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Date:___________ ________ - - -- <br />Organization:_________________________________' <br />Street and city:----------------------------------------------------- <br />State:_ ZIP: -------------------------------------------------- <br />Phone number: ( )__________________ _____________ __________________ <br />Appendix B-- Sample Summary Risk Assessment Notice Format <br />Note: This following appendix will not appear in the Code of <br />Federal Regulations <br />Summary Notice of Lead -Based Paint Risk Assessment <br />Address /location of property or structure(s) this summary notice <br />applies to: <br />i'------------------------ <br />-------- ------------------------------------------------- <br />Lead -based paint risk assessment description: <br />Date(s) of risk assessment:------------------------------------ - - - - -- <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 />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 />F- <br />F---------------------------------------------------------------------- <br />.---------------------------------------------------------------------- <br />�._ ___________________________ __________________ _____________ <br />I___- ______ _______________ _______________________________ <br />Contact person for more information about the risk assessment: <br />Printed name:________ _______________________________ <br />______ <br />_______________________________________ ____________ ___________________ <br />Organization:_________________________ __________ ______________ _______ <br />Street and city: <br />_______________ _____ -___-_---- _____________- __________ -__ <br />State: ZIP: Phone number: () - - -- <br />Attachment 3 <br />Page 2 of 5 <br />