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Date:---------------------------------------------------------------- Organization:-------------------------------------------------------- Street and city:----------------------------------------------------- State: ZIP: -------------------------------------------------- Phone number: ( )------------------------------------------------- Appendix B-- Sample Summary Risk Assessment Notice Format Note: This following appendix will not appear in the Code of Federal Regulations Summary Notice of Lead -Based Paint Risk Assessment Address /location of property or structure(s) this summary notice applies to: ---------------------------------------------------------------------- ---------------------------------------------------------------------- E---------------------------------------------------------------------- Lead -based paint risk assessment description: Date(s) of risk assessment:------------------------------------------ Summary of risk assessment results (check all that apply): (a) No lead -based paint hazards were found. (b) Lead -based paint hazards were found. (c) A brief summary of the findings of the risk assessment is provided below (required if any lead -based paint hazards were found) . Summary of types and locations of lead -based paint hazards. List at least the housing unit numbers and common areas (for multifamily housing), bare soil locations, dust -lead locations, and /or building components (including type of room or space, and the material underneath the paint), and types of lead -based paint hazards found: ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- Contact person for more information about the risk assessment: Printedname: -------------------------------------------------------- ---------------------------------------------------------------------- Organization: -------------------------------------------------------- ❑---------------------------------------------------------------------- Street and city: ----------------------------------------------------- State: ZIP: Phone number: ( )--------------------------- Attachment 3 Page 2 of 5