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<br />Person who prepared this summary notice: <br /> <br />Printed name:-------------------------------------------------------- <br /> <br />Ij______________________________________________________________________ <br /> <br />Siqnature:----------------------------------------------------------- <br /> <br />Date:---------------------------------------------------------------- <br /> <br />Orqanization:-------------------------------------------------------- <br /> <br />D---------------------------------------------------------------------- <br /> <br />Street and city:----------------------------------------------------- <br /> <br />D---------------------------------------------------------------------- <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br /> <br />u---------------------------------------------------------------------- <br /> <br />Appendix C--Sample Summary Presumption Notice Format <br /> <br />Note: The followinq 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 /> <br />'---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />'---------------------------------------------------------------------- <br /> <br />Type of <br />(a) <br />(b) <br />present. <br />Summary of presumption. List at least the housinq unit numbers and <br />common areas (for multifamily housinq), bare soil locations, dust- <br />lead locations, and/or buildinq components (includinq 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 /> <br />~---------------------------------------------------------------------- <br /> <br />presumption (check all that apply) : <br />Lead-based paint is presumed to be <br />Lead-based paint hazard(s) is (are) <br /> <br />present. <br />presumed to be <br /> <br />j---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />1--------------------------------------------------------______________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />1-------------------------------------------------------_______________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />'---------------------------------------------------------------------- <br /> <br />I '---------------------------------_____________________________________ <br /> <br />j---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />---------------------------------------------------------------------- <br /> <br />--~------------------------------------------------------------------- <br /> <br />'---------------------------------------------------------------------- <br /> <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of5 <br />