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<br />Printed name:-------------------------------------------------------- <br /> <br />L;---------------------------------------------------------------------- <br /> <br />Organization:-------------------------------------------------------- <br /> <br />Il---------------------------------------------------------------------- <br /> <br />Street and city:----------------------------------------------------- <br /> <br />j---------------------------------------------------------------------- <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />~---------------------------------------------------------------------- <br /> <br />Person who prepared this notice of presumption: <br /> <br />Printed name:-------------------------------------------------------- <br /> <br />~J---------------------------------------------------------------------- <br /> <br />Signature:----------------------------------------------------------- <br /> <br />Date:---------------------------------------------------------------- <br /> <br />u---------------------------------------------------------------------- <br /> <br />Organization:-------------------------------------------------------- <br /> <br />u---------------------------------------------------------------------- <br /> <br />Street and city:----------------------------------------------------- <br /> <br />[J---------------------------------------------------------------------- <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />1---------------------------------------------------------------------- <br /> <br />Appendix O--Sample Hazard Reduction Completion Notice Format <br /> <br />Note: The fo11owing appendix wi11 not appear in the Code of <br />Federa1 Regu1ations. <br /> <br />Summary Notice of Comp1etion of Lead-Based Paint Hazard Reduction <br />Activity <br /> <br />Address/1ocation of property or structure(s) this summary notice <br />app1ies to: <br /> <br />LJ---------------------------------------------------------------------- <br /> <br />u---------------------------------------------------------------------- <br /> <br />[J---------------------------------------------------------------------- <br /> <br />Summary of the hazard reduction activity: <br />Start and comp1etion date(s) :---------------------------------------- <br /> <br />Activity 1ocations and tyPes. List at 1east the housing unit numbers <br />and common areas (for mu1tifami1y housing), bare soi1 1ocations, <br />dust-1ead 1ocations, and/or bui1ding components (inc1uding tyPe of <br />room or space, and the materia1 underneath the paint), and tyPes of <br />hazard reduction activities performed at the 1ocations 1isted: <br /> <br />u-------------------------------------------------------------_________ <br /> <br />1------------------------------------------------------------------____ <br /> <br />~---------------------------------------------------------------------- <br /> <br />LJ-----------------------------------------------------------___________ <br /> <br />1-----------------------------------------------------_________________ <br /> <br />, ' <br />I '---------------_______________________________________________________ <br /> <br />Date(s) of c1earance testing and/or soi1 ana1yses: ____ <br />Locations of bui1ding components with 1ead-based paint remaining in <br />the rooms, spaces or areas where activities were conducted: <br /> <br />n-------------------------------------------------_____________________ <br /> <br />Attachment 3 <br />Page 4 of 5 <br />