### TRANSMITTA LO FOMAH A LEA D SIT E PAIN T STABILIZATIO N FIL EFOLDE R SAI D # : 5'/'=?Q Q Date : 1 Ic^i^ijrOocf i Address : ?^o Rfs J ^<= > .Q T LB PStabilizatio n Contractor : PRUDEN T TECHNOLOGIES , INC . Year : 200 9 PAIN T STABILIZATIO N PROPERT Y FIL EFOLDE RDOCUMENT S B T y y B y ^ y y y y y 0

^ y D ^ Vide o o f propert y (DVD) : Pre-Stabilizatio n & Post-Stabilizatio n Video s Executiv e Summary Signe dAcces s Agreement Form Advanc e Notic e Form Pre-Stabilizatio n Vide o Agreement Form Acces s Trackin g Form Propert y Acces s Assessmen t Form Neighbo r Acces s Agreement Form Pain t Matc hForm Pre-Stabilizatio n Propert y Safet y Assessment Form Work-Site Hazard s Analysi s Checklis t

Photographs : Pre-Stabilizatio n Propert v Hazar dAssessment Photograph s Dougla s County Assessor Propert y informatio n Propert y Completio n Agreement FormSignedby Propert y Owne r Propert y Close-Ou t Chec k Lis t SignedB y EPA Pruden t Technologies , Inc . Signatur e Dat e



### ' ' Date

3005487 4 

# IM I Superfun dTBCHNOLOGIBS ^ INC . 

# Propert y Summar y Date : 7/23/2009 | LB PSTABILIZATIO N EPA CONTRAC T EP-R7-08-0 7 | Mont hof : Jul y Propert y Address : 80 8 N 49 S T SAI D # : 51900 A . Executiv e Summarv ; a . Issue s Encountered : NON E b . Issue s Resolved : NON E c . Uniqu e Findings : NON E d . Othe r Relevan t Information : i . Acces s Date : 6/11/2009 u . Work Began : 6/26/200 9 iu . Close-Ou t Date : 6/29/200 9 B . Enclosures : 1 . Pre-Stabilizatio n Vide o 2 . Post-Stabilizatio n Vide o 3 . Signe dAcces s Agreemen t Form 4 . Advance-Notic e Form 5 . Pre-Stabilizatio n Vide o Agreemen t Form 6 . Acces s Trackin g Form 7 . Propert y Acces s Assessment Form 8 . Neighbo r Acces s Agreemen t Form 9 . Propert y Pain t Matc hForm 10 . Pre-Stabilizatio n Propert y Safet y Assessment Form 11 . Work-Sit e Hazard s Analysi s Checklis t 12 . Pre
- Stabilizatio n Propert y Hazar dAssessment Photograph s 13 . Dougla s County Assessor Propert y Informatio n 14 . Signe dPropert y Completio n Agreement Form 15 . Propert y Close-Ou t Chec k Lis t Signe dB y EPA

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Pruden t Technologies , Inc . (Prudent ) is unde r contrac t (Contrac t #EP-R7-08-07 ) wit hth e U. S. Environmental Protectio n Agenc y (EPA ) to stabiliz e LeadBase dPaint (LBP ) atMwmbero f propertie s locate d in Omaha , Nebraska , includin g th e property locate d at Qt) ^ ^ i T T 'Q T Th e EPA request s you r permissio n to allo w Pruden tto perfor mLB PStabilizatio nat thi s property . By signin g thi s form , th e property owne r grant s permissio n to Pruden t to perfor mactivitie s relate d to LB PStabilizatio n includir ^ scrapin g pain t an dpaintin g ofth e reference dproperty . Further , th e owner/tenan t verifie s that the y hav e receive d th e LB Ppamphle t "Renovat e Right. " By signin g thi s documen t I agre e to allo w an EPA contracto rto conduc t a soi l cleanu pat my property followin g completio n of lead-base dpain t stabilization . I understan dthat th e stabilizatio n contracto r canno t provid e assurance s tha t th e soi l cleanu p contracto r wil l be boun dto . 1 further understan dthat th e soi l cleanu p contracto r wil l make al l reasonabl e effort s to addres s concem s that I, as th e property owner , ma y hav e regardin g soi l cleanu pat my property . Ifyo u hav e an y question s abou t th e LB Pstabilizatio n planne dfor you r property , pleas e contac t Prudent' s Custome r Relations/Offic e Manage r for th e LeadBase dPain t Stabilization , Mrs . Shanno n Holt , at (402 ) 504-100 4 or (402)812-0223 . General question s abou t th e Omah aLeadSite cleanu p canbe directe d to th e EP A Publi c Informatio n Center s at (402 ) 73 1 -304 5 (SouthOmah aoffice ) or (402 ) 991-958 3 (NorthOmah aoffice) . Propert y Acces s Grante dBy: . (Please Prin t Name) Propert y Owne r Signature : 

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# 7is.'Z'i?& L Hot . ^ll-^Qj T OWNER' S TELEPHON E NUMBE R • HOME : i NUMBER OF OCCUPANT S UNDE R 7 YEAR S OLD : . NUMBER OF OCCUPANT S 7 YEAR S OL D AN D OLDER : 

# d NUMBE R OF CHILDRE N UNDE R 7 YEAR S OL D WHO M PLAY IN TH E YAR D FO R 5 HOUR S OR MOR E PE R WEEK : *> COMMENT S OR SPECIA L INSTRUCTIONS : (I.E . DOGS , ENTR YGATES . ETC. ) 

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AUTHORIT YFO R ENVIRONMENTA L RESPONS E ACTIONS : Th e activitie s to

be implemente d byEP Aunde rthi s agreement ar e pursuant to Sectio i 10 4 ofCERCLA , 42 U.S.C . 9604 . EPA' s righ t ofacces s to th e propert y is provide d fo r in Sectio n 104(e) ofCERCLA , 42 U.S . C 9605(e) , whic h provide s enti y fo r"determinin g th e nee d fo rresponse , orchoosin gortakin g anyrespons e actio n unde rthi s title , orotherwis e enforcin g th e provision s ofth e title. " ( BOS O War d Parkway , Suit e 40 5 250 5N. 24' " Street , Suit e 30 8 424 2 Medica l Drive , Suit e 425 0 KansasCity , MO 6411 4 Omaha , Nebrask a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402 ) 504-100 4 Phone : (210)822-958 8

# Advance dnotic e needed . Afte r

signin g th e acces s yo u allo w Prudent t o begi n Lea d Base dPaint Stabilization . Al l Plants , weed s andan y vehicle s or item s on open porc h(enclose dporche s wil l NO T b e stabilized ) mus t b e remove dprio r t o stabilization . Al l Pet s mus t b e ou t

o f yarddurin g stabilization . Ho w muc hnotic e do yo u nee dt o hav e abov e mentione dtask s completed ? Ifyo u ar e alandlor d yo u wil l nee dt o contac t th e tenant a s Prudent Technologie s wil l only infor myou . D o yo u hav e an y pet s tha t

resid e i n yard ? . [ | j

Notic e needed : ^ ^ h ^ Numbe r

to cal l t o giv e notice : Whomw e are givin g notic e to : Hom e Owner' s Signature

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## PRE-STABILIZATIO N VIDE O FOR M I UNDERSTAN D THATPRUDEN TTECHNOLOGIE S WIL L B E COMIN G OU T T O SHOO TAPRE-STABILIZATIO N VIDE O ATM YPROPERTY . TH E VIDE O I S JUS TATOO L USE D T O DOCUMEN TTH E CURREN TPROPERT Y STATUS/CONDITION . APOS TVIDE O WIL L ALS O B E SHOTPRIO R T O COMPLETIO N O F STABILIZATION . 

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## Acces s Assessmen t Forai : (Mus t b e complete dfor every property . Informatio n mus t b e obtaine dfrom apropert y wal k thru , no t give n b y owner ) I s th e propert y stucc o o r asbestos ? Ifyes , i s an y ofth e stucc o o r asbesto s damage do r cracked ? Ifyes , sto p a s w e can' t stabiliz e thi s property . I t require s special preparatio n techniques . I t wil l b e retume dt o EP A an dthe y wil l assig n at alate r date . Doe s thi s propert y requir e lot s o f scrapping ? ^ , ^r Q f^< ^ 

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Doe s thi s propert y requir e alif t o r scaffoldin g t o reac huppe r levels ? Doe s thi s propert y hav e lot s o f plant s o r item s i n area s wher e paintin g i s required ? A Doe s thi s propert y hav e an y significan t structura l damage ? Ifyes , EXPLAIN ? Doe s thi s propert y hav e agarage ? . Ifyes , describ e locatio n o f garage .

## Doe s thi s propert y hav e aterrintm i siding ? 

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Ifyes , i s i t origina l factor y finisho r ha s i t bee n painte dover ? Q tJ-jp/ l An f I ?

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Ifyes , EXPLAIN ?

I s thi s property vacan t o r occupied ?

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Ar e ther e an y lo w hangin g powe r lines ?

## I s ther e aneighborin g propert y tha t need s t o b e accesse dalon g withassigne d propert y t o complet e stabilizatio n process ? I f

so , get asigne dacces s fro mal l necessary neighborin g properties .

## TO B B FILLE D OU T ONL Y I FMATCHINGCOLO R Pain t matching form : Propert y address : fO ^ IU < 4 ^ €t ^ BVID : 5/^^ ^ I UNDERSTAN D SHERWI N WILLIAM S WIL LMATCH MY CURREN T COLORS . 

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# Curren t Sampl e We-Renovatio n For m Eftectiv e tmti l Apri l 2010 . Confinnatio n o f Receip t o f Lea d Pamphle t D1 hav e receive d a cop yo fth e pamphlet , Renovat e Right : Importan t Lea d Hazar d

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th e potentia l ris k o fth e lea d hazar d exposur e fro m renovatio n activit yt o b e perfonne d i n m ydwellin g unit . I receive d thi s pamphle t t)efbr e th e wori < began . 

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# y recipien t Setf-CertKicaKo n Optio n (fo rt»iant-cccupie d dvireiling s only ) — tfth e lea d pampMe t wa s delh/ere d bu t a tenan t signatur e wa s no t obtainable , yo u ma yched < th e appropriat e bo xbelow . •Refusa l t o sign— I certif ythat ! hav e mad e a goo d fait h effor t t o delive rth e pamphlet , ffenovat e fVgh t Importan t Lea d Hazan j Infbnnatkj n fb rFamilies , (M ^ car e f^Dvfcllsra an d Sc/x»ls , t o th e renta l dvvellin g uni t liste d belo wa t th e dat a an d tim e Indicate d an d tha t th e occupan t refuse d t o sig n th e confinnatio n o frec ^

I furthe rcertif ytha t I hav e lef t a cop yo fth e pamphle t a t th e uni t wit h th e occupant . Q UraMaBabl e fo rsignatur e — I certif ytha t I hav e mad e a goo d fait h effor t t o defive rth e pamphlet , Renovat e Righ t Importan t Lea d Hazar d Informatio n fo r Fences , (M i Car e pravkier s an d Sdwds , t o th e renta l dwein g uni t liste d belo wan d tha t th e occupan t wa s unavailabl e t o sig n th e confimiatio n o f receipt. I furtlie rcertif ytha t I hav e lef t a cop yo fth e pamphle t a t th e uni t b yslidin g i t uncto-ttedoor . , . Printe d name ^

perso n certifyin g Attempte d deliver y ' " dat e an d tim e lea d pamphle t delivery Signatur e o fpepto n certifyin g lea d pamphle t d^iver y 

# g/^g ^ M . 4^^< ^ UnltAddres s Not e Regaidln g Mtdlin g Optio n —A s a n altemativ e t o deliveryI n person , yo u ma ymai l th e lea d pamphle t t o th e owne rand/o rtenant . Pamphle t mus t b e maile d a t leas t 7 dc ^

befor e renovatio n (Documen t wit h a certificat e o f mailin g fro m th e postofiice) .Dougla s Count y Account Informatio n littp://douglasne.m|^ing-online.coni/E)ouglasCoNe/static/accountinfo. . ;.i^^ ] Dougla s County , Nebrask a Propert yRecor d - R075417000 0 Prin t Repor t NE

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Buil t As : 1 1/ 2 StoryFi n HVAC : Centra l Ai rt o Ai r Exterior : Fram e Aluminu m Interior : Drywal l Roo f Cover : Compositio n Shingl e

Roo f Type : Gabl e Floorcover : Allowanc e Yea r Percen t yea rBui7 * Remodele d Remodele d 191 5 0 0 % Defa/7 Typ e Ad d O n Applianc e Basemen t Fixtur e Fixtur e Garag e Porc h Porc h Use r Use r Detai l Descriptio n Fenc e Woo d Allowanc e Bsmn t Bloc k 8 f t Bas e Fixture s Bat h Ful l Basemen t Singl e En d Scree n En d Scree n renta l roo f fai r m v ••tt f t - l • • ~ i i i i J t m t

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## Pruden t Propert yClose-Ou t For m (Lead-Base d Pain t Stabilization ) SAID : S I 9(0 0 

# M Propert yAddress : *^O p JJ . ^ ^ ^ ^ Owner' s Name :

S.N 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 Performanc e Standards/close-Ou t Criteri a Ye s N O Wa s th e entir e structure(s ) painte d wit h th e exceptio n ofth e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . Wa s al l scrapin g an d othe rpreparatio n wor k complete d satisfactorily ? Were al l require d area s o f th e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? Ar e al l ofth e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s area s an d als o remov e an yothe rgenerate d debris ? I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea r product/quality ? Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et cproperl yremoved ? I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . Ar e ther e an ypropert yitem s tha t wer e temporaril yre-locate d b yth e contracto rtha t nee d t o b e move d back ? Ar e ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? Othe rConsiderations ? Propert yOwne rDiscussions ? Additiona l Wor k tha t i s Require d 

### Pruden t Representativ e Signature : 

## ^^cXj^iU b ^!:k:diiW v Date : 6\' ^ Propert yOwne rSignature : Date : 808 0 War d Parkway , Suit e 40 5 250 5 N . 24* " Street , Suit e 30 8 424 2 Medica i Drive , Suit e 425 0 Kansa s City , M O 6411 4 Omaha , Nebrasic a 6811 0 Sa n Antonio , TX 7822 9 Phone : (816 ) 363-370 3 Phone : (402)504-100 4 Phone : (210)822-958 8 Fax ; (816 ) 363-370 7 Fax : (402)504-100 5 Fax : (210 ) 579-657 7TECHNOLOGIES; , INC . 

## EPAClose-Ou t For m (Lead-Base d Pain t Stabilization ) BVID : ^ 

# 79 0 O Propert yAddress : 

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# ^ h Owner' s Name : vjoy ? 

## hj-j cPu<;^ \ S.N O Performanc e Standards/close-Ou t Criteri a 1 Wa s th e entir e structure(s ) painte d wit h th e exceptio n ofth e stated , exclude d areas ? Thi s woul d includ e paintin g o f othe rassociate d feature s includin g fascia , eaves , siding , al l trim , porches , bo x beams , columns , rails , an d exterio rsurface s o f garages . 2 Wa s al l scrapin g an d othe rpreparatio n wor k complete d satisfactorily ? 3 Were al l require d area s o f th e structure(s ) prime d a s neede d an d painte d wit h tw o to p coats ? 4 Ar e al l o f th e area s wher e contaminate d material s hav e bee n spille d thoroughl yvacuumed / cleaned ? 5 Di d th e contracto rcollect/vacuu m al l fallin g an d scrape d pain t chip s o n th e entir e property , roadways , alleyways , publi cacces s area s an d als o remov e an yothe rgenerate d debris ? 6 I s th e gras s are a tha t surround s th e structure(s ) i n reasonabl ygoo d condition ? 7 Wa s th e pain t product s utilize d equivalen t t o a 3 0 yea r product/quality ? 8 Ar e al l item s suc h a s polyethylen e sheeting , ladders , pain t brushes , cones , barrie rtap e et cproperl yremoved ? 9 I s ther e an yevidenc e o f propert ydamag e tha t wa s don e b yth e contractor ? An ypropert ydamag e need s t o b e complete d prio rt o th e EP AClose-Out . 1 0 Ar e ther e an ypropert yitem s tha t wer e temporaril yre-locate d b yth e contracto rtha t nee d t o b e move d back ? 1 1 Ar e ther e an y(known ) lingerin g issue s wit h th e propert yowner(s ) tha t hav e bee n lef t unresolved ? 1 2 Othe rConsiderations ? Propert yOwne rDiscussions ? Additiona l Wor k tha t i s Require d



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