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Printedname:-------------------------------------------------- - - - - -- <br />---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />---------------------------------------------------------•------------- <br />Streetand 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 />---------------------------------------------------------------- - - - - -- <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 i <br />Pa- e4 of' � <br />