Laserfiche WebLink
<br />Printed name:-------------------------------------------------_______ <br />C--------------------------------------------------____________________ <br />Organization:---------------------------------------------___________ <br />[---------------------------------------------------------------------- <br />Street and city:-----------------------------------------____________ <br />~---------------------------------------------------------------------- <br />State: ZIP: Phone number: (_) --------------------------- <br />J--------------------------------------------------____________________ <br />Person who prepared this notice of presumption: <br />Printed name:------------------------------------------------________ <br />n---------------------------------------------_________________________ <br />Signature:------------------------------------------------___________ <br />o Date:---------------------------------------------------_____________ <br />c--------------------------------------------__________________________ <br />Organization:--------------------------------------__________________ <br />[---------------------------------------------------------------------- <br />Street and city:-------------------------------------------__________ <br />~---------------------------------------------------------------------- <br />State: ZIP: Phone number: (_) --------------------------- <br />]---------------------------------------------------------------------- <br /> <br />Appendix D--Sample Hazard Reduction Completion Notice Format <br /> <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations. <br /> <br />Summary Notice of Completion of Lead-Based Paint Hazard Reduction <br />Activity <br /> <br />Address/location of property or structure(s) this summary notice <br />applies to: <br />0-------------------------------------------___________________________ <br /> <br />J----------------------------------------______________________________ <br />0---------------------------------------------_________________________ <br /> <br />Summary of the hazard reduction activity: <br />Start and completion date(s) :-------------------------_______________ <br /> <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 />[---------------------------------------------------------------------- <br />[---------------------------------------------------------------------- <br />]---------------------------------------------------------------------- <br />]---------------------------------------------------------------------- <br />0----------------------------------____________________________________ <br />0------------------------------------__________________________________ <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 />0-----------------------------------___________________________________ <br /> <br />Attachment 3 <br />Page 4 of 5 <br />