TRANSMITTAL O F OMAH A LEAD SITE 

PAINT STABILIZATION FILE FOLDER 

SAID #: 5'/'=?QQ Date: 1 Ic^i^ijrOocfi 

Address: ?^oR fsJ ^<=> .QT 

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

PAINT STABILIZATION 

PROPERTY FILE FOLDER DOCUMENTS 

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 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 

Prudent Technologies, Inc. Signature Date 

' ' Date 

30054874 

IMI 

Superfund 
TBCHNOLOGIBS^ INC. 

Property Summary 

Date: 7/23/2009 | LBP STABILIZATION EPA CONTRACT EP-R7-08-07 | Month of: July 

Property Address: 808 N 49 ST SAID #: 51900 

A. Executive Summarv; 

a. Issues Encountered: NONE 

b. Issues Resolved: NONE 

c. Unique Findings: NONE 

d. Other Relevant Information: 

i. Access Date: 6/11/2009 

u. Work Began: 6/26/2009 

iu. Close-Out Date: 6/29/2009 

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 
Sl^^l> 

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) atMwmberof properties located in Omaha, 

Nebraska, including the property located at Qt) ^ ^ i T T 'Q 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 includir^ 

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. 1 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. 

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:. (Please Print Name) 

Property Owner Signature: ^^^•W.ft^^^ ^j'ljm^ 

PROPERTY INFORMATION 

(Too ititee comolete comoletedd bbyy residen residentt and/o and/orr pn property owner - please print)

RESIDENT NAME 
 Owner Renter'

RESIDENT ADDRESS 


.. >J/My ££) c PiJ€ci^ IF RENTAL. PROPERTY OWNED BY 

OWNER'S MAILING ADDRESS 

OWNER'S TELEPHONE NUMBER • HOME: i 7is.'Z'i?&L Hot. ^ll-^Qj T

NUMBER OF OCCUPANTS UNDER 7 YEARS OLD: d . 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.) 

rp^^r ilJ H60 ^ 

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

ofCERCLA, 42 U.S.C. 9604. EPA's right ofaccess to the property is provided for in Section 104(e) ofCERCLA, 42 U.S. C 9605(e), which provides entiy 

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

( 

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

KansasCity, MO 64114 Omaha, Nebraska 68110 San Antonio, TX 78229 

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

[ 

| 

j 

Notice needed: ^ ^ h ^ 

Number to call to give notice: 

Whom we are giving notice to: 

Home Owner's Signature 

I \ 
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: JJf/J ^£i C r06Cl i 

PROPERTY ADDRESS: '^^ ^ y^y. //<^' ^ </ " 

BVID/SAID: ^/(j^ O 

HOMEOWNERS SIGNATURE: 

QcaJT- ^ T-mA) 

PRUDENT REPRESENTATIVE SIGNATURE 

••^ H 

ANY CONDITIONS NEED TO BE AWARE OF BEFORE SHOOTING VIDEO: 

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

£7^^^ Z ^ ^ f^S IV ^ r ^ 

Property Owned By: \]^A) SltlC fUSCH 

BVID: 

(If rtew property omier) 

f^iokelk T^dd -/^^^^ Cfe^Af^U 

Owners Phone No's: Home: SdS^-^ "713 n^ Work: 

Cell:3/^-W7y Fax: 

Access Contractor. ASW FDA MES PE Other rnA/':h'Ayt' 

fOrcleCne; 

DATE TIME Accessor CX)MTACT DETAIL 

^£ •S-Sr. 5 ^/Wg/ ; /^£f HJriujiiEe 

Comments: 

^ 

(iff.-Gd^dfJ "^e l sidiu^i^ 

Phase vnite leglblyl 
Access Assessment Forai: (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? 

Ifyes, is any ofthe stucco or asbestos damaged or cracked? 

Ifyes, 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? ^ , ^ r Q f^<^ ^ tf^odcm^ 

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? A 

Does this property have any significant structural damage? 

Ifyes, EXPLAIN? 

Does this property have a garage? . 

Ifyes, describe location of garage. 
Does this property have aterrintmi siding? f^ 

Ifyes, is it original factory finish or has it been painted over? Q tJ-jp/l An f I? 

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? d^c , A ^;// ^ ^^/J j j^SlOe y 

Are there any low hanging power lines? 
Is there a neighboring property that needs to be accessed along with assigned 

property to complete stabilization process? 

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

Paint matching form: 

Property address: fO^ IU< 4 ^ €t ^ 

BVID: 5/^^ ^ 

I UNDERSTAND SHERWIN WILLIAMS WILL MATCH MY CURRENT COLORS. 

,/,„, <V.a a«i6 ,/ MUik •''l'^""f 

Page 1 
PRE-STABILIZATION PROPERTY SAFETY ASSESSMENT FORM 

PROPERTY ADDRESS: 

BVID/SAID: 

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.): 

REQUIRES K.ROTHER APPROVAL YES/NO 

SUBMITTED TO K.ROTHER ON: 
808 

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• W * - ;

f\ 

OLOGIBS M

 4-1" s-t . INC 

Checklist for the Worksite Hazard Analysis 

Address: 09) H 4-1 ^ ^^ 

Crew: Date '-(^hH 

arp-p Item OK? Hazard Corrective Action 

Overhead Lines A- Pp«a»r l^^r^e. heUf^A ttt^~ie>m,£ 

In-transit Vehicle Clearance 

\F*^^r* t - ' Cou p U_ i d Cs»cs p«x-V**ti »*^ CT9*-^ 

Levels around high wires 

Vehicle Clearance around 

high wires when working T(A 

Phone lines y g S -: c>Ht(Ve.csk k^Ur^^ . pr^(p^f4^ uy.'N^ p^au^ .^v»< 

Cabl e lines yg-s 

Gas Line JH. ^ 

Water Line 

Sewer Line 

Septic Tank 

Propane/Butane 

^ Access to/on Property 

Neighbor Access Required yg5 r ro w^ g^> ^^ ^>^ bg^^'n^. 'Hy V>(top 

High Traffic Area N P 

I Garage 

y^is- — fi-H-^r.Ui (h ^5^^^^^- ^ 

X 

Structures >>>P 

Driveway 

Sidewalk 

Foundation 

Retaining Walls 

Fences 

Trees e ^ L 'K'rejy. coders ^ocko n o C j^^KSg 

Foliage W ^ 

General Condition of yard 

- ^ Damaged Areas: sink 

holes/rotted wood 

Sprinkler System 

Pets 

i 

i Insects 

Weather Conditions 

Unsafe driving conditions 

Unsafe neighborhood 

m 

Cre> 

Site Safety Officer 

I'auiiQ Ward Pafrkway, Suite 405 2505 N. 24 ' Street. Suite 308 4242 Medical Drive. Suite 4250 

' Kansas Cl'/WIO 64114 Omaha. Nebraska 68110 San Antonio, TX 78229 

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

: F;:^ i816i 363-3707 Fax: (402) 504-1005 Fax: (210)579-6577 






Current Sample We-Renovation Form 

Eftective tmtil April 2010. 

Confinnation of Receipt of Lead Pamphlet 

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

- Informatton for Fmffies, Chiki Care Provhjers and Schools infonning me of 

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

perfonned in my dwelling unit. I received this pamphlet t)efbre the wori< began. 

£ L A 

^nii y 

recipient 

Setf-CertKicaKon Option (for t»iant-cccupied dvireilings only) — 

tf the lead pampMet was delh/ered but a tenant signature was not obtainable, you may ched< the appropriate box below. 

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

pamphlet, ffenovate fVght Important Lead Hazanj Infbnnatkjn fbr Families, 

(M ^ care f^Dvfcllsra and Sc/x»ls, to the rental dvvelling unit listed below at the 

data and time Indicated and that the occupant refused to sign the confinnation 

of rec ^ I further certify that I have left a copy of the pamphlet at the unit with 

the occupant. 

Q UraMaBable for signature — I certify that I have made a good faith eff ort to 

defiver the pamphlet, Renovate Right Important Lead Hazard Information for 

Fences, (M i Care pravkiers and Sdwds , to the rental dweing unit listed 

below and that the occupant was unavailable to sign the confimiation of receipt. 

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

uncto-ttedoor. , . 

Printed name ^ person certifying Attempted delivery 

'" date and time 

lead pamphlet delivery 

Signature of pepton certifying lead pamphlet d^ivery 

g/^g^ M. 4^^< ^ 

UnltAddress 

Note Regaidlng Mtdling Option — As an altemative to delivery In person, you 

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

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

postofiice). 
Douglas County Account Information littp://douglasne.m|^ing-online.coni/E)ouglasCoNe/static/accountinfo. ;.i^^ ] . 

Douglas County, Nebraska Property Record - R0754170000 

Print Report 

NEW Feature - Parcel Dimensions available @ scale 0-50 ft west of 52nd St - VJew On Ma p I Information is valid as of 2009-5-12 

Treasurer's Tax Report 

New Feature - • -4 -> Auto Sales Search 

Owner 

PUSCH JAN E 

S M D 5WflO 

P O BOX 540432 

OI\/IAHA NE 68154-0000 

Property Information 

Key Number: 5417 0000 07 

Account Type: Residential 

Parcel Number: 0754170000 

Parcel Address: 808 N 49 ST 

OIWIAHAjC 68132-0000 

Legal Description: CARTHAGE ADD LOT 11 BLOCK 23 E 60 IH" 47 X 60 

Value Information 

I Land Improvement Total 

2009 $4,300.00 $105,200.00 $109,500.00 

2008 $4,300.00 $105,200.00 $109,500.00 

^2007 I $4,300.00 $105,200.00 $109,500.00 

I 2006 $4,300.00 $73,500.00 $77,800.00 

; 2005 ^ $4,300.00 $73,500.00 $77,800.00 

; 2004 $4,300.00 $73,500.00 $77,800.00 

Land Information 

I Acres i SF Units Depth Width Vacant 

L 0.06 2820.0 1.0 60.0 47.0 No 

Improvement Information 

Building 1 

11 of 2 6/8/2009 11:40 AM 1 
Douglas Coimty Account Infonnation http://douglasne.niaaping-onIine.com/DouglasCoNe/static/accountinfo.. :.m^^i 

1^ ''j^^^^^ ^

1 ^ 

\ 

p^tf'lll, li ^'" 

1 cue K t o EfJ UmGE IMAGE 

Square Footage: 1413.0 

Perimeter 0.0 

Unit Type: 

Built As: 1 1/2 Story Fin 

HVAC: Central Air to Air 

Exterior: Frame Aluminum 

Interior: Drywall 

Roof Cover: Composition Shingle 

Roof Type: Gable 

Floorcover: Allowance 

Year Percent 

year Bui7* Remodeled Remodeled 

1915 0 0% 

Defa/7 Type 

Add On 

Appliance 

Basement 

Fixture 

Fixture 

Garage 

Porch 

Porch 

User 

User 

Detail Description 

Fence Wood 

Allowance 

Bsmnt Block 8 ft 

Base Fixtures 

Bath Full 

Basement Single 

End Screen 

End Screen 

rental 

roof fair 

mv ••tt f 

t -l 

•• ~ i 

i 

i 

i Jt 

mt 

CLICK TO ENLARGE IMAGE 1 

Percent Complete: j 100.0% 

Quality: | Average 

Condition: Fair 

Condo Square Footage: 0.0 

Rooms: 4.0 

Units: 1.0 

Baths: 1.0 

Bedrooms: 3.0 

Stories: 1.5 

Foundation: Block 

Sprinkler Square Footage: 0.0 

— — • — 

Adjusted Year Physical Age Built 

1915 94 

Units 

1.0 

1.0 

1064.0 

1.0 

1.0 

1.0 

70.0 

70.0 

1.0 

1.0 1 

of 2 6/8/2009 11:40 AM 
WhitePages.com - Online Directory Assis .t^t ^ http://www.whitMMges.com/search/ReverseAddress?street=115+S+. lltM^ : .. 

1 Result matching "115 S 121 St, Omaha, NE". 

Jan E Pusch 

115 3 121st St 

Omaha, NE 68154-2229 

phone number unavailable 

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0B'/«Mlp«1 SI 

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NlvacEowLi 

voTTi- i.j.> H!!r v ' 

Listing date Apr. 2009 

SPOrMSORED LII«S 

Research Background info on Jan Pusch 

Name

Jan Pusch

Research Background Info 

 Location 

 Omaha, NE 

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pages 

2 of 3 6/8/2009 11:43 AM 
TECHNOLOGIES. INC. 

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

SAID: S I 9(00 M 

Property Address: *^O p JJ . ^ ^ ^ ^ 

Owner's Name: 

S.N0 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

Performance Standards/close-Out Criteria Yes NO 

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, porches, box 

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

Was all scraping and other preparation work completed 

satisfactorily? 

Were all 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 all falling and scraped paint chips 

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

and also remove any other generated debris? 

Is the grass area that surrounds the structure(s) in reasonably good 

condition? 

Was the paint products utilized equivalent to a 30 year 

product/quality? 

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

cones, barrier tape etc properly removed? 

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. 

Are there any property items that were temporarily re-located by the 

contractor that need to be moved back? 

Are there any (known) lingering issues with the property owner(s) 

that have been left unresolved? 

Other Considerations? Property Owner Discussions? Additional 

Work that is Required 

Prudent Representative Signature: ^^cXj^iUb ^!:k:diiWv 

Date: 6\'^ 

Property Owner Signature: 

Date: 

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

Kansas City, MO 64114 Omaha, Nebrasica 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. 

EPA Close-Out Form (Lead-Based Paint Stabilization) 

BVID: ^ 79 0 O 

Property Address: g^g U /j(^ ^h 

Owner's Name: vjoy ? hj-j c Pu<;^ \ 

S.NO Performance Standards/close-Out Criteria 

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, porches, box 

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 collect/vacuum 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. 

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 

Work that is Required 

EPA COR/ Representative Signature: 

Date: 7/z^/^ f 

Yes NO 

i ^ 

y 

l y 

i x 

y 

y 

^ 

y 

^ 

$ ^ 

^ 

y