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<br />Date:--------------------------------------------____________________ <br /> <br />Organization:--------------------------------------__________________ <br /> <br />Street and city:-------------------------------------------------____ <br /> <br />State: ZIP: -------------------------------------------_______ <br /> <br />Phone number: (____)------------------------------------------------- <br /> <br />Appendix B--Sarnple Summary Risk Assessment Notice Format <br /> <br />Note: This following appendix will not appear in the Code of <br />Federal Regulations <br /> <br />Summary Notice of Lead-Based Paint Risk Assessment <br /> <br />Address/location of property or structure(s) this summary notice <br />applies to: <br /> <br />u------------------------------------------------------------__________ <br /> <br />G-----------------------------------------------------------___________ <br /> <br />0-------------------------------------------------------_______________ <br /> <br />Lead-based paint risk assessment description: <br />Date(s) o~ risk assessment:------------------------------------------ <br /> <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 /> <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 /> <br />i------________________________________________________________________ <br /> <br />LJ--------------------------------------------------____________________ <br /> <br />L--------------------------------------------------____________________ <br /> <br />n----------------------________________________________________________ <br /> <br />_1----------------------------------------------------__________________ <br /> <br />---------------------------------------------------------------------- <br /> <br />LJ-----------------------------------------_____________________________ <br /> <br />" <br />, 1-----------------------------------------------------_________________ <br /> <br />i-' <br />1-----------------------------------------------------_________________ <br /> <br />1---___-----------------------------------------------_________________ <br /> <br />.---------------------------------------------------------------------- <br /> <br />_1----------------------------------------------------__________________ <br /> <br />Contact person for more information about the risk assessment: <br /> <br />Printed name:--------------------------------------------------______ <br /> <br />c---------------------------------------_______________________________ <br /> <br />Organization:-----------------------------------_____________________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />Street and city:-----------------------------------------____________ <br /> <br />~----------------------------------------------------------------------- <br /> <br />State: <br /> <br />ZIP: <br /> <br />Phone number: (____)--------------------------- <br />Attachment 3 <br />Page 2 of5 <br />