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Date:---------------------------------------------------------------- Organization:-------------------------------------------------------- Street and city:----------------------------------------------------- State: ZIP: -------------------------------------------------- Phone number: (____)------------------------------------------------- Appendix B--Sample Summary Risk Assessment Notice Format Note: This following appendix will not appear in the Code of Federal Regulations Summary Notice of Lead-Based Paint Risk Assessment Address/location of property or structure(s) this summary notice applies to: J---------------------------------------------------------------------- ~---------------------------------------------------------------------- c---------------------------------------------------------------------- Lead-based paint risk assessment description: Date(s) of risk assessment:------------------------------------------ Summary of risk assessment results (check all that apply) : (a) No lead-based paint hazards were found. (b) Lead-based paint hazards were found. (c) ____ A brief summary of the findings of the risk assessment is provided below (required if any lead-based paint hazards were found) . Summary of types and locations of lead-based paint hazards. List at least the housing unit numbers and common areas (for multifamily housing) I bare soil locations, dust-lead locations, and/or building components (including type of room or space, and the material underneath the paint), and types of lead-based paint hazards found: J---------------------------------------------------------------------- 1---------------------------------------------------------------------- 1---------------------------------------------------------------------- J---------------------------------------------------------------------- n---------------------------------------------------------------------- u---------------------------------------------------------------------- 0---------------------------------------------------------------------- u---------------------------------------------------------------------- D---------------------------------------------------------------------- C---------------------------------------------------------------------- 1 ---------------------------------------------------------------------- 1---------------------------------------------------------------------- Contact person for more info~tion about the risk assessment: Printed name:-------------------------------------------------------- cJ______________________________________________________________________ Orqanization:-------------------------------------------------------- n---------------------------------------------------------------------- Street and city:----------------------------------------------------- rc____________________________________________________------------------ State: ZIP: Phone number: ( )--------------------------- Attachment 3 Page 2 of5