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Printed name: <br />------------------------------------- <br />------------------- <br />--------------------------------------- <br />------------------------------- <br />Organization:-------------------------------------------------------- <br />------------------------ <br />------------------------------- <br />Street and city ----------------------------------------------------- <br />--------------------------------------------------------------------- <br />State: ZIP: Phone number: (_)--------------------------- <br />❑-------------------- <br />--------------------------- <br />Person who prepared this notice of presumption: <br />Printed name: -------------------------------------------------------- <br />---------------------------------- <br />------------------------------------- <br />Signature:----------------------------------------------------------- <br />Date: ---------------------------------------------------------------- <br />---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />L'---------------------------------------------------------------------- <br />Street and city: ----------------------------------------------------- <br />---------------------------------------------------------------------- <br />State: ZIP: Phone number: ()--------------------------- <br />L---------------------------------------------------------------------- <br />Appendix D--Sample Hazard Reduction Completion Notice Format <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations. <br />Summary Notice of Completion of Lead -Based Paint Hazard Reduction <br />Activity <br />Address/location of property or structure(s) this summary notice <br />applies to: <br />-1---------------------------------------------------------------------- <br />---------------------------------------------------------------------- <br />---------------------------------------------------------------------- <br />Summary of the hazard reduction activity: <br />Start and completion date(s): ---------------------------------------- <br />Activity locations and types. List at least the housing unit numbers <br />and common areas (for multifamily housing), bare soil locations, <br />dust -lead locations, and/or building components (including type of <br />room or space, and the material underneath the paint), and types of <br />hazard reduction activities performed at the locations listed: <br />F---------------------------------------------------------------------- <br />------------------------------------------------------------------ <br />---------------------------------------------------------------------- <br />---------------------------------------------------------------------- <br />----------------------------------------------------------------------- <br />'-J---------------------------------------------- <br />------------------------ <br />Date(s) of clearance testing and/or soil analyses: _ <br />Locations of building components with lead -based paint remaining in <br />the rooms, spaces or areas where activities were conducted: <br />❑---------------------------------------------------------------------- <br />Attachment 3 <br />Page 4 of 5 <br />