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<br />Printed name:---------------------------------_______________________ <br /> <br />Q---------------------------------------------------------------------- <br /> <br />Organization:-----------------------------___________________________ <br /> <br />n----------------------------------____________________________________ <br /> <br />Street and city:---------------------------------____________________ <br /> <br />0-------------------------------------_________________________________ <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />C-------------------------------------_________________________________ <br /> <br />Person who prepared this notice of presumption: <br /> <br />Printed name:--------------------------------________________________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />Signature:----------------------------------_________________________ <br /> <br />n Date:------------------------------------____________________________ <br /> <br />0-----------------------------------___________________________________ <br /> <br />Organization:----------------------------____________________________ <br /> <br />n---------------------------------_____________________________________ <br /> <br />Street and city:-------------------------------______________________ <br /> <br />C----------------------------------____________________________________ <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <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 /> <br />C-------------------------------_______________________________________ <br /> <br />0-------------------------------_______________________________________ <br /> <br />Q---------------------------------------------------------------------- <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 />C---------------------------___________________________________________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />n--------------------------____________________________________________ <br /> <br />n--------------------------____________________________________________ <br /> <br />n----------------------------__________________________________________ <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 />n------------------------______________________________________________ <br /> <br />Attachment 3 <br />Page 4 of5 <br /> <br />