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Printed name: -------------------------------------------------------- <br />-1 ---------------------------------------------------------------------- <br />Organization: -------------------------------------------------------- <br />�---------------------------------------------------------------------- <br />Street and city:----------------------------------------------------- <br />---------------------------------------------------------------------- <br />State: ZIP: Phone number: ()--------------------------- <br />❑---------------------------------------------------------------------- <br />Person who prepared this notice of presumption: <br />Printed name: -------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Signature: ----------------------------------------------------------- <br />❑ Date:---------------------------------------------------------------- <br />C---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />L---------------------------------------------------------------------- <br />Streetand city:----------------------------------------------------- <br />E---------------------------------------------------------------------- <br />State: ZIP: Phone number: () --------------------------- <br />r --- - - -- -- - - - - - -- ------- ---- - - - - -- ---------- ---------- -- - - - - -- <br />Appendix D-- Sample Hazard Reduction Completion Notice Format <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations. <br />Summary Notice of Completion of Lead -Based Paint Hazard Reduction <br />Activity <br />Address /location of property or structure(s) this summary notice <br />applies to: <br />D---------------------------------------------------------------------- <br />Summary of the hazard reduction activity: <br />Start and completion date( s):---------------------------------- - - - - -- <br />Activity locations and types. List at least the housing unit numbers <br />and common areas (for multifamily housing), bare soil locations, <br />dust -lead locations, and /or building components (including type of <br />room or space, and the material underneath the paint), and types of <br />hazard reduction activities performed at the locations listed: <br />r---------------------------------------------------------------------- <br />E---------------------------------------------------------------------- <br />E---------------------------------------------------------------------- <br />L---------------------------------------------------------------------- <br />I---------------------------------------------------------------------- <br />El---------------------------------------------------------------------- <br />Date(s) of clearance testing and /or soil analyses: _ <br />Locations of building components with lead -based paint remaining in <br />the rooms, spaces or areas where activities were conducted: <br />---------------------------------------------------------------------- <br />Attachment 3 <br />Page 4 of 5 <br />