WISE Place 14 - Laserfiche WebLink

Home Browse Search

.. .. Printed name:------------------------------------------______________ D-----------------------------------------------_______________________ Organization:-------------------------------------___________________ ---------------------------------------------------------------------- Street and city:---------------------------------------______________ D----------------------------------------------________________________ State: ZIP: Phone number: (____)--------------------------- c-----------------------------------------------_______________________ Person who prepared this notice of presumption: Printed name:------------------------------------------______________ D-------------------------------------------___________________________ Signature:---------------------------------------____________________ U Date:--------------------------------------------____________________ D----------------------------------------------________________________ Organization:---------------------------------------_________________ D------------------------------------------____________________________ Street and city:-----------------------------------------____________ D------------------------------------------____________________________ State: ZIP: Phone number: (____)--------------------------- D------------------------------------------____________________________ 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: D----------------------------------------______________________________ D--------------------------------------________________________________ C--------------------------------------________________________________ 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: D--------------------------------______________________________________ D-----------------------------------___________________________________ u---------------------------------_____________________________________ D--------------------------------______________________________________ D-------------------------------_______________________________________ D----------------------------------____________________________________ 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: D------------------------------________________________________________ Attachment 3 Page 4 of5