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Printed name: -------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Organization: -------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Street and city: ----------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />State: ZIP: Phone number: ( ) --------------------------- <br />❑---------------------------------------------------------------------- <br />Person who prepared this notice of presumption: <br />Printedname: -------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Signature: ----------------------------------------------------------- <br />❑ Date: ---------------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Organization: -------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Street and city: ----------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />State: ZIP: Phone number: ( ) --------------------------- <br />F1---------------------------------------------------------------------- <br />Appendix D-- Sample Hazard Reduction Completion Notice Format <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations. <br />Summary Notice of Completion of Lead -Based Paint Hazard Reduction <br />Activity <br />Address /location of property or structure(s) this summary notice <br />applies to: <br />❑ ---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Summary of the hazard reduction activity: <br />Start and completion date( s):---------------------------------- - - - - -- <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 />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <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 />Attachment 3 <br />Page 4 of 5 <br />