TRANSMITTA L O F OMAH A LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 9K\ln i Date: OK \ TJI^J U>t <^ 

Address: Zl-Fi^n P^Uan< \ ^ b 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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

Q Executive Summary 

D Signed Access Agreement Form 

D Advance Notice Form 

D Pre-Stabiiization Video Agreement Form 

D Access Tracking Form 

D Property Access Assessment Form 

D Neighbor Access Agreement Form 

D Paint Match Form 

D Pre-Stabilization Property Safety Assessment Form 

D Work-Site Hazards Analysis Checklist 

D Photographs: Pre-Stabilization Property Hazard Assessment Photographs 

D Douglas County Assessor Property information 

Q Property Completion Agreement Form Signed by Property Owner 

D Property Close-Out Check List Signed By EPA 

Trudent Technologies, Inc. Signature f ' Date 

____„___ Wv^f 

CPA Signature ' ' Da'te 

30054332 iunnnii 

Superfund 
TEOINOLOGIES, INC 

Property Summary 

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

Property Address: 4530 Seward St. 

SAID #: 81477 

A. Ex|gcutive Summary; 

a^ Issues Encountered; NONE 

b. Issues Resotyed: NONE 

0, Unique Findings; NONE 

d. Other Releyant Information; 

i. Access Date; 7/29/2009 

u. Work Began: 7/31/2009 

iii. Close-Out Date; 8/03/2009 

B. Enj!|psures; 

1. |<fre-StabiIization Video 

2. ' Fost-Stabilization Video 

3. Signed Access Agreement Form 

4. Adyance-Notice Form 

5. Pre-Stabilization Video Agreement Form 

6. Access Tracidng Form 

7. Property Access Assessment Form 

8. Neighbor Access Agreement Form 

9. I^roperty Paint Match Form 

10. Fre-Stabilization Property Safety Assessment Form 

11| Work-Site Hazards Analysis Checklist 

12. Pre- Stabilization Property Hazard Assessment Photographs 

13^ |i|ouglas County Assessor Property Information 

14. Signed Property Completion Agreement Form 

15, nropcrtj- Cloac Out Check List Signed By EPA­
TBCHNOLOCIBS, IN C 

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

Agency (EPA) to stabilize J^^dBase^ Paint (LBP) atamanber of properties located in Omaha, Nebraska, including the 

property located at ^tS u ^KlAjf^fiO ^ 

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 of the 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, if the soil cleanup has not abeady been performed. I understandtiiat the stabilization contractor 

cannot provide assurances of which contractor will be bound to the soil cleanup. I further understand that the soil cleanup 

contractor will make all reasonable efforts to address concerns that I, as the property owner, may have regarding soil 

cleanup at my property. 

7/^^ j^^") 

Date 

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 (402) 731­

3045 (South Omaha office) or (402) 991-9583 (North Omaha office). 

Property Access Granted By: 

r. (Please Print,>tene) 

Property Owner Signature: 

(Signature) 

;/^ ^ /j^go? 

(Date) 

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:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
INC 

PROPERTY INFORMATION 

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

RESIDENT NAME: Chr-ts^ft^^ OoQ^ Owner /Renter /

RESIDENT ADDRESSSS: ^ ~ / / ^ /- \ Ly

IF RENTAL, PROPERTY OWNED BY: ^ . 

OWNER'S MAILING ADDRESS; ^ 

OWNER'S TELEPHONE NUMBER - HOME: {'idiX.\ QJ ^ -^X^ l WORK: (Vg^J ^£' J - X ^i~ ^ 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: O NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

3 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHOM PLAY IN THE YARD FOR 5 HOURS OR MORE PER WEEK: 

£L 

COMMENTS OR SPECIAL INSTRUCTIONS: (I.E. DOGS, ENTRY GATES, ETC.) 

AUTHORITY FOR ENVIRONMENTAL RESPONSE ACTIONS: The activities to be implemented by EPA under this agreement are 

pursuant to Section 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 of the 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 

Fax: (816) 363-3707 

Phone: (402)504-1004 

Fax: (402)504-1005 

Phone: (210)822-9588 

Fax: (210) 579-6577 
TECHNaUX;iES»INC. 

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? 

JVQ 

Notice needed: 

9^1 M^' 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owner's Signature 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS>] 

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: Q^^^J (^ ^^^^ 

PROPERTY ADDRESS

'' H^3o <^tvua4 

BVID/SAID: ?7y77 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVE SIGNATURE: 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (I.E. PETS, NOTICE NEEDED): 

fJ6Al£^ 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNCHJOGIES, INC 

ACCESS INFORMATION TRACKING SHEET 

BVID: ^V7 7 

PROPERTY ADDRESS: H^^O ^eiOkm ^ T 

VmU fUsi6 Property Owned By: 

(If new property owner) 

Owners Phone No's: 

Home: Work: 

Cell: Fax: 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACTI)ETAIL 

r-jaf'/)^ ji'i^om 

t 

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7 

6'j^mjkJ 

^V /4 Wg<r Comments: 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBSb INC 

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? 

If yes, is any of the stucco or asbestos damaged or cracked? 

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

techniques. It will be returned 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? 

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

required? 

/r< 

Does this property have any significant structural damage? 

UONO 

If yes, EXPLAIN? 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TBCHNOLOCIES, INC 

Does this property have a garage? fe 

If yes, describe location of garage. 

Does this property have aluminum siding? 

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

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

shingles as siding)? 

If yes, EXPLAIN? 

Is this property vacant or <^cupie( 

Are there any pets at this property? 

f U^ 

Are there any low hanging power lines? 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIBS, INC 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

NO 

IF IT IS, GET ACCESS FROM ALL REQUIRED NEIGHBORHOOD PROPERTIES. 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES, INC 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: /^^^Q ^ehfti ^ ^ 

BVID: ?//7 7 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

2. TO BE FILLED OUT ONLY IF CHANGING COLOR 

PROPERTY ADDRESS: 

BVID: 

AREA: COLOR: 


EXPALNATION: 

AREA: COLOR: 


EXPANATION: 


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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
-naCHNOLOGIES, INC 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS : ^'Sdb ^Bum 5 ^ 

BVID/SAID: "^jU "^ 1 

PRUDENT ASSESSMENT REPERSENTATIVE 

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

KATHY ROTHER BEFORE IT CAN BE ASSIGNED TO A CREW/SUB. 

REPERSENTATIVE REMARKS/FINDINGS: 

(POWER-LINE PROXIMITY TO PROPERTY, SCAFFOLDING/ LADDERS/ LIFTS 

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

(P 

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 

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: (816) 363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
TECHNOLOGIES. INC 

Checklist for the Worksite Hazard Analysis 

Address : 462>6 JJQA^C ^ M -

Crew: Date: 

Item OK? Hazard Corrective Action 

Overhead Lines 

In-transit Vehicle Clearance V 

Levels around high wires t^^-^L 

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 VY\aXV\ ^4-^e©^ 0]J ^ 

Neighbor Access Required \ T, LP'^^r 

High Traffic Area t v o 

Garage I A ^ AAJJ) ^L^ ^ O^y^-*-^ 

Structures OfroC^- g ^v^r^^re>^Afc4•^^'^'J^ [JKC^Y^S-^ ffVUSoP^^^ 

Driveway 

Sidewalk 

Ox- r^H ^ j[\ ^ ; \ 3 "v\A ^^"^ ^ 

Foundation -Sg>v^^<H^^^^»f^ _^M ^ 

Retaining Walls 

Fences 

Trees 

Foliage 7 ^ 

General Condition of yard 

^^(^riti ^ c^AM^^iT^^g? ^ 

Damaged Areas: sink '^/)C^rrf^dAae ^ "j^^^- ^ 

holes/rotted wood • ^ ^ 

Sprinkler System 

Pets 

Insects ^PAQAjCU^t7<li5Uje^^ — L»-W>^(yJH ^ <^(eu\£-^JL.~^ fc:i*h^ 

Weather Conditions ^Xc^r^ 

-S&JH'^ Unsafe driving conditions / ^ 

Unsafe neighborhood 

Crew Foreman/ Sub-Contractor "ety Officer 

mi[\/U­ 8080 \Afard Parkwa^/Su !405 2505 N. 24*" Street, Suite 308 ffedlcal Drive, Suite 4250 

Kansas City, MO Ml 1^ Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577 

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Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

^ 1 have received a copy of the pamphlet, Renovate Right: Important Lead Hazard 

Information for Families, Child Care Providers and Schools informing me of 

the potential risk of the lead hazard exposure from renovation activity to be 

performed in my dwelling unit. I received this pamphlet before the work began. 

7/^ ^ ./r^^o ^ 

Signature of recipient 

Self-Certification Option (for tenant-occupied dwellings only) — 

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

you may check the appropriate box below. 

• Refusal to sign — I certify that I have made a good faith effort to deliver the 

pamphlet, Renovate Right: Important Lead Hazard Information for Families, 

Child Care Providers and Schools, to the rental dwelling unit listed below at the 

date and time indicated and that the occupant refused to sign the confirmation 

of receipt. I further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

U Unavailable for signature — I certify that I have made a good faith effort to 

deliver the pamphlet, Renovate Right: Important Lead Hazard Information for 

Families, Child Care providers and Schools, to the rental dwelling unit listed 

below and that the occupant was unavailable to sign the confirmation of receipt, 

1further certify that I have left a copy of the pamphlet at the unit by sliding it further certity that 1 nave lett 

und^ftne door^ 

Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of persow certifying lead pamphlet delivery 

•~f536 ^wmf S 

Unit Address 

Note Regarding Mailing Option — As an alternative to delivery in person, you 

may mail the lead pamphlet to the owner and/or tenant. Pamphlet must be mailed 

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

post office). 
Douglas County Account Inf(^|fcation Page 1 of2 

Douglas County, Nebraska Property Record - R2147560000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJCW On Ma p Information is valid as of 2009-7-20 Treasurer's Tax Report 

New Feature ••-»- • Auto Sales Search 

Owne (\ r 

PETERS DAVID C 1! ^ 

ETAL ScJ ^ ^^'^^'^ 0^' 

725 N 57 ST 

OMAHA NE 68132-0000 

Property Information 

Key Number: 4756 0000 21 

Account Type: Residential 

Parcel Number: 2147560000 

Parcel Address: 4530 SEWARD ST 

OMAHA NE 68104-0000 

Legal Description: SAUNDERS & HIMEBAUGHS ADD LOT 20 BLOCK H 50 X 150 

Value Informatio n 

Land Improvement Total 

2009 $6,800.00 $49,000.00 $55,800.00 

2008 $6,800.00 $49,000.00 $55,800.00 

2007 $6,800.00 $49,000.00 $55,800.00 

2006 $6,800.00 $49,000.00 $55,800.00 

2005 $6,800.00 $32,300.00 $39,100.00 

2004 $6,800.00 $32,300.00 $39,100.00 

Land Informatio n 

Acres SF Units Depth Width Vacant 

0.17 7500.0 1.0 150.0 50.0 No 

Impro vemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R21... 7/28/2009 
Douglas County Account Infi^^ation Page 2 of 2 

f i r 

tifir" 

J 

CLICK TO ENLARGE IMAGE 

Square Footage: 1086.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Fair 

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

HVAC: Forced Air Rooms: 6.0 

Exterior: Frame Siding Units: 1.0 

Interior: Drywall Baths: 1.0 

Roof Cover: Composition Shingle Bedrooms: 3.0 

Roof Type: Gable Stories: 1.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1920 0% 1920 86 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 992.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Garage Detached 216.0 

Porch Slab Roof Ceil 112.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R21... 7/28/2009 
ENVIRONMENTAL & 

CONSTRUCTION 

TECHNOLOGIES, EVC. SERVICES 

Date: July 28, 2009 

David Peters 

725 N 57"^ Street 

Omaha, NE 68132 

Re: 4530 Seward St, Omaha, NE 

Dear Mr. Peters: 

Prudent Technologies (Prudent) is EPA contractor for stabilizing lead based paint (LBP). 

Environmental Protection Agency (EPA) has tested your property and has identified it as 

containing LBP. 

EPA has assigned the referenced property to Prudent for paint stabilization. The paint 

Stabilization activity includes scraping the loose and peeling exterior paint, applying a coat of 

primer and painting the exterior of the house. The EPA pays for the cost associated with 

paint stabilization. That means it is free for the homeowner. 

We need your permission to get on your property. Therefore, please contact Prudent as 

soon as you receive this letter. We are requesting your speedy response because we have a 

deadline to complete LBP stabilization of your property. 

If you have any questions please feel free to call Mr. Chandra Shekar at 402-504-1004 or call 

EPA Public Information Center at 402-991-9583. 

Sincerely, 

Mr. Chandra Shekar, P.E. 

Project Manager 

Cell: 402-504-1004 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 218 4242 IMedical Drive, Suite 7250 

Kansas City, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone: (816) 363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax:(816)363-3707 Fax: (402)504-1005 Fax: (210) 579-6577 
i 

TECHNOLOGIES, INC. 

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

SAID: g/V7 7 

l^^^o Se<^^'^'^ Property Address: _ 

Owner's Name: J>^^> ^ Peter s 

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

1 Was the entire structure(8) 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 X 

beams, columns, rails, and exterior surfaces of garages. 

2 Was all scraping and other preparation work completed 

satisfactorily? / 

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

painted with two top coats? / 

4 Are all of the areas where contaminated materials have been spilled 

thoroughly vacuumed/ cleaned? / 

5 Did the contractor collectAracuum all falling and scraped paint chips 

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? / 

7 Was the paint products utilized equivalent to a 30 year 

product/quality? / -

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

cones, barrier tape etc properly removed? / 

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. 1 ^ 

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? J 

12 other Considerations? Property Owner Discussions? Additional 

Work that is Required •J 

Prudent Representative Signature V^ 

Date: 

Property Owner Signature 

Date: 

^]3M 

8080 Ward Parkway, Suite 405 2505 N. 24'" Street, Suite 308 4242 NIedical Drive, Suite 4250 

Kansas City, lUlO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

Phone:(816)363-3703 Phone: (402)504-1004 Phone: (210)822-9588 

Fax: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577