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Printed name:--------------------------------------__________________ J-----------------------------------------_____________________________ Organization:-----------------------------------_____________________ J---------------------------------------_______________________________ Street and city:-----------------------------------__________________ J------------------------------------------____________________________ State: ZIP: Phone number: (____)--------------------------- ---------------------------------------------------------------------- Person who prepared this notice of presumption: Printed name:-------------------------------------___________________ [---------------------------------------------------------------------- Signature:----------------------------------_________________________ J 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: J----------------------------------------______________________________ ]---------------------------------------------------------------------- ]---------------------------------------------------------------------- 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: ]---------------------------------------------------------------------- [---------------------------------------------------------------------- J------------------------------------__________________________________ ]---------------------------------------------------------------------- [---------------------------------------------------------------------- ]---------------------------------------------------------------------- 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