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Appendix A --Sample Summary Inspection Notice Format Note: The following appendix will not appear in the Code of Federal Regulations Summary Notice of Lead -Based Paint Inspection Address/location of property or structure(s) this summary notice applies to: ❑-------------------------------------------------- -------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- Lead-based paint inspection description: Date(s) of inspection: ----------------------------------------------- Summary of inspection results (check all that apply): (a) No lead -based paint was found. (b) Lead -based paint was found. (c) A brief summary of the findings of the inspection is provided below (required if lead -based paint found). Summary of where lead -based paint was found. List at least the housing unit numbers and common areas (for multifamily housing), and building components (including type of room or space, and the material underneath the paint): ❑------------------------------------------ ---------------------------- ❑---------------------------------------------------------------------- ❑------------------------------------------ ---------------------------- ❑-------------------------------------- -------------------------------- ❑--------------------------- -- ----------------------------- ❑-----------------------------------•------------------------------------ ❑------------------------------------------ ---------------------------- ❑------------------------------------------ ---------------------------- ❑---------------------------------------------------------------------- ❑------------------------------------------ ---------------------------- ❑-------------------------------------------------- -------------------- ❑---------------------------------- ------------------------------------ ❑------------------------------------------ ---------------------------- ❑---------------------------------------------------------------------- Contact person for more information about the inspection: Printed name:-------------------------------------------------------- Organization:-------------------------------------------------- Street and city: ----------------------------------------------------- [[Page 50231]] State: ZIP: ------------------------------------------------------ Phone number: ( )------------------------------------------------- Person who prepared this summary notice: Printed name:-------------------------------------------------------- Signature:----------------------------------------------------------- Attachment 3 Page 1 of 5