization includmg scraping paint and paintiii^ ofthe referenced property. Furtiier, the owner/tensnt 

verifies that they have received tiie LBP pamphlet "Renovate Right." 

Ifyou have any questions about the LBP stabiiization plamied for your property, please contact Prudent's 

Adrt^inistfative Clerk for tiie Lead Based Paint Stabilization, Mrs. Deborah Akerelg-Jftlminn, 

at (402) S04-1004. General questions about the Omaha Lcad Site cleanup can be directed to the EPA 

Public Infonnation Centers at (402) 731-3045 (South Omaha ofEice) or (402) 991-9583 (North Omaha 

office). 

Propoly AecenOnnied By: Ro5<l 7. .A/eaL

(Please Print Name) 

V (StSMture flJtte^ (Signature)) ^ate ) 

PROPERTY INFORMATION 

(To be coapleted by reiident aid/or property omer - piciae prlnO 

RESIDENTNAME: Ko^ t AJeq,/ . ^__ (SiJw) 

nesmeiiTAPOREasi^Srt? ploT^nc^ . Bil/(/ . 

IF REKTAL, PROPERTY OWNED BY: Se^j-fOWNERTS HAIUNOADDRESS; 14/ ^ S£L 

OWNERTS TELEPHONE NUMBER • HOMEi

! jil^eiL^iiz^H^RK: J L 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLO: Q NUMBER OP OCCUPANTS 7 YEARS OU) ANO OLDER: ^ 

NUHBER OPOHILOREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 8 HOURS OR MORE PER WEEK: .0 _ 

COHHENTS ORSPECIAL INSTRUCTIONS: (I.& DOOS. ENTRY QATES, ETC.) 

M6/\/g 

AUTHORrrY FOR ENVQtONMBNTAI'RBSPONSB ACTIONS; TheacttvMwtDbehnplcineatcdhyBPAondertMaagweineirtatepurwanttoSectloalM 

ofCERCLA.42U.S.C9604. EPA'8rightofaooeuto1lwpnpettyupcovi(ledfoTinSectionl04(e>ofCmC3^42U.S.C960S(eX«Aidiprovide» 

lb( •'(tetennlninfdie need Ibr napoue. or cboosing ortaldgg aiy letponae Bcten under thn 

080 WsnlPaiWny, Suits 408 2809 N. 24* Straet, Suito 308 4242 Medleal Driv*, Suit* 4280 

Isnt M City, MO 64114 Omaha, MebrwH* 88110 »»nant^u r^'^"*^ 

ihAMv/M M «a« ••'It* 
Current Sample Pre-Renovation Form 

Bteotlvs untn AprU aoiO. 

Conibrmtlon of Rsoslpt of Load Pamphlet 

b(\\m9teoaiiietiBoopfalVnepBn<flt1ieit,FianavateRigM: Important Laad Hea ^ 

IrfiarrnalkxttorFamSaa, ChBd Care Pixjvklers and Schoola intemiing rne 01 

ttw potential risk of the lead hasard CKpoeure fronf) renovation activity to be 

performed In my dwelling uilt. I lecehwd tNs pami^ M before ti>e vvori< began. 

Printed named recipient Date 

fkai.^ 

Signatur •ignature orrecipient

SelNCartHlcatiojn Option (lor tenantoccupled dweWngs only)— 

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

you may checi< the appropriate box beiow. 

Q Refusal to sign—i certify that I have made a good taithellbrt to deliver ihe 

pamphlet, flenovate nigfit: tuportant Lead Itezard Intonnation tor ^mSea, 

Oiicf Care AovibiBrs antf Scftoofs, to the rental dwelling uni 1 t

data and time indicated and that the oocupant rstused to sign the confirmation 

of reoelpL I further certify that I have left a copy of the pemphiet at the unit with 

tnaocoupeni, 

Q Unavallabio for signature' I certify that I have made a good faith efbtt to 

delh«r the pamphlet, Asriorafe n^ & Jhipcrtant Z.eatf/ib ^ 

/^vnl99^ CMcl CSsre pravMors ffKf Sc^x ^ 

beiow and tliat the occupant vvas unavallabie to eign the corrfirmation of receipt. 

I further certify tiiat i iiave left a copy of the pamphlet at tlie unit by sliding It 

AOemfAeddeXNer^ 

dateandtime 

leed pamphlet delivery 

Signaiure or persoi^Certlfying lead pamphiet delivery 

Uhtt Address --•—------——--—---------—----— -

Itote Rogaidkig Mailing Option •--As an alleiTiatlve to deRveiy in person, you 

may msD the lead pemphiet to the owner and^or tenant. Pamphlet must be mailed 

at least 7 days before renovation (Document with a certlticate of mailing from the 

poetoffloe). 

^ 
paint matcli Jcaro .\, , 

Paint matcliing form: ~- /K s-kl^q 

Area: 5^^^:^^ 5-//^^ Color: 0(i^e.{ 5lo ^//V 

Explanation: I^^I^^Mk^ m^^P' 

Area: ;^////^ T^'^"^ ^^ /^^^^Colf fs^l / ^^/^ ^^^^^^ 

Area: Color: 

Explanation: 

Area: color: 

Explanation: 

Area: color: 

Explanation: 

UOwdl^X Page 1 
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Access iffFO/^MATioNTRAOKOHSSI^ET 

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L 
Douglas Coimty AccounlJ|tformation Page 1 of2 

Douglas County, Nebraska Property Record - R1512530000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of SOth St - Vle W O n Ma p Information is valid as of 2008-9-4 Treasurer's Tax Report 

New Feature -•-*- > Auto Sales Search 

Owner 

IMEAL ROSE 

3817 FLORENCE BLVD 

OMAHA NE 68110-0000 

Property Informatio n 

Key Number: 1253 0000 15 

Account Type: . Residential 

Parcel Number: 1512530000 

Parcel Address. 3817 FLORENCE BD 

OMAHA NE 68110-0000 

Legal Description: KIRKWOOD ADD LOT 4 BLOCK 4 W 1/2 50 X 70 

Value Informatio n 

I Land Improvement Total 

2008 j $1,900.00 $36,400.00 $38,300.00 

2007 ; $1,900.00 $36,400.00 $38,300.00 

2006 $1,900.00 $36,400.00 $38,300.00 

2005 $1,900.00 "'" $5700.00^ $7,660,00 

2004 i $1,900.00 $5,200.00 $7,100.00 

2003 $1,900.00 $5,200.00 $7,100.00 

Land Informatio n 

Acre s '•• S F Unite ! Depth Width Vacant 

0.08 3500.0 1.0 

1­

70.0 50.0 No 

Improvemen t Informatio n 

Building 1 

.IIA, ./r\ . .,/-'„XT„/-.+., 1 A/ I i'^r-f\o 
Douglas County AccountjBformation Page 2 of 2 

•l-.t fU/.-

i-J :(•:+(•<• MM 

CLICK TO ENLARGE (MAGE 

Square Footage: ' 1351.0 

Perimeter .• 0.0 

Unit Type: • 

BuiitAs : ; 1 1/2 Story Fin 

HVAC: I Forced Air 

Exterior: j Frame Stucco 

Interior: ' Drywall 

Roof Cover: Composition Shingle 

Roof Type: i Gable 

Floorcover: : Allowance 

YearBuilt Year 

Remodeled 

Percent 

Remodeled 

1905 0% 

Detail Type Detail Description 

Appliance Allowance 

Basement Bsmnt Block 8 ft 

Fixture Base Fixtures 

Fixture Bath Full 

Porch Slab Roof Ceil 

User Attic Full Finish 

.... CyCK TO ENUj,RGg IMAGE_ 

Percent Complete: 100.0% 

Quality: Fair 

Condition: ; Fair 

Condo Square Footage: '. 0.0 

Rooms: : 7.0 

Units: ; 10 

Baths: 1.0 

Bedrooms: : 3.0 

Stories: 1.5 

Foundation: Block 

Sprinkler Square Footage: 0.0 

Adjusted Year Physical Age Built 

1905 104 

Unita 

10 

881.0 

__1.0 

i.o 

160,0 

470,0 

.rr\. ,1—r<„-M-/„+ .^*:.,f.> ;r,.«0o ..i^^—D 1 c in/i nnfkfi 
AEFA 

lime26,2008 (Istest nivisffn) 

EPA Property CloseOut Form (Lead-Based Paint Stabilizafion) 

Performance Standards /Close-Ont Criteria 

yes BD 

1. WsilliBeaiirBsliactiira(s)i«iiitodwiaiaeeroe|^ofthestatsdfcxchidid81^ TUswooId 

iBctodeiniolIn

buBMtfftK'T'w'SbiallsyaBdeixtBilflfsuiibocsflfgBnigw

g of odMr associated ftatnres iochidbi

. 

sflneia, eave^ R

2. WSI an scnptagiiid olber fnpanMioovraAooiDpbledsadsfiuiovOy? 

3. Wemdlnqaindaie8Sofdisitnictue(s)iiriinBda8iioededandpaiiited^ K 

4. Wafli8i»liitiiiodiiGOiitflixedeqiifvaIenttoB30yearpto<}^^ 

5. Aro an of tte areas iwtiere oonwiinlnatBil laaterials haw been spilled thorocgjily vacttmned/cle«ned? K 

d. DidteeoatiBGtDroonectAneonmaUfUUag and scraped paitt chips OD tbe cotiRp^ ^ 

wadwuys, alhywaySi pobHc access aroas aad also rcaove sgy ofliar poueraicd ddais? A 

7. b Iho glass area tet snnoQnds Qw 8lnicuut(8) in roasonably good condition? 

> • 

8. itei n itenis sodi88 p(4yedQ'laiesbe0tin8;Iadden,paimlinB])es,coae8^ban^ 

HBOWd ? I X

9. bAerevvcvidoaoeQfpiopoftydainflgiBtetwasdoiiobyAeciontnctor? Any propaty damage A 

10. Aietew any laopottyiftems that were teiuporarlly relocated l y to contractor tt o 

novedbacK? > < 

11. AndMnanyCkaawn) Bngeringlssimvrididieproperty owners) dua have been leftunrew X 

Oflier CoosidentioDa/Propaty Owne r Discussions/AdditiQnal Work that is Requh«d 

EPA GQR/Repceseatadve 

//-a-or ^^y^rdu /).,,,A^ 
G(y^4 ^ ^ AERA 

Jun e 26,200 8 (latest revlstoD) 

EPA Property Close-Out Form (Lead-Based Paint Stabilization) 

Btack and Veatdi Fraperty ID Nooilwr:, 

,-3S n F^/i>r.^c. &\y 

Performanee Standards /Oose-Ont Criteria ISL no 

tadndo paintfng of oto r assodated tatDKS iaehidiDgfiacia, eawe8> sidb^ an trim, poidie^ 

boaB8iy001innBSjndh,andflxlietiorsmftoesofBBa8e8. y 

2> Was dl icniping and ciBiflf|iie|)iuatlonvwAcoiwptetedsatisflM<ority? y 

3« Wttediniidiod anas ofd]9sinictnie(ji)priDad IS needed and painted vidi two top ooats? y 

4 Wttdiepaintpcodne(siitllizedeqidvalemtoa30year|m)dact/qQality^ y 

5. Aie diofdieaieas where ootttaniinaiednurtBrialstuivo bees spiDeddumiQ^ vacuu m i/^ 

i, KddiBCCBtnwtoconect^vaciiam an Ming snd scrtyedpsirtch^wi tiie entire 

and also renwve any oflwrgBnenBeddebria? y 

7. bifcegBMS area dial SMiuuiids die atroctaw(s) in teasonaibly good condition? f/ ^ 

1 AieaBitemisoGh as polyeiliykoosbeeting.!adden,paimtoiAes» cooes, baiTiert ^ 

WBOWtt? • y 

9. blkieaiyenddeaoeofinnpettydanu^diaiwas done liy dMcwotraetot? Any property toiage 

floedilDbeooBipleted trier to die BPA Cloae-Om. y 

10. Aiedwe any proiwityiteBB tt o wele^e^^lo^arily relocated by the contmctor that need to be y novedback? 

11. Aiedae any (iaiown)nngeringbsaesividitte {nnpertyo«nar(s) diat bave been 1 ^ y 

Ofiier ConrideiatioDs/PiDperty Owne r Discosaons/Additional Work iSuit is Required 

BPA CCTH/Rqaoeiitalive. fifi ^ >a. ^ 

Dale.