## TRANSMITTA Lo f OMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAI D # : 40C^? n Date : rS-n-7r)l( ^ Address : 24 1 \T^-eVs'^prj ' AV^, / Stabilization Contractor : Professiona l Environmenta l Engineer s Year : 2010
_ PAINT STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S y C Video ofpropert y (DVD ) p . . Executiv e Summar y ^ Signe dAcces s Agreemen t fo r subjec t propert y Jf C Pre-Renovatio nFor msigne db y Propert y Owne r

D Pre-Renovatio nFor mfo r Occupant/Tenant , i f applicabl e D Paintin g Agreemen t D Settlemen t document s (i.e. , fo r damag e o r t o replace plants , etc. ) 1S ^ Renovatio nRecordkeepin g Checklis t signe db y Certifie dRenovato r ^ Photograph s b^O/ P/}[\ A oJpl w ^8; ^ Satisfactor y close-ou t chec k lis t signe db y Propert y Owne r D Propert y close-ou t chec k lis t signe db y EP A ^ Propert y informatio nfro mDougla s Coimt y Assessor' s Oflic e

aHazar danalysis , i f prepare d aSafety Audi t D Othe r (describe) :

Professiona l EnViir^menta l Engineer s Signatiu e ^ 

# 3(LiirCt
. JLa 6 ^( M l O Eur e Dat e (afte r file folde r review ) 3020423 6 

# I Superfun d

# 0 | PROFESSIONA L 50 0 S
. Ewing , Suit e E 

# ENVIRONMENTA L ENGINEERS , INC
. St
. Louis
. M O 6310 3 (314)531-006 0 

## [|ll | "Providin g cost-effectiv e environmenta l solutions ' Fa x(314 ) 531-006 8 Coi'isiilliiic i • • EiigiiiBeriii! ! Di;sJ!;ii i * f-:aneillaiio n• At-aittmttni « Eineigsnc y ri^.siAjiif..- ; 

# 201 0 

# Propert y Owne r

Close-Out For m (Lead-Base dPain t Stabilizatio nEP A Contrac t EP-R7-08-06 ) SAID : 

# ^6 0 

# n Property Address : 

# ^Mt | fsf/.wftar f AnK . Owner' s Name : 

# (i<\Mf(i WOb. s Performanc e Standards/Close-Ou t Criteri a YE S 

## N O 1 . Wa s th e entir e structure(s ) painte dwithth e exceptio nofth e stated , exclude dareas ? Thi s woul dinclud e paintin g o f othe r associate dfeature s includin g fascia , eaves , siding , al l trim , ^ / 

## porches , bo x beams , columns , rails , an dexterio r surface s o f garages . 2 . Wa s al l scrapin g an dothe r preparatio n wor k

complete dsatisfactorily ? 

## V/ " 3 . Were al l require darea s ofth e structure(s ) prime da s neede dan dpainte dwit htw o to p / 

## coats ? 4 . Wa s th e pain t product s utilize dequivalen t t o a2 5 yea r product/quality ? 

# ^ y 5 . Ar e al l ofth e area s wher e contaminate dmaterial s hav e bee nspille dthoroughl y vacuumed / cleaned ? 

# v / 6 . Di dth e contractor collect/vacuu mal l fallin g an dscrape dpain t chip s o nth e entir e property , roadways , alleyways , publi c acces s area s an dals o remove an y othe r generate d / 

## debris ? 7 . I s th e gras s are athat surround s th e structure(s ) i nreasonably goo dcondition ? x / 

## 8 . Ar e al l item s suc ha s polyethylen e sheeting , ladders , pain t brushes , cones , barrie r tape , ^ 

## etc . properi y removed? 9 .

I s ther e an y evidenc e ofpropert y damag e that wa s don e b y th e contractor ? An y property / 

## damag e need s t o b e complete dprio r t o th e EP A Close-Out . 10 . Ar e yo u satisfie dwithth e wor k

performed ? > ^ 

## 11 . Ar e ther e an y property item s that wer e temporaril y re-locatedb y th e contractor that / 

## nee dt o b e move dback ? 12 .Ar e ther e an y (known ) lingerin g issue s withth e property owner(s ) that hav e bee nlef t / ­ 

## unresolved ? Othe r Considerations/Property Owne r Discussions/Additiona l Wor k

that i s Required :

Property Owne r Signatur e
Professional Envitvnmwlfa T Engineer s Signatur e 

# v/ 06U\l[ o Date 

# S-JJ^j O Dat e

# PROFESSIONA L 250 5 Nort h 24"
. Suit e 21 9 

# ENVIRONMENTA L ENGINEERS , INC
. Omaha
. N E 6811 0 

## "Providin g cost-effectiv e environmenta l solutions "^^ ^

jjjg j IJJiJ ^ Consultin g • Engineerin g Oesig n • Remediatio n • Abatemen t • Emergenc yRespons e



## LeadBas e Stabilizatio n Omaha , N e Clos e Ou t Report 201 0 

## SAID#4008 7 241 1 Newport Ave .

•Date s worked : 05/07/1 0 t o 05/07/1 0 •Pr e propert y condition : Hous e an dgarag e hav e viny l sidin g withpainte dwoo dtrim s an dfoundatio n areas . Pain t wa s flakin g ofTfro mwoodtrim s on t o th e ground . •Problem s encountered : None •Owne r request/concerns : N/ A •Inspection/closeou t dates . Owne r signe d05/11/10 , Inspecte dby P Eprojec t manager .

### SAID # Propert yAddres s Storie s Garage ? Acces s signe d Pre-vlde o Pos t vide o Contracto rAssigned , Dat e starte d Weatherftem p Dat e ende d Pain t use d Prim e use d Poi yuse d / 

# S ^ EP APain t Stabiiizatio n 201 0 

# '2A-\ \

^icv<i^or + A/ ^ 

# X 5

^e s 

# 4-15-ZOI O 4'IU-TOI O
5/>7/?^/c ^
• 5-v ' 

# 5/1 / Z^/ ^ /f^ ^ / 

# 2i4li ^ - ^ 

# S'^A^^ ^ Problems/Issue s

# '>m r >ra i CONSEN T FO RACCES S T O PROreRT Y OMAH A LEA D SIT EREMEDIA LACTIO N- LEAD-BASE D PAIN T STABILIZATIO N PROPERT Y ID : 4^^ 1 PROPERT Y ADDRESS : SA WNetOpflH ? a V - OWNE RNAME : , . ^ DAYTIM EPHONE : (^02 ^ A^S'^C ^ CEL LPHONE : 

# fiii'.^Q.^/ ^

E-MAIL : Aviii wfeg p ro)c
. Mg r OWNER' S ADDRES S I FDIFFERENT : TENANT' S NAM EIFAPPLICABLE : DAYTIM E PHONE : CEL L PHONE : E-MAIL : ProfeuioDa i EnviroBmenta l Engineers , Inc
. (PE ) b unde rcontrac t (#EP-R7-<W-06 ) wit h th e U.S
. Environmenta l Protectio n Agenc y(EPA ) t o stabiliz e lea d base d pain t (LBP ) o n residentia i structure s a t a numlM ro f propertie s locate d i n Omaha , Nebraska
. Th e pain t stabilizatio n wor k i s bein g don e t o protec t th e soi l cleanup s tha t ar e bein g performe d b yEP Acontractors . Pain t stabilizatio n activitie s wii l include : scrapin g ofcracke d o rflakin g LB P fh> m structures , applicatio n of a prim e coa t an d tw o (2 ) coat s o f pain t Movin g part s o f window s an d door s ar cno t include d an d wil l no t b e addressed
. You rcooperatio n i s requeste d i n givin g permissio n t o th b EP Acontracto r(PE ) t o ente ran d hav e acces s t o th b propert yfo rth e purpos e o f stabilizin g lea d -base d pain t a s outline d o n th e propert yidentifie d above
. B ysignin g thi s documen t I agre e t o alio wa n EP Acontracto rt o conduc t a soi l cleanu p a t m ypropert yfolk>win g completio n o f lead-lmsc d pain t stabilization , i f th e soi l deann p ha s no t alread ybee n performed
. I understan d tha t th e stabilizatio n contracto r ca n no t provid e assurance s tha t th e soi l cleanu p contracto rwil l b e boun d to . I furthe runderstan d tha t th e soi l cleanu p contracto rwil l mak e al l reasonabl e eflbrt s t o addres s concera s tha t I , a s th e propert yowner , ma yhav e regardin g soi l cleanu p a t m yproperty . iP^cs , I ha w raad an d undtntni d th e pangiap h haboM
. 

# o^lish o Signabir a o f I rPnpeft y rOmnc r I fbll yunderstan d tha t b ysignin g th b Consen t fo rAccess , (1 ) th b acces s wil l remai n i n effec t unti l th e wor k ha s bee n satbfactoril ycompleted , (2 ) tha t th e Propert yOwne ro rTenant , i f applicable , wil l l wgive n th e Housin g an d Urlm n Developmen t (HUD ) an d EP Apamphlet , "Renovat e Right , Importan t Lea d Hazar d informatio n fo rFamilies , Da yCar e Providers , an d Schoob" , (3 ) th e Propert yOwne ro rtenan t wii i remov e al l obstmetion s flro m surface s t o b e painted , (4 ) wil l abid e b yhealt h an d safet yguidanc e provide d b yEPA , (5 ) wil l allo wphotograph yo f propert ybefor e an d afte rth e pain t stabilfantlo n work , (6 ) wil l b e contacte d b ya P E representativ e approiimatel y4 8 hour s i n advanc e o f startin g work , (7 ) agre e no t t o obstrac t o rtampe rwit h an yofth e LB P stabilizatio n actkins , an d (8 ) wil l participat e i n final propert yinspectio n an d sig n th e Completio n Agreemen t an d Propert yOwne rSatbhctio n Survey
. Shoul d yo u hav e aa yquestion s abou t th e pfaine d Lea d Based-Pain t stabilizatio n activitie s fo ryou rproperty , pleas e contac t Professiona l Environmenta l Engineen , Inc
. Projec t Manager , Willi e Cfai yA t 402-504-4688
. Genera l question s abou t th e Omah a Lea d Sit e cleanu p ca n b e directe d t o Paulett a France-lsetts , EP ARemedfai l Projec t Manage r402-731-2454 , o rth e EP APubli c Informatio n Center s a t 402-991-958 3 (Nort h Omah a oflice ) o r402-731-304 5 (Sont h Omah a office)
. B Yet , I gran t aooes a t o mypropert yan d IM S gim n th t pamphb t D NOildonotgrsntaooaMtomyprepaityindlvM S "Ranovat e IQglit , knpoitn t Loa d InfonrnHo n fo rFanrinat , Chil d fllMn tli e pmiph M 'RBnont e Wgh ^ hnportan t Laa d Car a Providan , an d Schools. " intonnilkH i forFamllba , Child e Car a Pnwidtn , an d Schoob. * Signatur a O Dat e Signatur a 

### Dat e eocriA i iMffrmirrirMSAMnrniittinrPATini K

# Curren t Sampl e Pre-Renovatio n For m Effectiv e unti i Apri l 2010
. Confirmatio n o f Receip t o f Lea d Pamphle t a n have receive d a cop yo f tti e pamptiiet , Renovat e Ri^t : Importan t Lea d Hazar d Informatio n forFamilies , Chil d Car e Provider s an d School s informin g m e o f tti e potentia i risi < o f tti e lea d hazard exposur e fro m renovatio n activityt o iD e perfonne d i n m ydwellin g unit
. I receive d thi s pamphle t befor e th e wort< t)egan
. 

# AnHn^ AWllkA c04 - if\-f O Printe d nam e o f recipien t ; Dat e Signatur e o f recipien t C l Self-Certificatio n Optio n (fb rtenant-occupie d dwelling s only ) — I f th e lea d pamphle t wa s delivere d txi t a tenan t signatur e wa s no t obtainable , yo u maycheci t th e appropriat e tx> xbelow
. Q Refusa l t o sig n —I certifytha t I hav e mad e a goo d fait h effor t t o delive rth e pamphlet
. Renovat e Right : importan t Lea d Hazar d Infonnatio n forFamilies , CNk l Car e Provider s an d Schools , t o th e renta l dwellin g uni t liste d tielo 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 lef t a cop vof th e pamphle t a l th e uni t wit h th e occupant . •Unavailabl e fo rsignatur e - • I codify!!V h •'-iv p -•"od ^ n 3:;:^: : fr;:-' ; ^^.••jr \ t o delive rtli e pamphlet
. Renovat e Right : linponini i Loa d Hazar d Informatio n fo r Fctmilies , Qiil d Cai vpru-.'iJora an d SJiijuL , i u ih o JufIILS ; dwoiiin g urii i lisio d belov. ' jinc l th^^ l t'-ecccup/in t v/n: ^ u-nvnihl^!' ^ ^

c:'j ' !*•- • ;o^rT-nritioi - of 'cceipt
. I fuiIhG'i ' certif yll'ici i I hav e lo' i u cop yo f ili u piJiVip!uii' i u i il' AUi'ii t L- yS^iu.riC ; .' i undc- rth e door
. Printe d nam e o f peroo n certifyin g Artcmp^o d ^ci^'cr ; dat e an d tim e lea d pamphle t derfivfirySignatur e o f perso n certifyin g lea d pamphle t delwer, '

Uni t Addres s Not e Regardin g Mailin g Optio n —As a n aiternaliv e t o oeiivc-r yi n person , yo u ma ymai l th e lea d pcinipltle t l o lli s ownerand/'o i lonanl
. Painpliie i liius i be(iiaiie J at idas t 7 day s befoi c renovatio n Pocurricn t wit h a cciifical co f mailin g 'ror : th e pos t offics:
.

# Futur e Sampl e Pre-Renovatio n For m Thi s sampl e for m mayb e use d b yrenovatio n firm s t o documen t complianc e wit h th e Federa l pre-renovatlo n educatio n an d renovation , repair , an d paintin g regulallons
. Occupan t Confirmatio n Pamphle t Receip t a I have receive d a cop yo f th e lea d hazard informatio n pamphle t infonnin g m e o f th e potentia l ri8i < o f th e lea d hazard exposur e fro m renovatio n activityt o b e performe d i n m ydwellin g unit
. I receive d thi s pamphle t befor e th e wor1 < began
. Owner-occupan t Opt-ou t Acknowledgmen t lv(A ) I confir m tha t I ow n an d liv e i n thi s property , tha t n o chil d unde rth e ag e o f 6 reside s here , tha t n o pregnan t woma n reside s here , an d tha t thi s propert yi s no t a child-occupie d facility
. Note : Achil d reside s i n th e primar yresidenc e of hi s o rhe rcustodia l parents , lega l guardians , foste rparents , o rinforma l caretake rif th e chil d live s an d sleep s mos t o f th e tim e at th e caretaker ^

residence
. Note : Achild-occupie d facilit yi s a pre-197 8 buildin g visite d regularl yt> ytli e sam e child , unde r6 years o f age , o n a t leas t tw o differen t day s withi n an yweek , fo ra t least 3 hour s eac h day
. provide d tha t th e visit s tota l at leas t 6 0 hour s annuall y I f Bo xAi s checked , chec k eithe rBo xB o rBo xC , bu t no t both
. SftB ) I reques t tha t th e renovatio n fir m us e th e lead-saf e wor k practice s require d b yEPAI s Renovation , Repair , an d Paintin g Rule ; o r •(C ) I understan d tha t th e fin n performin g th e renovatio n wil l no t b e require d t o us e th e lead-saf e wor k practice s require d b yEPA! s Renovation , Repair , an d Paintin g Rule
. Printe d Nam e o f Owner-occupan t/ ) , ', 1 , \'AA..If Signaiur e o f Owner-occupan tSignatur e (Dat e V Renovator's
. Sel f Certificatio n Optio n (fo rtenant-occupie d dwelling s only ) Instruction s t o Renovator : I f th e lea d hazard informatio n pamphle t wa s delivere d bu t a tenan t signatur e wa s no t obtainable , yo u maychec k th e appropriat e bo xbelow
. U Decline d - 1 certifytha t I hav e mad e a goo d fait h effor t t o delive rth e lea d hazar d informatio n pamphle t t o th e renta l dwellin g uni t liste d t)elo wa t th e dat e an d tim e indicate d an d tha t th e occupan t decline d t o sig n th e confirmatio n o f receipt
. I furthe r certifytha t I hav e lef t a cop yo f th e pamphle t at th e uni t wit h tti e occupani
. • Unavailabl e fo rsignatur e - 1 certifytha t I hav e mad e a goo d fait h effor t t o delive r th e lea d hazard informatio n pamphle t t o th e renta l dwellin g uni t liste d tielo wan d tha t th e occupan t wa s unavailabl e l o sig n th e confinnatio n o f receipt
. I fulhe rcertif ytha t I hav e left a cop yo f th e pamphle t at th e uni t ty yslidin g i t unde rth e doo ro rb y(fil l i n ho wpamphle t wa s left) Printe d Nam e o f Perso n Certifyin g Deliver yAttempte d Deliver yDat e Signatur e o f l^rso n Certifyin g Lea d Pamphie t Deliver y
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 maymai l th e lea d hazard infbrmatio n pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d a t leas t seve n day s befor e renovation
. Mailin g mus t t> e documente d tr ya certificat e o f mailin g fro m th e pos t office
. Note : Thi s for m i s no t effectiv e unti l Apri l 2010
.

# CONISN T FO RACCES S T O 

# PROTERT Y OMAHA LEAD SIT EREMEDIALACTIO N - LEAD-BASE D PAIN T STABILIZATIO N 1 PROPERT Y ID : PROPERT Y ADDRESS :

OWNERNAME : DAYTIMEPHONE : CELLPHONE : E-MAIL : OWNER' S ADDRES S I FDIFFERENT : TENANT S NAMEI FAPPLICABLE : DAYTIM EPHONE : CELLPHONE : E-MAIL : Professiona l Environmenta l Engineers , Inc
. (PE ) b unde rcontrac t (#EP-R7-08-06 ) wit h th e U.S
. Environmenta l Protectio n Agenc y(EPA ) t o stabiliz e lea d base d pain t (LBP ) o n residentia l structure s a t a numbe ro f propertie s locate d i n Omaha , Nebraslu
. Th e pain t stabilizatio n worl i i s bein g don e t o protec t th e soi l cleanup s tha t ar e bein g performe d b yEP Acontractors . Pain t stabiiizatio n activitie s wil l include : scrapin g ofcracke d o rflakin g LB P fro m structures , applicatio n of a prim e coa t an d tw o (2 ) coat s o f pain t Movin g part s o f window s an d door s ar cno t include d an d wil l no t b e addressed
. You rcooperatio n i s requeste d i n givin g permissio n t o thi s EP Acontracto r(PE ) t o ente ran d hav e acces s t o thi s propert yfo rth e purpos e o f stabilizin g lea d -base d pain t a s outline d o n th e propert yidentifie d above
. B ysignin g thi s documen t I agre e t o allo wa n EP Acontracto rt o conduc t a soi l cleanu p a t m ypropert yfollowin g completio n o f lead-base d pain t stabilization , i f th e soi l cleanu p ha s no t alread ybee n performed
. I understan d tha t th e stabilizatio n contracto r ca n no t provid e assurance s tha t th e soi l cleanu p contracto rwii i b e boun d to . I furthe runderstan d tha t th e soi l cleanu p contracto rwil l mak e al i reasonabl e effort s t o addres s concern s tha t I , a s th e propert yowner , ma yhav e regardin g soi l cleanu p a t m yproperty . D Yes, ! hav e laa d an d undentan d th e paragrap h above
. Signahir a o f Propeit yOime rDat e I full yunderstan d tha t b ysignin g thi s Consen t fo rAccess , (1 ) th b acces a wil l remai n i n effec t unti l th e wor k ha s bee n satisCactoril ycompleted , (2 ) tha t th e Propert yOwne ro rTenant , i f applicable , wil l b e give n th e Housin g an d Urba n Developmen t (HUD ) an d EP Apamphlet , "Renovat e RJght , Importan t Lea d Hazar d infonnatio n fo rFaniilies,.Da yCar e Providen , an d Schools" , (3 ) th e Propert yOwne ro rtenan t wil l remov e al l obstruction s fro m surface s t o b e painted , (4 ) wil l abid e b yhealt h an d safet yguidanc e provide d b yEPA , (5 ) wil l allo wphotograph yofpropert ybefor e an d afte rth e pain t stabilizatio n work , (6 ) wil l b e contacte d b ya P E representativ e approximatel y4 8 hour s i n advanc e o f startin g work , (7 ) agre e no t t o obstruc t o rtampe rwit h an yofth e LB P stabilizatio n actions , an d (8 ) wil l participat e i n Una l propert yinspectro n an d sig n th e Completio n Agreemen t an d Propert yOwne rSatisfactio n Survey
. Shouk i yo u hav e an yquestmn s abou t th e plane d Lea d Based-Pain t stabilizatki n activitie s fo ryou rproperty , pleas e contac t Professiona l Environmenta l Engineers , Inc
. Projec t Manager , Willi e CU yA t 402-504-4688
. Genera l question s abou t th e Omah a Lea d Sit e cleanu p ca n b e directe d t o Paulett a France-lsetts , EP ARemedia l Projec t Manage r402-731-2454 , o rth e EP APubli c Informatw n Center s a t 402-991-958 3 (Nort h Omah a office ) o r402-731-304 5 (Sout h Omah a office)
. D Yes , I gran t access to mypropert yan d was give n th e pamphlet D No
. I d o no t gm t access to mypropert yan d I wa s 'Renovat e iOght , Importan t i.ead InformaHo n fo rFamilias
. Chil d give n ttie pamph M 'Ranovat e Right , hnportan t Laa d Car e ProvMere
. an d Schools. " Infonnatio n forFamilies , ChlM cCar e ProvUers , an d Schools. " Signater e Dat e Slgnahir e Dat e fippriAi iu«T«imrtM S AunrnusirwoATiniif i

## Douglas Count y Accoun t Information Page 1 of3 

# m ^001 1 Dougla s County , Nebrask a Propert yRecor d - R174979000 0 Prin t Repor t Vie wInteractiv e GI S Ma o Informatio n i s vali d a s o f 2010-4-1 6 Treasurer' s Ta xRepor t Ne wFeatur e - ^ • * • ^ Subdivisio n Sale s Searc h Owne r 

## WILKE S ANDRE AYt^^bSi i fe ^QOX
. AJ ^ 241 1 NEWPOR TAV E OMAHAN E 68112-000 0 Z/C" ^

^/^- ? O ^^Z ) '^yOSv Propert yInf ormati i } n 

### Key N umber : 497 9 000 0 1 7 Accoun t Type : Residentia l Parce l Numbe r174979000 0 Parce l Address : 241 1 NEWPOR TA V OIVIAHAN E 68112-000 0 Lega l Description : l\/IINN E LUS ALO T2 7 BLOC K7 4 4 X 12 0 Valu e Informatio n Lan d Improvemen t Tota l 200 9 $5,900.0 0 $53,700.0 0 $59,600.0 0 200 8 $5,900.0 0 $53,700.0 0 $59,600.0 0 200 7 $5,900.0 0 $54,900.0 0 $60,800.0 0 200 6 $5,900.0 0 $54,900.0 0 $60,800.0 0 200 5 $5,900.0 0 $54,900.0 0 $60,800.0 0 200 4 $5,900.0 0 $49,800.0 0 $55,700.0 0 Sale s Informatio n Sale s Date : 2002-09-3 0 Dee ( rf Type : Price : Grantor : W D $72,777.0 0 i Book : 222 3 Page : 47 9

Grantee : Valid/Invalid : Vali d Exclusio n Reason : Sale s Date : 1998-06-1 2 

# 1 Dee d Type : Price : Grantor
. 

# ° $44,500.0 0 Book : 209 8 Page : 03 0



## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R17.. . 4/22/201 0

## Dougla s County Accoun t Informatio n Pag e 2 of 3
Grantee : Valid/Invalid : Vali d Exclusio n Reason : Lan d Informatio n Acre s S F Unit s Dept h Widt h Vacan t 0.1 2 5280. 0 1. 0 

### 120. 0 44. 0 N o Improvemen t Informatio n Buildin g 1 241 t Newpor t Av e 1 1/2aorvlMi n 

### "Sratr " '•It!? ? M l ^ 1 • V Wt t

* « jgjsrti« .

nf f 

## £»r+ » • « • BVB5M *

CLIC KT O ENLARG E IMAG E CLIC KTO ENLARG E IMAG E 

### Squar e Footage : 980. 0 Percen t Complete : 100.0 % Perimete r 0. 0 Quality : Fai r Uni t Type : Condition : Averag e

Buil t As : 1 1/ 2 Stor yUnfi n Cond o Squar e Footage : 0. 0 HVAC : Centra l Ai rt o Ai r Rooms : 4. 0 Exterior : Fram e Aluminu m Units : 1. 0 Interior : Drywal l Baths : 2. 0 Roo f Cover : Compositio n Shingl e Bedrooms : 2. 0

Roo f Type : Gabl e Stories : 1. 5 Floorcover : Allowanc e Foundation : Bioci c Sprinkle rSquar e Footage : 0. 0 Yea rBuil t Yea r Remodele d Percen t Remodele d Adjuste d Yea r Buil t Physica l Ag e 0 % 193 0 7 9
= < Deta'k , Detai l Descriptio n Unit s Ad d O n Unfinislie d Atti cW/floo r 204. 0 Applian c Allowanc e 1. 0 Applianc j Fireplac e Masonr y 1. 0 Baseme i Bsmn t Bloci s 8 ft 980. 0 

## http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R17. . . 4/22/201 0(eifectiv e Apri l 2010 )


## RENOVATIO N RECORBKEEPIN GCHECKLIS T
Nam e o f Finn : 

# 0(itm s ?fliOlin^ Dat e an dLocatio no f Renovation : Z^) / /VCWpC^f/Wf , BriefDescriptionofRenovation : \t.Cv( i St(M)ill7jGA)Q n Nam e o f Assigne dRenovator : (f>0^ t iM(\f(\ ^ Name(s ) o f TrainedWorkers : jjei ^ Si c i< . CA/ijc , A ' ^AJO^- C 

## , ' Nam e o f Dus t Samplin g Technician , Inspector , and/o r Ris k Assessor , i f used : U Copie s o f renovato r an ddus t samplin g technicia nqualification s (trainin g certificates , certifications ) o nfile . D Certifie drenovato r provide dtrainin g t o worker s o n(chec k al l tha t apply) : D Postin g warnin g sign s • Settin g u p plasti c containmen t barrier s aMaintainin g containmen t D Avoidin g sprea dofdus t t o adjacen t area s D Wast e handlin g D Post-renovatio ncleanin g D Tes t kit s use db y certifie drenovato r t o determin e whethe r lea dwa s pi«sen t o ncomponent s affecte db y renovatio n(identif y kit s use dan ddescrib e samplin g location s an dresults :
Seamin g sign s poste da t entranc e t o work area . B^^or k are acontaine dt o preven t sprea dofdus t an ddebris . j>Wuidow s i nan dwithi n2 0 fee t ofth e wor k are aar e close d ...-elSoor s i nan dwithi n2 0 feet o f tfa e wor k area s ar e close dan dseale d ^^.Sf^/ ^ tfaa t mus t b e use di ntfa e woi k are aar e covere dt o allo w passag e bu t preven t sprea do f dust . )un dcovere db y plasti c sheetin g extendin g 1 0 feet fromwor k are a- plasti c anchore dt o th e buildin g an dweighte ddow nb y heav y objects . D I f necessary , vertica l containmen t installe dt o preven t migratio nofdus t an ddebri s t o adjacen t property . Qwast e containe don-sit e an dwhil e bein g transporte doff-site .

Renovatio n Recordl»epln g Checlclis t Omah a Lea d Sit e(effectiv e Apri l 2010 )



## f ] Wor k

sit e properl y cleane dafter renovation .
• e'Alfchip s an ddebri s picke dup , protectiv e sheetin g misted , folde ddiri y sid e inward , an dtape dfo r removal . ^^^B'^r k are aHEP A vacuume dt o ge t pain t chip s fromgroun dsurface , i f necessary . D Certifie drenovato r performe dpost-renovatio ncleanin g verificatio n(describ e results) :
[^^„./tcertji yunde rpenalt yo f la wtha t th e abov e informatio n i s tru e an d complete
. 

## ctfit. - r>yL- ^ "S// 1 / v-.cf ^ Nam e an dTitl e Dat e

Renovatio n Recordlieepin g Checklis t Omah a Lea d Sit e