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11 ---------------------------------------------------------------------- <br />Person who prepared this summary notice: <br />Printed name: -------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Signature:----------------------------------------------------------- <br />❑ Date: ---------------------------------------------------------------- <br />❑---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />❑------------------------------------------------------------ <br />Street and city: ----------------------------------------------------- <br />---------------------------------------------------------------------- <br />State: ZIP: Phone number: ( )--------------------------- <br />❑------------------------------------------------- <br />--------------------- <br />Appendix C--Sample Summary Presumption Notice Format <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations <br />Notice That Lead -Based Paint or Lead -Based Paint Hazards Are Presumed <br />to be Present <br />Address/location of property or structure(s) this notice of <br />presumption applies to: <br />❑------------------------------------------ <br />---------------------------- <br />❑------------------------------------------ <br />---------------------------- <br />❑------------------------------------------------------- <br />--------------- <br />Type of presumption (check all that apply): <br />(a) Lead -based paint is presumed to be present. <br />(b) Lead -based paint hazard(s) is(are) presumed to be <br />present. <br />Summary of presumption. List at least the housing unit numbers and <br />common areas (for multifamily housing), bare soil locations, dust - <br />lead locations, and/or building components (including 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 />---------------------------- <br />=]---------------------------------- --------------------------- <br />--------------------------------------------------- <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of 5 <br />