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<br />D-------------------------------------------___________________________ <br />Person who prepared this summary notice: <br />Printed name:--------------------------------------__________________ <br />~---------------------------------------------------------------------- <br />Signature:-------------------------------------______________________ <br />J Date:----------------------------------------________________________ <br />l-------------------------------------------___________________________ <br />Organization:----------------------------------______________________ <br />J--------------------------------------________________________________ <br />Street and city:--------------------------------_____________________ <br />]---------------------------------------------------------------------- <br />State: ZIP: Phone number: (____)--------------------------- <br />L-----------------------------------------_____________________________ <br /> <br />Appendix C--Sample Summary presumption Notice Format <br /> <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations <br /> <br />Notice That Lead-Based Paint or Lead-Based Paint Hazards Are Presumed <br />to be Present <br /> <br />Address/location of property or structure(s) this notice of <br />presumption applies to: <br /> <br />!,---------------------------------------------------------------------- <br /> <br />j---------------------------------------------------------------------- <br /> <br />J---------------------------------------_______________________________ <br />Type of presumption (check all that apply) : <br />(a) Lead-based paint is presumed to be <br />(b) Lead-based paint hazard(s) is (are) <br />present. <br />Summary of presumption. List at least the housing unit numbers and <br />common areas (for multifamily housing), bare soil locations, dust- <br />lead locations, and/or building components (including type of room <br />or space, and the material underneath the paint), and types of lead- <br />based paint hazards presumed to be present: <br />c-----------------------------------___________________________________ <br />[---------------------------------------------------------------------- <br />J------------------------------________________________________________ <br />l---------------------------___________________________________________ <br />]---------------------------------------------------------------------- <br />[---------------------------------------------------------------------- <br />]---------------------------------------------------------------------- <br />l-------------------------_____________________________________________ <br />D-------------------------------_______________________________________ <br />[---------------------------------------------------------------------- <br />[---------------------------------------------------------------------- <br />Cl-----------___________________________________________________________ <br />D--------------------------____________________________________________ <br />1-----------------------------------------------------_________________ <br /> <br />present. <br />presumed <br /> <br />to be <br /> <br />1------------------------______________________________________________ <br /> <br />J-------------------------_____________________________________________ <br />D------------------------______________________________________________ <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of5 <br />