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Printed nave; ------------------------------------------------------- <br />--------------------------------------------------------------------- <br />Organization:------------------------------------------------------- <br />Streetand city: ---------------------------------------------------- <br />---------------------------------------------------------------------- <br />State: ZIP: Phone nunber: ( )--------------------------- <br />---------------------------------------------------------------------- <br />Per son vkho pr epar ed t hi s not i ce of pr esurrpt i on: <br />Printed narm: -------------------------------------------------------- <br />---------------------------------------------------------------------- <br />Signature: ---------------------------------------------------------- <br />❑ Date: ---------------------------------------------------------------- <br />---------------------------------------------------------------------- <br />Organization: ------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Street and city: ----------------------------------------------------- <br />�---------------------------------------------------------------------- <br />State: ZIP: Phone nunber: ( —) --------------------------- <br />---------------------------------------------------------------------- <br />Appendi x D. - Sarrpl a Hazar d Reduct i on Corrpl et i on Not i ce For rmt <br />Not e: The f of 1 ow ng append! x W I I not appear i n the Code of <br />Federal Regul at i ons. <br />Sumner y Not i ce of Corrpl et i on of Lead- Based Pai nt Bazar d Reduct i on <br />Act i vi t y <br />Address/ 1 ocat i on of property or structure(s) this sunnar y notice <br />appl i es to: <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Sumrar y of the hazard reduction activity: <br />Start and conpletion date(s): ---------------------------------------- <br />Activity <br />--------------------------------------- <br />Activity I ocat i ons and types. List at least the housing unit nunber s <br />and corm n areas ( f or rrul t i f arriI y housi ng) , bare soil l ocat i ons, <br />dust -lead locations, and/ or bui I di ng conponent s (including type of <br />r oom or space, and the net er i al underneath the paint), and types of <br />hazard reduction activities per f or ned at the I ocat i ons listed: <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Dat e(s) of clearance t est i ng and/or soil analyses: <br />Locat i ons of bui I di ng corrponent s w t h I ead- based paint r ermi ni ng in <br />the r oons, spaces or areas Mere activities were conducted: <br />❑---------------------------------------------------------------------- <br />Attachment 3 <br />Page 4 of 5 <br />