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❑ ---------------------------------------------------------------------- Person who prepared this summary notice: Printed name: -------------------------------------------------------- ❑---------------------------------------------------------------------- Signature: ----------------------------------------------------------- ❑ Date: ---------------------------------------------------------------- ❑---------------------------------------------------------------------- Organization: -------------------------------------------------------- ❑---------------------------------------------------------------------- Street and city: ----------------------------------------------------- ❑ ---------------------------------------------------------------------- State: ZIP: Phone number: ( ) --------------------------- Appendix C-- Sample Summary Presumption Notice Format Note: The following appendix will not appear in the Code of Federal Regulations Notice That Lead -Based Paint or Lead -Based Paint Hazards Are Presumed to be Present Address /location of property or structure(s) this notice of presumption applies to: ❑ ---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- Type of presumption (check all that apply): (a) Lead -based paint is presumed to be present. (b) Lead -based paint hazard(s) is(are) presumed to be present. Summary of presumption. 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 presumed to be present: ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- Contact person for more information about the presumption: Attachment 3 Page 3 of 5