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Date:---------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />Streetand 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 />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <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 />❑ ---------------------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑ ---------------------------------------------------------------------- <br />Contact person for more information about the risk assessment: <br />Printed name: -------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Organization: -------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Street and city: ----------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />State: ZIP: Phone number: ( )--------------------------- <br />Attachment 3 <br />Page 2 of 5 <br />