WOMEN'S TRANSITIONAL LIVING CENTER - 2007

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Printed name:-----------------------------------------------------___ ~J--------------------------------------------------____________________ Organization:-------------------------------------------------------- ~---------------------------------------------------------------------- Street and city:----------------------------------------------------- J---------------------------------------------------------_____________ State: ZIP: Phone number: (____)--------------------------- 0------------------------------------------------------------------____ Person who prepared this notice of presumption: Printed name:-------------------------------------------------------_ -1----------------------------------------------------__________________ Signature:----------------------------------------------------------_ Date:---------------------------------------------------------------- ,J---------------------------------------------------------------------- Organization:-------------------------------------------------------- iJ---------------------------------------------------------------------- Street and city:----------------------------------------------------- 1-----------------------------------------------------_________________ State: ZIP: Phone number: (____)--------------------------- ---------------------------------------------------------------------- Appendix D--Sample Hazard Reduction Completion Notice Format Note: The fo11owing appendix wi11 not appear in the Code of Federa1 Regu1ations. Summary Notice of Comp1etion of Lead-Based Paint Hazard Reduction Activity Address/1ocation of property or structure(s) this summary notice app1ies to: i---------------------------------_____________________________________ i______________________________________________________________________ 1--_-__-----------------------------------------------_________________ Summary of the hazard reduction activity: Start and comp1etion date(s) :-----------------------------------_____ Activity 1ocations and types. List at 1east the housing unit numbers and common areas (for mu1tifamily housing), bare soi1 1ocations, dust-1ead 1ocations, and/or bui1ding components (inc1uding type of room or space, and the materia1 underneath the paint), and types of hazard reduction activities performed at the 1ocations 1isted: '---------------------------------------------------------------------- ---------------------------------------------------------------------- ---------------------------------------------------------------------- i~----------------------------------------______________________________ 0-----------------------------------------_____________________________ 0-----------------------------------------_____________________________ Date(s) of c1earance testing and/or soil ana1yses: Locations of bui1ding components with 1ead-based paint remaining in the rooms, spaces or areas where activities were conducted: J------------------------------------__________________________________ Attachment 3 Page 4 of5