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<br />0---------------------------------------------------------------------- <br />Person who prepared this summary notice: <br />Printed name:-------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />Signature:----------------------------------------------------------- <br />U Date:---------------------------------------------------------------- <br />U---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />street and city:----------------------------------------------------- <br />11---------------------------------------------------------------------- <br />State: ZIP: Phone number: (____)--------------------------- <br /> <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 />1 1---------------------------------------------------------------------- <br />I 1---------------------------------------------------------------------- <br />u---------------------------------------------------------------------- <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) I 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 />1---------------------------------------------------------------------- <br />u---------------------------------------------------------------------- <br />1---------------------------------------------------------------------- <br />U---------------------------------------------------------------------- <br /> <br />present. <br />presumed <br /> <br />to be <br /> <br />~---------------------------------------------------------------------- <br />i_I---------------------------------------------------------------------- <br /> <br />0---------------------------------------------------------------------- <br /> <br />;---------------------------------------------------------------------- <br /> <br />c---------------------------------------------------------------------- <br />L---------------------------------------------------------------------- <br />C---------------------------------------------------------------------- <br />Il---------------------------------------------------------------------- <br />:]---------------------------------------------------------------------- <br />1---------------------------------------------------------------------- <br />l---------------------------------------------------------------------- <br />1---------------------------------------------------------------------- <br /> <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of5 <br />