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Printed name: -------------------------------------------------------- ❑---------------------------------------------------------------------- Organization:-------------------------------------------------------- ❑---------------------------------------------------------------------- Street and city: ----------------------------------------------------- ❑---------------------------------------------------------------------- State: ZIP: Phone number: ( ) --------------------------- ---------------------------------------------------------------------- Person who prepared this notice of presumption: Printed name: ---- ---------------------------------------------------- ❑---------------------------------------------------------------------- Signature:----------------------------------------------------------- ❑ Date: ---------------------------------------------------------------- ❑---------------------------------------------------------------------- Organization:-------------------------------------------------------- ---------------------------------------------------------------------- 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: ------ - ----------------------------------------------------------- ----------------------------------------------------------------------- ---------------------------------------------------------------------- ---------------------------------------------------------------------- ❑-------------------------------------------------------------------------------------------------------------------------------------------- - 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