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<br />Printed name:----------------------------------------------__________ <br /> <br />IJ----------------------------------------------------__________________ <br /> <br />Organization:------------------------------------------------________ <br /> <br />I j------------------------------------------------______________________ <br /> <br />Street and city:-------------------------------------------------____ <br /> <br />1-----------------------------------------------------_________________ <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />1-----------------------------------------------------_________________ <br /> <br />Person who prepared this notice of presumption: <br /> <br />Printed name:------------------------------------------------------__ <br /> <br />j---------------------------------------------------------------------- <br /> <br />Signature:--------------------------------------------------_________ <br /> <br />1 Date:----------------------~---------------------------------________ <br /> <br />1------------------------------------------------------________________ <br /> <br />Organization:-------------------------------------------------------_ <br /> <br />]---------------------------------------------------------------------- <br /> <br />Street and city:----------------------------------------------------_ <br /> <br />1------------------------------------------------------________________ <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />1-----------------------------------------------------_________________ <br /> <br />Appendix D--Sample Hazard Reduction Completion Notice Format <br /> <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations. <br /> <br />Summary Notice of Completion of Lead-Based Paint Hazard Reduction <br />Activity <br /> <br />Address/location of property or structure(s) this summary notice <br />applies to: <br /> <br />,---------------------------------------------------------------------- <br /> <br />1]_____-----------------------------------------------__________________ <br /> <br />1-----------------------------------------------------_________________ <br /> <br />Summary of the hazard reduction activity: <br />Start and completion date(s) :------------------------------------____ <br /> <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 perfor.med at the locations listed: <br /> <br />---------------------------------------------------------------------- <br /> <br />]---------------------------------------------------------------------- <br /> <br />1-----------------------------------------------------_________________ <br /> <br />]---------------------------------------------------------------------- <br /> <br />1-----------------------------------------------------_________________ <br /> <br />1______-----------------------------------------------_________________ <br /> <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 />1-----------------------------------------------------_________________ <br /> <br />Attachment 3 <br />Page 4 of5 <br />