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<br />. u------------------------------------------------______________________ <br />Person who prepared this summary notice: <br />Printed name:---------------------------------------------___________ <br />]---------------------------------------------------------------------- <br />Signature:----------------------------------------------_____________ <br />U Date:--------------------------------------------------______________ <br />n---------------------------------------------------___________________ <br />Organization:-------------------------------------------_____________ <br />[---------------------------------------------------------------------- <br />Street and city:-------------------------------------------__________ <br />J----------------------------------------------________________________ <br /> <br />State: ZIP: Phone number: (____)--------------------------- <br />J-----------------------------------------------------_________________ <br /> <br />Appendix C--Sample Summary Presumption Notice Format <br /> <br />Note: The following appendix will not appear in the Code of <br />Federal Regulations <br /> <br />Notice That Lead-Based Paint or Lead-Based Paint Hazards Are Presumed <br />to be Present <br /> <br />Address/location of property or structure(s) this notice of <br />presumption applies to: <br />U----------------------------------------------________________________ <br />J---------------------------------------------_________________________ <br />J-----------------------------------------_____________________________ <br />Type of presumption (check all that apply) : <br />(a) Lead-based paint is presumed to be present. <br />(b) Lead-based paint ha~ard(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 />J------------------------------------__________________________________ <br />n-----------------------------------------_____________________________ <br />]---------------------------------------------------------------------- <br />L-------------------------------------_________________________________ <br />[---------------------------------------------------------------------- <br />J----------------------------------____________________________________ <br />~---------------------------------------------------------------------- <br />]---------------------------------------------------------------------- <br />0--------------------------------------________________________________ <br />L-----------------------------------___________________________________ <br />[---------------------------------------------------------------------- <br />-1------------------------------________________________________________ <br />0-------------------------------_______________________________________ <br />j---------------------------------------------------------------------- <br />1[----------------------------------------------------__________________ <br />0----------------------------__________________________________________ <br />J----------------------------__________________________________________ <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of5 <br />