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<br />Printed name:-------------------------------------------------------- <br />D---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />1 1---------------------------------------------------------------------- <br />street and city:----------------------------------------------------- <br />D---------------------------------------------------------------------- <br />state: ZIP: Phone number: (____)--------------------------- <br />1]---------------------------------------------------------------------- <br />Person who prepared this notice of presumption: <br />Printed name:-------------------------------------------------------- <br />D---------------------------------------------------------------------- <br />Signature:----------------------------------------------------------- <br />I] Date: ---------------------------------------------------------------- <br />U---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />I~--------------------------------------------------------------------- <br />Street and city:----------------------------------------------------- <br />LJ---------------------------------------------------------------------- <br />State: ZIP: Phone number: (____)--------------------------- <br />D---------------------------------------------------------------------- <br /> <br />Appendix O--Sample Hazard Reduction Completion Notice Format <br /> <br />Note: The following appendix wi~~ not appear in the Code of <br />Federa~ Regu~ations. <br /> <br />Summary Notice of Comp~etion of Lead-Based Paint Hazard Reduction <br />Activity <br /> <br />Address/~ocation of property or structure(s) this summary notice <br />app~ies to: <br />C---------------------------------------------------------------------- <br />D---------------------------------------------------------------------- <br />LJ---------------------------------------------------------------------- <br /> <br />Summary of the hazard reduction activity: <br />Start and comp~etion date(s) :---------------------------------------- <br /> <br />Activity ~ocations and types. List at ~east the housing unit numbers <br />and common areas (for multifamily housing), bare soil locations, <br />dust-~ead ~ocations, and/or bui~ding components (inc~uding type of <br />room or space, and the material underneath the paint), and types of <br />hazard reduction activities perfo~d at the locations listed: <br />D---------------------------------------------------------------------- <br />U---------------------------------------------------------------------- <br />U---------------------------------------------------------------------- <br />D---------------------------------------------------------------------- <br />D---------------------------------------------------------------------- <br />D---------------------------------------------------------------------- <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 />I 1----------------------------------------------------------____________ <br />Attachment 3 <br />Page 4 of5 <br />