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<br />0----------------------------------------------------__________________ <br />Person who prepared this summary notice: <br />Printed name:---------------------------------------------___________ <br />0------------------------------------------------______________________ <br />Signature:--------------------------------------------_______________ <br />o Date:--------------------------------------------------------________ <br />n------------------------------------------------______________________ <br />Organization:------------------------------------------______________ <br />C-----------------------------------------------------_________________ <br />Street and city:-------------------------------------------------____ <br />C-------------------------------------------------------_______________ <br />State: ZIP: Phone number: (____)--------------------------- <br />~---------------------------------------------------------------------- <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 />0--------------------------------------------__________________________ <br />0----------------------------------------------------__________________ <br />D-------------------------------------------------_____________________ <br />Type of presumption (check all that apply) : <br />(a) ____ Lead-based paint is presumed to be present. <br />(b) Lead-based paint hazard(s) is (are) presumed to be <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 />0-------------------------------------_________________________________ <br />0--------------------------------------------__________________________ <br />L------------------------------------------____________________________ <br />L----------------------------------------______________________________ <br />[---------------------------------------------------------------------- <br /> <br />~---------------------------------------------------------------------- <br /> <br />J--------------------------------------________________________________ <br />D---------------------------------------_______________________________ <br />0------------------------------------__________________________________ <br />0-----------------------------------___________________________________ <br />[---------------------------------------------------------------------- <br />[---------------------------------------------------------------------- <br />J--------------------------------______________________________________ <br />J-----------------------------------------------------_________________ <br />L------------------------------------__________________________________ <br />L------------------------------------__________________________________ <br />~---------------------------------------------------------------------- <br />Contact person for more information about the presumption: <br />1\ttachrnent3 <br />P.e3~5 <br />