PAINT YOUR HEART OUT - 2006 - Laserfiche WebLink

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Printed name:-------------------------------------------------------- ~---------------------------------------------------------------------- Organization:-------------------------------------------------------- U---------------------------------------------------------------------- Street and city:----------------------------------------------------- 8---------------------------------------------------------------------- State: ZIP: Phone number: (_____)--------------------------- u---------------------------------------------------------------------- Person who prepared this notice of presumption: Printed name:-------------------------------------------------------- ~---------------------------------------------------------------------- Signature:----------------------------------------------------------- o Date:---------------------------------------------------------------- u---------------------------------------------------------------------- Organization:-------------------------------------------------------- !l---------------------------------------------------------------------- Street and city:----------------------------------------------------- J--------------------------------------------------------------------__ State: ZIP: Phone number: (_____)--------------------------- G-----------------------------------------------------------------_____ Appendix D--Sample Hazard Reduction Completion Notice Format Note: The fo~~owing appendix wi~~ not appear in the Code of Federa~ Regu~ations. SUlIIIIlary Notice of Comp~etion of Lead-Based Paint Hazard Reduction Activity Address/~ocation of property or structure(s) this SUJlllllary notice app~ies to: u---------------------------------------------------------------_______ J-----------------------------------------------------------------_____ 0-----------------------------------------------------------___________ SUIIlIIlllry of the hazard reduction activity: Start and comp~etion date(s) :--------------------------------________ Activity ~ocations and types. List at ~east the housing unit numbers and common areas (for lIlU~tifami~y housing), bare soi~ ~ocations, dust-~eed ~ocations, and/or bui~ding components (inc~uding type of room or space, and the materia~ underneath the paint), and types of hazard reduction activities performed at the locations ~isted: ~---------------------------------------------------------------------- ~ ---------------------------------------------------------------------- L--------------------------------------------------------------________ '1--------------------------------------------------------______________ ~---------------------------------------------------------------------- r!--------------------------------------------------__-_________________ Date(s) of clearance testing and/or soi~ ana~yses: ____ Locations of bui~ding components with lead-based paint remaining in the rooms, spaces or areas where activities were conducted: 1______-----------------------------------------------_________________ Attachment 3 Page 4 of 5