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Date: --------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />Streetand city: ---------------------------------------------------- <br />State: ZIP: -------------------------------------------------- <br />Phone nurrber: ()------------------------------------------------- <br />Appendi x B- - Sampl a Sumrar y Fa sk Assessment Not i ce For mat <br />Not e: Thi s f of I oW ng appendi x W I 1 not appear i n t he Code of <br />Federal Regulations <br />Surnmry Notice of Lead -Based Paint Risk Assessnent <br />Address/ I ocat i on of property or st r uct ur e( s) this sunnar y notice <br />appl i es to: <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Lead- based paint risk assessnent description: <br />Date(s) of risk assessnent:----------------------------------------- <br />Sumrar y of risk assessrwnt results ( check all that apply): <br />( a) No I ead- based paint hazards ver a found. <br />( b) Lead-based paint hazards mere found. <br />( c) A br i of sunner y of the f i ndi ngs of the risk assessment <br />i s pr ovi ded bel ow ( r equi r ed i f any I ead- based pal nt hazar ds ver e <br />f ound) . <br />Summar y of t ypes and I ocat i ons of I ead- based pal nt hazar ds. Li st at <br />I east t he housi ng uni t numbers and comman areas ( f or nul t i f ani I y <br />housi ng) , bare soil I ocat i ons, dust -lead locations, and/ or bui 1 di ng <br />components (including t ype of r oom or space, and the nat er i al <br />under neat h the paint), and types of lead-based pai nt hazards found: <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />a---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />❑--------------------- ------------------------------------------------ <br />❑---------------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />G---------------------------------------------------------------------- <br />Cont act person for more i of or rmt ion about the risk assessment : <br />Printedname: ------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />u---------------------------------------------------------------------- <br />Street and city: ---------------------------------------------------- <br />J---------------------------------------------------------------------- <br />State: ZI P: Phone nurrber: ( )--------------------------- <br />Attachment 3 <br />Page 2 of 5 <br />