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<br />Date:----------------------------------------________________________ <br />Organization:------------------------------------____________________ <br />Street and city:-------------------------------______________________ <br />State: ZIP: ----------------------------______________________ <br />Phone number: (____)------------------------------------------------- <br /> <br />Appendix B--Sample Summary Risk Assessment Notice Format <br /> <br />Note: This following appendix will not appear in the Code of <br />Federal Regulations <br /> <br />Summary Notice of Lead-Based Paint Risk Assessment <br /> <br />Address/location of property or structure(s) this summary notice <br />applies to: <br />0--------------------------------------------__________________________ <br />U-----------------------------------------_____________________________ <br />U-----------------------------------------_____________________________ <br />Lead-based paint risk assessment description: <br />Date(s) of risk assessment:----------------------------------________ <br /> <br />Summary of risk assessment results (check all that apply) : <br />(a) ____ No lead-based paint hazards were found. <br />(b) ____ Lead-based paint hazards were found. <br />(c) ____ A brief summary of the findings of the risk assessment <br />is provided below (required if any lead-based paint hazards were <br />found) . <br /> <br />Summary of types and locations of lead-based paint hazards. List at <br />least the housing unit numbers and common areas (for multifamily <br />housing), bare soil locations, dust-lead locations, and/or building <br />components (including type of room or space, and the material <br />underneath the paint), and types of lead-based paint hazards found: <br />0-----------------------------------___________________________________ <br />0---------------------------------_____________________________________ <br />l------------------------------________________________________________ <br />~---------------------------------------------------------------------- <br />[---------------------------------------------------------------------- <br />J-----------------------------------------------------_________________ <br />l-----------------------------_________________________________________ <br />0---------------------------------_____________________________________ <br />L--------------------------------______________________________________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />J-----------------------------------------------------_________________ <br />]---------------------------------------------------------------------- <br /> <br />Contact person for more information about the risk assessment: <br />Printed name:-----------------------------___________________________ <br />J-----------------------------------------------------_________________ <br />Organization:-------------------_____________________________________ <br />[---------------------------------------------------------------------- <br />Street and city:-----------------------______________________________ <br />iJ----------------------------__________________________________________ <br />State: ZIP: Phone number: (____)--------------------------- <br />Attachment 3 <br />Page 2 of5 <br />