TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: _2£,Ci£i_3 _ Date: g/li)^n^«^ 

Address: S>Ar>t^ r^(Y\r^fi. tY\ / y 

LBP Stabilization Contractor: PRUDENT TECHNOLOGIES, INC. Year: 2009 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

Videoof property (DVD): Pre-Stabilization & Post-Stabilization Videos 

Executive Summary 

Signed Access Agreement Form 

V Advance Notice Form 

Pre-Stabilization Video Agreement Form 

Access Tracidng Form 

1 / Property Access Assessment Form 

Neighbor Access Agreement Form 

i / Paint Match Form 

0 Pre-Stabilization Property Safety Assessment Form 

< / Worl<-Site Hazards Analysis Checklist 

^ Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

Iv Douglas County Assessor Property information 

i A Property Completion Agreement Form Signed hy Property Owner 

D Property Close-Out Check List Signed By EPA 

Prudent Technologies, Inc. Signature Date 

EP A Signature DatT 

30054688 

IIIIIHI 

Superfund 
lECHNOLOGIBS, INC 

Property Summary 

Date: 8/Ai/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of; Aug. 

Property Address: 2604 Camden Av. SAID #: 36403 

A. Executive Summarv; 

a. Issues Encountered; NONE 

b. Issues Resolved; NONE 

c. Unique Findings; NONE 

d. Other Relevant Information: 

i. Access Date: 7/21/2009 

ii. Work Began; 7/30/2009 

iu. Close-Out Date; 7/31/2009 

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 
3i^^o^ 

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) at a number of orooerties located in Omaha, 

Nebraska, including the property located at ^LPU' 7 (^777/177£/l TTl/P 

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 including 

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. 

If you 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 (40202)731- ) 731-304 3 5 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Property Access Granted By:. L C U 

Property Owner Signature: 7]y^. y -7-3/-tD? 

(Signature) (Date) 

PROPERTY INFORMATION 

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

RESIDENT NAME: l^loi. & 

^i 44.-U- Owner 

RESIDENT ADDRESS:. 3U>H ^^mJpn A\lf 

IF RENTAL, PROPERTY OWNED BY: V\^c_4oe '^ooii'f.l ^ 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER -^StPd^i^^iiis^. ORK: J L 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 0 NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: D 

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.) 

\ iJc 

^ 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS; The activities to be implemented by EPA under this agreement are pursuant to Sectioi 104 

of CERCLA, 42 U.S.C. 9604. EPA's right of access to the property is provided for in Section 104(e) of CERCLA. 42 U.S. C 9605(e), which provides entry 

for "determining the need for response, or choosing or taking any response action under this title, or otherwise enforcing the provisions ofthe title." 

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

Fax- (R16)36.1-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
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? If you 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: 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owner's Signature ., 

7l.^.y\J±yt.^Q<^s.hM 
PRE-STABILIZATION VIDEO FORM 

I UNDERSTAND THAT PRUDENT TECHNOLOGIES WILL 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 WILL ALSO BE SHOT PRIOR TO 

COMPLETION OF STABILIZATION. 

OWNERSNAME: f^a^c^'cL KJ.-UueUr /(IcLtt-^CL^^^^ 

PROPERTY ADDRESS: 

BVID/SAID: 3,^1/0^ . 

HOMEOWNERS SIGNATURE: 

TidA^y^iUlr 

PRUDENT REPRESENTATIVE SIGNATURE: 

Qr/i ^ ^-<y7y 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING VIDEO: 

(I.E. PETS, NOTICE NEEDED): 
ACCESS INFORMATION TRACKING SHEET 

PROPERTY 


BVID: '^fi<^03> ADDRESS: J^f^o^ Qayrri/lcM /Qy^ . 

Property Owned By: 

(ltMmptCD»itiicmtn) 

Owners Phone No's: Home: Work: 

Cell: Fax: 

Access Contractor ASW FDA MES PE other rn.-( /ii- h t ' 

(CictoOMt; 

DATE TIME Nossssxx COrfTACr DETAIL 

ipi l\(h^ m Ws)k|/i.Hf/^#Atv6^ . 

hil ^

CA^ue^ J^h^ 

Comments: >x^ ^ 

Ple9semttol9glbiyl 
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? 

'^\/\oS s\(M ^ . 

: ( If yes, is any ofthe stucco or asbestos damaged or cracked? 

WV. vJ 

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

techniques. It will be retumed 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? 

;^^-yO 

Does this property have lots of plants or items in areas where painting is required? 

Does this property have any significant structural damage? 

^'^J^ipovciN, )rn ^ ^ fpo-JU^- , If yes, EXPLAIN? 

V L ^ 

7 

Does this property have a garage? / ^ he t^/^A'"^'' ^ 

If yes, describe location of garage. 
Does this property have aluminum siding*^ 

fV^^ ^ 

If yes, is it original factory finish or has it been painted over? 

fyj 0 

Does this property have any other type of structural components? (i.e. roof shingles 

as siding)? 

/v-O 

If yes, EXPLAIN? 

y^ 

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Is this property vacant or occupied? ^ ^ ^ 

QCCU) ^ y ^y-^^y /4, 

Are there any pets at this property? /-—ext 

y^A, UK ^ M ^ ^v ^t^ y <^ ^l^ 

Are there any low hanging power lines? 

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Is there a neighboring property that needs to be accessed along with assigned 

property to complete stabilization process? 

A7) 

If SO, get a signed access from all necessary neighboring properties. 
TO BE FILLED OUT ONLY IF MATCHING COLOR 

Paint matching form: . 

Property address: SlGO ^ G2oi^4 (Uy |/Jv^^^— 

BVID: 3GM0 ^ 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Page 1 
PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTYADDRESS: 2G^ H C^f^^^^"^ N—e^ 

BVID/SAID: > e? t j> 

PRUDENT REPRESENTATIVE DOING ASSESSMENT: 

^ ^ 

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

TO KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A 

CREW/SUB. 

REPRESENTATIVE REMARKS/FINDINGS (POWER-LINE 

PROXIMITY TO HOUSE, SCAFFOLDING/LADDERS/LIFT 

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

} 

.t 

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 

if 
# 

TECHNOLOGIBS,] 

Checklist for the Worksite Hazard Analysis 

Address 

Crew: 

Item 

Overhead Lines 

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required 

High Traffic Area 

Garage 

Structures 

Driveway 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees 

Foliage 

General Condition of yard 

Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

Crew 

8080 Ward Parkn^ , Suit( 

Kansas City, MO 64114 

Phone: (816) 363-3703 

Fax: (816) 363-3707 

OK? 

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Date: 

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2505 N. 24'" Street, Suite 308 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

Corrective Action 

I J 1 >--b^fui^ fffvaL 0 r 

fety Officer 

/ledical Drive, SuTtfr4250 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577 
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'^sb 
Current Sample Pr^Renovatio 'M\ 

n Form 

effeofiveunHI April 2010. 

Contlnnation of Receipt of Laad Pamphlet 

Q/\ have (eceived a copy of the pampNet, Renovate njgfir; Important Lead Hazard 

Infonretton torftunSes, Child Care Providers and Schools Conning me of 

the potenty risk of the lead hazard exposijre from renovation actMty to be 

perfomted In my dwelling unit. I received thia pamphlet betoie the work began. 

Printed name of redplait . r , , Date 

Signature onedpient 

SeK-Certifieation Option (Tor tenant'occupied dweilinge only) — 

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

you may check the appropriate box t)elow. 

Q Refusal to sign — I certify that i have made a good M h effort to deliver the 

parr^ihlet, Renovate RI!EI^' important Lead Hazard Infonnation fyr f^anSes, 

C t M Cara Providers and &:hod3, to the rental dwelling unit listed below at the 

date and time mdcated and that the occupant refused to sISn the confirmation 

of rece ^ I further certify that I have left a copy of the pamphlet at the urft with 

theoocupanL 

Q^navaliable fn* signatine—I certify that t have made a good feith effort to 

deDver the pamphlet, Renovate Right Important Laad Hazssti Informatiai tor 

FamBoa, ChHd Cara providera and Schoda, to the rental dwelling unit listed 

below and Ihat the occupant was unavailable to tign the confinnaQon of receipt, 

I further certify that I have left a copy of the pamphlet at the unit by sliding it 

unc 

1^'MI ^ A^Uk-^ 7-Z-r-o^ q P^ 

Attempted dellveiy 

date and time 

lead pamphlet deRvety 

SIgnetuie of person oertityb^ lead pamphlet delivery 

UmtAdttess 

Note RsgsRflng MaWng Option—As an alternative to delivery in person, you 

may mao the lead pamphlet to the ownor and/or tenant. PamphIA must be mailed 

at least 7 deyB before renova ^ {Document with a certificate of rnailing (ifom the 
Douglas County Account Infomiation http://douglasne.nia|^^-online.com/DouglasCoNe/static/accountinfo.. ajg^ -

Douglas County, Nebraska Property Record - R1301950000 

1 Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VleW On ll/lap 

Information is valid as of 2009-5-12 Treasurer's Tax Report 

New Feature -*-¥-¥ Auto Sales Search 

Owner 

OAS OBED 

^^ iui f\ Ol 1 ir\n 

P 0 BOX 53 

i BELLEVUE NE 68005-0000 1 

Propert y Informatio n 

1

Key Number 0195 0000 13 

1 

Account Type: Residential t 

Parcel Number \ 1301950000 

Parcel Address: 2604 CAIVIDEN AV 

Oi^AHANE 68111-0000 

Legal Description: HASTINGS & HEYDENS ADD LOT 18 BLOCK 1 50 X 120 

Value Informatio n 

"•' " " 1 1 l^n d • Improvement \ Total 

2009 $2,500.00 $19,600.00 \ $22,100.00 

2008 $2,500.00 $19,600.00 $22,100.00 

2007 $2,500.00 $19,600.00 $22,100.00 

2006 $2,500.00 . $19,600.00 $22,100.00 

L^ 

2005 $2,500.00 $12,800.00 $15,300.00 

2004 i $2,500.00 $11,600.00 $14,100.00 

! Sales Informatio n 

1 Sales Date: 2001-01-26 

Deed Type: D Book: j 2173 i Page: 403 

Price: • $23,000.00 

1 Grantor •'

Grantee: 

Valid/Invalid: Valid 

1 Exclusion Reason: 

-

' Land Informatio n 

Acres \ SF Units Depth Width Vacant 

0.13 6000.0 1.0 1 120.0 50.0 No 

: Improvem e nt Informatio n 

Building 1 

lof 2 6/8/2009 10:14 AM 
pouglas County Account Information http://doug1asne.niai^fcg-online.com/DouglasCoNe/static/accountinfo.. 

aiOfi CJJ.'OE'. 3T 

•I f f It.ff . , 432.0 5f 

first Floor 

&B&5sf 

Ml 

1 IC STORY FIN 

nMJsi g ^ E SI 

Square Footage: ' " I 1322.0 

' 

CLICK TO ENLARGE IMAGE 

Percent Complete: I 100.0% 

Perimeter 0.0 Quality: Fair 

Unit Type: Condition: Poor 

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

HVAC: Forced Air Rooms: 5.0 

Exterior: Frame Vinyl Units: 1.0 

interior: Drywall Baths: 1.0 

Roof Cover: Composition Shiingle Bedrooms: 2.0 

Roof Type: Hip/Gabie Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

year Percent Adjusted Year Year Built Physical Age Remodeled Remodeled Built 

1906 0% 1906 103 

Detail Type Detail Description Units 

Add On Fence Chain Link 1.0 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 890.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Porch Cvrd Wood Deck 120.0 

Porch Cvrd Wood Deck 176.0 

Porch End Solid Wall 72.0 

User SOURCE 2 1.0 

2 of 2 6/8/2009 10:14 AM 
TBOINOLOGIBS, INC 

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

SAID: 36^0' ^ 3 y 

Property Addresst:: 2^7:)^d///^^7Ulr ^ ( ^^^ ^ Q^o/e^ Av^ 

Owner's Name: 

S.NO Performance Standards/close-Out Criteria Yes NO 

1 Was the entire structure(s) 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. 

2 Was all scraping and other preparation work completed 

3 

4 

5 

satisfactorily? 

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

painted with two top coats? 

Are all ofthe areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? 

Did the contractor collect/vacuum ail falling and scraped paint chips 

%

7

71 

on the entire property, roadways, alleyways, public access areas 

and also remove any other generated debris? 

6 is the grass area that surrounds the structure(s) in reasonably good / 

condition? y

7 

Was the paint products utilized equivalent to a 30 year •T\ product/quality? 

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

cones, barrier tape etc properly removed? X, 9 

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. A

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 t

7} Work that is Required h 

Prudent Representative Signature 

Date: 9 ' 3 <-^' ^ ' , 

Property Owner Signature: / l(7/Lsi:J*7Ly / l -

Date: 7•5^^^f 

8080 Ward Parkway, Suite 405 

Kansas City, MO 64114 

Phone: (816) 363-3703 

Fax: (816) 363-3707 

2505 N. 24'" Street, Suite 308 

Omaha, Nebraska 68110 

Phone: (402)504-1004 

Fax: (402)504-1005 

4242 Medical Drive, Suite 4250 

San Antonio, TX 78229 

Phone: (210)822-9588 

Fax: (210) 579-6577