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