TRANSMITTAL OF OMAHA LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID#: «g.^ y ^ ?^ , Date: 

Address: S^:? ^ ^V^>9>^^/^ r .<" ^ • 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

0

^

m

0

M

15^

M

u

y

H

D

^ 

/ 

/ 

 Video of property (DVD): Pre-Stabilization & Post-Stabilization Videos 

 Executive Summary 

 Signed Access Agreement Form 

 Advance Notice Form 

 Pre-Stabilization Video Agreement Form 

 Access Tracking Form 

 Property Access Assessment Form 

 Neighbor Access Agreement Form 

Paint Match Form 

Pre-Stabilization Property Safety Assessment Form 

Work-Site Hazards Analysis Checklist 

Photographs: Pre-Stabilization Propertv Hazard Assessment Photographs 

 Douglas County Assessor Property information 

 Property Completion Agreement Form Signed by Property Owner 

 Property Close-Out Check List Signed By EPA 

PrudSnt TeciinoTogies, Inc. Sign ature Date 

EPA Signature ^ ' Date 

30054953 

nni i 

Superfund 
TECHNOLOGIBS, INC 

Property Summary 

Date: 11/~/2009 LBP STABILIZATION EPA CONTRACT EP-R7-08-07 Month of: Nov. 

Property Address: 3325 Charles St. SAID #: 25573 

A. Executive Summarv: 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 9/21/2009 

ii. Work Began: 9/24/2009 

iii. Close-Out Date: 9/25/2009 

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 
^—-^^^^MJP^'^^^^^^^^ _ ^ TBGHNOLOCIBS^ . INCT" 

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

Agency (EPA) to stabiUj^ Lead£ased Paint (LER) at a number of properties located in Omaha, Nebraska, including the 

propeti, located ^x3%^flX U C^ . ^ ^ T 

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 1 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 bound to the soil cleanup. I further imderstand 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. 

[v'j^es, I have read and understand the paragraph above. 

Signati 

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, 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: ^;fy til ^ 

(Please Print Name) 

Property Owner Signature: 

(Date) 

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

Kansas City, AAO 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 
iiafLOCIBS, INC. 

PROPERTY INFORMATION 

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

RESIDENT NAME: fOv/ne Ownera /Renter 

RESIDENT ADDRESS: 

IF RENTAL, PROPERTY OWNED BY: 

OWNER'S MAILING ADDRESS; 

OWNER'S TELEPHONE NUMBER - HOME: Vjf Q ) . *£ ^ jf ^ ^^ORK : (M^ l y^o O &^/ 7 

NUMBEUM1 R OF OCCUPANTS UNDER 7 YEARS OLD: f j NUMBER OF OCCUPANTS 7 YEARS OLD AND OLDER: 

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.) 

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

pursuani to Seclion 104 ofCERCLA, 42 U.S.C. 9604. EPA's right ofaccess to the property is provided for in Seclion 104(e) ofCERCLA, 

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: (816) 363-3707 Fax: (402)504-1005 Fax:(210)579-6577 
TECHNOLOGIES, 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. AU 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: 3 L^ kA } 

Number to call to give notice: S' ^ ^ 

8&0 

Whom we are giving notice to: 

Home Owner's Signature 

(Es^ . 

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 
TKCHNQLOCIBS,] 

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. 

?>3:>.5 cVyc^^e^ sV OWNERS NAME: 

PROPERTY ADDRESS: 26S7 3 

BVID/SAID: "X S S 7 ^ 

HOMEOWNERS SIGNATURE: 

PRUDENT REPRESENTATIVIVEE SWiNATURE S^I : 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING 

VIDEO: (LE. PETS, NOTICE NEEDED): Cl A/Jy^'t^^'^tij^ 

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,] 

ACCESS INFORMATION TRACKING SHEET 

BVID: 7''5^7 ^ PROPERTY ADDRESS: 1??>^ ^ C/>ff^ 

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 CONRACT DETAIL 

^\>\] ^ 10 t o d^.^^ /f^AyX^^y-Z^J • 

M l 

1 A 

i l 

\ / 

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 
TEQiNOILOGIBS^ INC 

Access Assessment Form: (Must be completed for every property. 

Information must be obtained from a property walk thru, not given 

by owner) 

ry} 

Is the propertjl stucco/Or asbestos? 

>^U- /V 

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

/ ^ ^ O 

Ifyes, 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? 1

Does this property have any significant structural damage? 

Ifyes, 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-«577 
TECHNOUXilSS.] 

Does this property have a garage? 

If yes, describe location of garage. 

Does this property have aluminum siding? 

Ifyes, 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)? 

Ifyes, EXPLAIN? 

Is this property vacant or occupied? 

Are there any pets at this property? 

>.*-<::> 

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-«577 
TSGHNOIXX;iBS.INC. 

NEIGHBORHOOD PROPERTY ACCESS FORM 

IS THERE A NEIGHBORING PROPERTY THAT NEEDS TO BE ACCESSED ALONG 

WITH ASSIGNED PROPERTY TO COMPLETE STABILIZATION PROCESS? 

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 
^OLOGIBS, INC. 

PAINT MATCHING FORM: 

1. TO BE FILLED OUT ONLY IF MATCHING3 COLOR L-UL.UK 

PROPERTY ADDRESS: 33/^_ C ( ^ 

BVID: 2S<:7'a . 

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

Paint Yes Paint No Location Paint Description 

Siding ilvct*) ^ \ / 

Soffit P[\mMi\\uvA (^iJUVt\ 

^ ^ 

Fascia ik.id»J (^^>^^^ | v ^ 

Comer Trim 

Window Trims C^JO<HJ t'^V<' ^ 

Doo \iit6^ tu^Uir*^ r Trims 

Front Porch Ceiling uooo*^ C««^'^k\ 

Front Porch Ceiling Beams 

Front Porch Floor 

Front Porch Railings 

»^e•felJ (, Q la cV^ ^ v ^ 

U^ Front Porch Steps \>SAO^{^^^" ^ \ ^ 

Siding Baseboards 

Foundation 

U«***K^ <Jooans,^a^S 

•htWl'^U-k) y 

^)0* ^ C**^^ ^ i'lM'eHlM^ OtK>t* * 

A l l 1^15^5= Ttcb ^ r3 

yv f ^ I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

Homeowner signature: ITXAJISJ ^ T\.l^^LA^ 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 

^ 
TECHNaUOGIB&] 

PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 

BVID/SAID: 

PRUDENT ASSESSMENT REPERSENTATIVE: 

(2^. ^ U^^^ 

REPERSENTATIVE REMARKS/FINDINGS: 

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

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

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-€577 
Current Sample Pre-Renovation Form 

Effective until April 2010. 

Confijxnation of Receipt of Lead Pamphlet 

!3n 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. 

^^//^ ^ 

Printed nan^e of recipient w/ rriiiitJU I 

Date 

Signature of recipient^ 

Self-Certlflcatlon 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. 

\JAJT^navallabl \ e 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. 

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 ^ Attempted delivery 

date and time 

lead pamphlet delivery 

Signature of person cei/tifying lead pamphlet delivery 

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). 
TECMNOUX;iBS. 

Address: 

Checklist for the VS^prksite Hazard Analysis 

/ 

Crew: Date: 

Item OK? Corrective Action 

Overhead Lines l>-& ^ <^ ^v Jyt<­ 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 cMA^ ai 

Neighbor Access Required („:g^^ ^ 

High Traffic Area 

Garage {jJOdf^ 

i2£ '6 .srz^g^ p v^^x^^. Structures v54uc<>e^ 

Driveway 

Sidewalk 

Foundation 

Retaining Walls . QJCWC^ i 

Fences 

Trees JJX hi>-ci'^ Foliage (XAj.xuuy ^ 

General Condition of yard C \XAJX^ IA/\ 

Damaged Areas: sink .fifeW-t^ ctcO\>a 

holes/rotted wood (jji jy/vs. 

i Sprinkle ^ r System 

Pets ^ i^^-^ 

Insects .j^oS'i.uyts 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood ^ 

rew Foreman/ Sub-Contractor 

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 

j m n 
Douglas County Account Information Page 1 of2 

Douglas County, Nebrasica Property Record - R1642050000 

Print Report 

NEW Feature - Parcel Dimensions available ffl scale 0-50 ft west of 52nd St - VlO W O n Ma P Information is valid as of 2009-9-15 Treasurer's Tax Report 

New Feature •* -•- * Auto Sales Search 

Owner 

KING RILEY 

ETAL 

3325 CHARLES ST 

OMAHA NE 68131-0000 

Property Informatio n 

Key Number 4205 0000 16 

Account Type: Residential 

Parcel Number: 1642050000 

Parcel Address: 

Legal Description: 

3325 CHARLES ST 

OMAHA NE 68131-0000 

LOWES ADD LOT 5 BLOCK TN1/2E40FT40 X 78.5 

Value Informatio n 

2009 

2008 

2007 

2006 

2005 

2004 

Land 

$1,800.00 

$1,800.00 

$1,800.00 

$1,800.00 

$1,800.00 

$1,800.00 

Improvement 

$64,500.00 

$64,500.00 

$64,500.00 

$64,500.00 

$64,500.00 

$28,000.00 

Total 

$66,300.00 

$66,300.00 

$66,300.00 

$66,300.00 

$66,300.00 

$29,800.00 

Land Informatio n 

Acres 

0.07 

SF 

3120.0 

Units 

1.0 

Depth 

78.0 

Width 

40.0 

Vacant 

No 

Improvemen t Informatio n 

Building 1 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.J3p?accountno=R1642050000 9/16/2009 
Douglas County Account Information Page 2 of2 

»KCHWi£Ssr 

11«8T0IIYWmMr<r •«<.• 

CLICK TO ENLARGE IMAGE CLICK TO ENLARGE IMAGE 

Square Footage: i 1664.0 Percent Complete: 100.0% 

Perimeter 0.0 Quality: Average 

Unit Type: Condition: Fair 

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

HVAC: Central Air to Air Rooms: 8.0 

Exterior: Frame Stucco Units: 1.0 

interior Drywall Baths: 1.5 

Roof Cover: Composition Shingle Bedrooms: 4.0 

Roof Type: Hip Stories: 2.5 

Floorcover: Allowance Foundation: Block 

Sprinkler Square Footage: 0.0 

Year Built Year 

Remodeled 

Percent 

Remodeled 

Adjusted Year 

Built Physical Age 

1910 0% 1910 100 

Detail Type Detail Description Units 

Appliance Allowance 1.0 

Basement Bsmnt Block 8 ft 832.0 

Basement Finished 400.0 

Fixture Base Fixtures 1.0 

Fixture Bath Full 1.0 

Fixture Bath Half 1.0 

Garage Detached 264.0 

Porch Slab Roof Ceil 154.0 

http://douglasne.mapping-online.com/DouglasCoNe/static/accountinfo.jsp?accountno=R 1642050000 9/16/2009 
TBCHNOLOGIBS; INC. 

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

SAID: y^^7 ^ 

Property Address: $523 C^a^^^ . ^ 

Owner's Name: 

S.NO Performance Standards/close-Out Criteria Yes 

1 Was the entire 8tructure(s) painted with the exception ofthe 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 

satisfactorily? 1 ^ 

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

painted with two top coats? y 

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

thoroughly vacuumed/ cleaned? y 5 Did the contractor collect/vacuum all falling and scraped paint chips 

an

on

d

 th

 als

e entir

o remov

e property

e any othe

, roadways

r generate

, alleyways

d debris? 

, public access areas y

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 

product/quality? y 

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

cones, barrier tape etc properiy removed? y 

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. 

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 

Woric that is Required 

Prudent Representative Signature 

'Of 

Property Owner Signature: 

Date: 

NO 

y 

i ^ 

^ ' 

1 ^ ­

8080 Ward Parkway, Suite 2506 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) 579-8577