TRANSMITTAL of OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: c?5}6 ^ , Date: /^J^jlO 

Address: ^lU / ft-fi^vff^tTF i ^ . 

Stabilization Contractor: Prudent Technologies, Inc. Year: 2010 

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

S/ Video of property (DVD) 

^ Executive Summary 

B^ Signed Access Agreement for subject property 

B^ Pre-Renovation Form signed by Property Owner 

D Pre-Renovation Form for Occupant/Tenant, if applicable 

H Painting Agreement 

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

0^ Renovation Recordkeeping Checklist signed by Certified Renovator 

^ Photographs 

Q^ Satisfactory close-out check list signed by Property Owner 

D Property close-out check list signed by EPA 

y Property information from Douglas Coimty Assessor's Office 

y Hazard analysis, if prepared 

D Safety Audit 30260028 

D Other (describe): 

, .Jl 

Superfund 

ent Technorogy, hic. Signature /Dater 

T5ate 

(afterfile folder review) 
TECHNOLOGIES. 

Property Summary 

Date: 6/29/2010 LBP STABILIZATION EPA CONTRACT EP-R7-08-0' '' Month of: June 

Property Address : 3111 Lafayette Av. SAID #: 25169 

A. Executive Summary: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 04/23/2010 

ii. Work Began: 05/03/2010 

iii. Close-Out Date: 05/04/2010 

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 
- TECHNOLCXSIBS, INC. ~ 

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 ofpropcrties 

located in Omaha, Nebraska, including tiie property located at: " ^ \\ \ (^HJ/ g«_»^ f <?lKy^ -A^- x^ 

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

signing this form, die 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, ifthe soil cleanup has not already been 

performed. I understand that the stabilization contractor cannot provide assurances of which 

contractor will be botmd to the soil cleanup. 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. 

[i^ Yes, I have read and understand the paragraph above. 

J=A. frty Owner's Signature Date 

Ifyou 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, Mr. Chandra 

Shekar at 402- 504-1004 or 402-889-3821. General questions about the Omaha Lead Site cleanup can 

be directed to the EPA Public hiformation Centers at (402) 731-3045 (South Omaha office) or (402) 

991-9583 (North Omaha office). 

Propertv Access Granted By: 

Uij}M^Z^^^.y>zT)^^J/^J 

! Property Owner's Signature Date 

 Please Print Name 

8080 Ward Parkway, Suite 40S 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 

I
PROPERTY INFORMATION 

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

RESIDENT NAME: A\.Ve_A V-gg. ., L Owner y Tenant 

RESIDENT ADDRESS: ^\ \ \ G^^-«^gQ1 d ^ i^^-<. 

IF RENTAL, PROPERTY OWNED BY: _ 

OWNER'S MAILING ADDRESS: ^ 

OWNER'S TELEPHONE NUMBER: 

Home: <^2-.^M^y-IOiC, Work: _ Cell: 

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: 

TOTAL NUMBER OF OCCUPANTS: 2 . 

NUMBER OF CHILDREN UNDER 7 YEARS OLD WHO PLAY IN THE YARD FOR 5 HOURS 

OR MORE PER WEEK: 

COMMENTS OR SPECIAL INSTRUCTIONS (such as dogs, entry gates, etc.): 

<^^c^A. k U r. — ^Qjt ^ ^ K--r 

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 

ofaccess 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." 

Property Owner Signature : C0yCe^.^A^ ^gyyJzL j 

(Signature) 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 
'TBCHNClJOClBS,INCr 

PRE & POST PAINT STABILIZATION VIDEO AND PICTURES 

I understand that prudent Technologies (Prudent) will be conning out to shoot a PreStabilization video and to take pictures of my property. Prudent will use the videos and 

pictures to docunnent the current property status/condition. Also, Prudent will shoot a video 

shot following the completion of the paint stabilization. I give permission to videos and 

pictures of my property. 

Please list any special conditions that Prudent employees need to be aware of before 

shooting a video (such as pets, prior notice, etc.). 

3H l LtLLo^r^^lM (^^,^oJU^ M e ^^t ^ I 

Property Add res^ ' 

Owner's Name Signature Date 

ADVANCE NOTICE REQUIREMENT 

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. Please indicate below how much advance notice you need to have the abovementioned tasks completed. If you are a landlord you will need to contact the tenant as 

Prudent will only inform the property owners. 

Do you have any pets that reside in yard: y^u ^ 

Notice needed: 

Phone number to call to give notice: 

Whom we are giving notice to: 

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 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confirmation of Receipt of Lead Pamphlet 

• I 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. 

I f Printed name of recipient 

/ Sianatur Signature of recipien recioient

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. 

Q 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. 

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

deliver the pamphlet. Renovate Right: Important Lead Hazard Infomnation 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. 

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

under the door. 

Printed name of person certifying

Signature of person certifying lead pamphlet delivery 

Unit Address 

Attempted delivery 

date and time 

lead pamphlet delivery 

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). 
WSl 

TECHNG i,INC 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING COLOR 

PROPERTY ADDRESS: ^\ \ I Lcxjju^ e^^-g-

BVID: 

The following notes are for the benefit of paint crew only. 

Location 

Siding 

Soffit 

Fascia 

Comer Trim 

Window Trims 

Door Trims 

Front Porch Ceiling 

Front Porch Ceiling Beams 

Front Porch Floor 

Front Porch Railings 

Front Porch Steps 

Siding Baseboards 

Foundation 

NJo cu ^^^<_ 

Paint Description 

^ <" CC o 

INSCOX 

V^ood 

N/A 

VOOD ci 

Wood} 

Wtrzjdl 

lO00(^ 

y^oo d 

WJo d cd 

Cor\Cv^-gi^--€--. 

r^/A 

C_O^Cav-«3-e_. 

-7 

 A^^tPaint Yes Paint No 

L ^ 

• I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS 

X^ Homeowner signature: UJ/iyZ^J^/^^.Ult ^ 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 
ACCESS ASSESSMENT FORM: 

Is the property/§tuccaJ)r 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? 

Does this property have any significant structural 

damage? If yes, EXPLAIN? 

Does this property have a garage? 

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 occupied? 

Are there any pets at this property? 

Are there any low hanging power lines? 

Do we need neighbor's access? If yes please explain 

and get neighbor's property address and owner 

information. If possible, get signature from the 

neighbor. 

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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 

ACCESS INFORMATION TRACKING SHEET 

BVID: PROPERTY ADDRESS: 

Property Owned By: Kci^V<^ A L<::&£fe:J-J&. 

(If new property owner) 

Owners Phone No's: Home: Work: 

Cell: Fax: — 

Access Contractor: ASW PDA MES PE Other (Prudent) 

DATE TIME ACCESSOR CONRACT DETAIL 

M)?3 i:p ^ %j \ .v ^ V^ dUcd i^o^- 0»vci ^ <J*^ Cp^'Jr^lASrv^to ^ H> Lo)4-r4 S7f - g 11<_

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 
402-505-8606
 p.2 


RENOVATION RECORDKEEPING CHECKLIST 

Name of Firm: fh £ ^UZ/tdPtniXU ^ 

n"'«e and Location of Renovation: \^J l I f. fl^hUirrt if^lZ/. y , 

.^. .f Description of Renovation: ^^J-Pld L ^^JP L kM^ f I/^/^\ n / ) 

Name of Assigned Renovator: 

Name(s) of Trained Workers, if useed:n./ d / (/zu£ Ip/jrnryJ 

Name of Dust SampHng Technician, 

Inspector, or Risk Assessor, if used: ifz>i "TTrXnokazs •^opies of renovator and dust sampling technician qualifications (training certifications, certifications on fite. 

Certifiedrenovator provided training to workers on (check all that appiy) 

•^-l^ating waming signs vSetting up plastic containment barriers 

Hwiintaining containment v ^Avoiding spread ofdust to adjacent areas 

vwaste handling _i^P6st-renovation cleaning 

Test kits used by certified renovator to determine whether lead was present on components affected 

by renovation (identify kits used and describe sampling locations and results): 

_:^Waming signs posted at entrance to work area. 

\/Work area contained to prevent spread cf dust and debris 

^All objects in the work arearemoved or covered (interior) 

HVAC ducts in the work area closed and covered (interior) 

^Windows in the woric area closed (interior) 

v^indows in and within 20 feet ofthe work area closed (exterior) 

Doors in the work area closed and sealed (interior) 

jj^^poati in and within 20 feet ofthe work area closed and sealed (exterior) 

ySoors that must be used in the work area covered to allow passage but prevent spread ofdust 

^Floors in the work area covered with taped-down plastic (interior) 

y/dround covered by plastic extending 10 feet from work area (exterior) 

v^lastic anchored to building and weighed down by heavy objects (exterior) 

j^ f necessaiy, vertical containment installed to prevent migration ofdust and debris (exterior) 

•^Waste contained on-site and while being transported ofF-site 

.•Work site properly cleaned after renovation 

^^All chip and debris picked up, protective sheeting misted, folded dirty side in, A taped for removal 

Work area surfaces and objects cleaned using HEPA vacuum and/or wet cloths or mops (interior) 

. Certifiedrenovator performed post-renovation cleaning verification (describe results, including the number of wet and 

dry cloths used): 

y If dust clearance testing was performed instead, attach a copy of report, 

y^\ certify under penalty;»fllaw that the above information is true and complete. 

^ f - 4^ M 

Name and Title / / jf Date 
# 

TECHNOLOGIBS, IN C 

Checklist for the Worksite Hazard Analysis 

Address: ^11) ^OLOJI^ ^ /^ y/^y^<v/rry.r y^y.) 

Crew: Date: "^-Al- ib 

Item OK? Hazard Corrective Action

Overhead Lines L</Y\. fcS^

In-transit Vehicle Clearance 

Levels around high wires 

Vehicle Clearance around 

high wires when working 

Phone lines lj(yv^±cpp ~0ci IA J t t^-^irJ - CD h i U^J ^ .^f^Xr€cAj ^ 

Cable lines 

Gas Line 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

Access to/on Property 

Neighbor Access Required :bh^^)-^i-^-' I\ A 

High Traffic Area /U 

Garage AA. structures 

Driveway ^hlhJLk^ JZ^ lUfLul) ^ liyy^n^r^JLJ 'ciZ^.^ ]jiock^ ^v^ *4»^^feaf:^ . 

!4idew9ik oTyyvyTi ' r ^ ^c..*^ 

Foundation j y ^ ^aJluA^^ ^ Ci»»,y^ O^^^^t: ^ 17^-4.^*4^^1^f^JC^tl^M^' 

Retaining Walls CXYly (j}6t UHSC^AJL ^ 

Fences 

Trees ; ^ ^ 

Foliage 

General Condition of yard < 'yt/.6A^ 

Damaged Areas: sink 

boles/rotted wood ^fj?Q.^c.^a^L^^Z^^«^_ A^^n ^ 

Sprinkler System 

Pets (fULX^Yt^i^Jti ^ 

~3BS ^ Insects . ^ ^ trU^AAAiA,y ^ rZ ^ y . va*.otS Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood I ^ 

7W^ - dy^jOu ^ f^^^<UjiM^^>^ 

Crew Foreman 

AtiA >A.x 

8080 Ward P3rkway>5u arkwayrSuitHe 40155 ^ 1 2505 N. 24'"Street, Suite 308 aical Drive, Suite 4250 

Kansas City, MO 64114 i/\Aik 3//6Pmaha,NNebraska 68110 San Antonio, TX 78229 

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

[fyiir l <y\ Phone: ( Fax: (816) 363-3707 (402)504-1005 Fax:(210)579-6577 Fax: (4 
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ENVIRONMEN TAL & CONS'I RUC I lO.N 

TECHNOLOGIES, INC. SERVICK.S 

OMAHA LEAD BASED PAINT REMEDIATION 

Property Owner Close-Out Form 2010 

(Lead-Based Paint Stabilization EPA Contract EP-R7-08-07) 

SAID: J^S-{6^ 

Property Address: 3ift mj.a^jp^Q ML 

Owner's Name: / \ '/v-i ce4^J^J^^ iQ/jy ^ 

Performance Standards/Close-Out Criteria YES NO 

1. Was the entire structure(s) painted with the exception ofthe stated, excluded areas? This 

would include painting of other associated features including fascia, eaves, siding, all trim, 1—'' ' porches, box beams, columns, rails, and exterior surfaces of garages. 

2. Was all scraping and other preparation work completed satisfactorily? y 

3. Were all required areas ofthe structure(s) primed as needed and painted with two top coats? y ^ 

4. Was the paint products utilized equivalent to a 25 year product/quality? y 5. Are all ofthe areas where contaminated materials have been spilled thoroughly vacuumed/ 

1 / cleaned? 

6. Did the contractor collect/vacuum all falling and scraped paint chips on the entire property, 

roadways, alleyways, public access areas and also remove any other generated debris? \ ^ 

7 w< . Is the grass area that surrounds the structure(s) in reasonably good condition? 

8. Are all items such as polyethylene sheeting, ladders, paint brushes, cones, barrier tape, etc. 

properly removed? K y 

9. Is there any evidence ofproperty damage that was done by the contractor? Any property -^ damage needs to be completed prior to the EPA Close-Out. 

10 v / . Are you satisfied with the work performed? 

11. Are there any property items that were temporarily re-located by the contractor that need . y 

to be moved back? 

12. Are there any (known) lingering issues with the property owner(s) that have been left f

unresolved? 

Other Considerations/Property Owner Discussions/Additional Work that is Required: 

Property Owner Signature^ ^ 

^ 

Prudent Inc. Signature 

8080 Ward Parkway, Suite 405 2506 N. 24'" Street, Suite 218 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 
Douglas County Account Information Page 1 of2 

Douglas County, Nebraska Property Record - R1802660000 

Print Reoort 

NEW Future - Parcel Dimensions availabie O scale 0-50 ft west of 52nd St - Vie w OH Ma p Information is valid as of 2010-4-5 Treasurer's Tax Reoort 

New Feature ->-•• • Auto Sales Search 

Owner 

LEWIS MARCEL L 

ETAL 

3111 LAFAYfcTTE AVE 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number 0266 0000 18 

Account Type: Residential 

Parcel Number 1802660000 

Parcel Address: 3111 LAFAYETTE AV 

OMAHA NE 68131-0000 

Legal Description: MONTCLAIR ADD LOT 61 BLOCK 0 45 X 115.7 

Vaiue Infor matio n

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

$2,400.00 

Improvement 

$48,800.00 

$48,800.00 

$48,800.00 

$48,800.00 

$48,800.00 

$21,400.00 

Total 

$51,200.00 

$51,200.00 

$51,200.00 

$51,200.00 

$51,200.00 

$23,800.00 

Land Informatio n 

Acres . 

0.11 

SF 

5175.0 

Units 

1.0 

Depth 

115.0 

Width 

45.0 

Vacant 

No 

Improvemen t Info rmatio n

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R1802660000 4/16/2010 
Douglas County Account Information Page 2 of2 

3111 

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CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: 1540.0 

Perimeter 0.0 

Unit Type: 

Built As: 1 1/2 Story Fin 

HVAC: Central Air to Air 

Exterior: Frame Stucco 

Interior: Drywall 

Roof Cover: Composition Shingle 

Roof Type: Gable 

Floorcover: Allowance 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Percent Complete: 100.0% 

Quality: Average 

Condition: Average 

Condo Square Footage: 0.0 

Rooms: 7.0 

Units: 1.0 

Baths: 1.0 

Bedrooms: 3,0 

Stories: 1.5 

Foundation: Block 

Sprinkler Square Footage: 0.0 

Adjusted Year 

Built Physical Age 

1919 0% 1919 91 

Detail Type 

Appliance 

Basement 

Detail Description 

Allowance 

Bsmnt Block 8 ft 

Units 

1.0 

928.0 

Fixture 

Fixture 

Additional Fixtures 

Base Fixtures 

1.0 

1.0 

Fixture 

Porch 

User 

Bath Full 

Cvrd Wood Deck 

See Notes 

1.0 

116.0 

1.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=Rl 802660000 4/16/2010