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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: D--------------------------------------------__________________________ ---------------------------------------------------------------------- ---------------------------------------------------------------------- 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: D--------------------------------------________________________________ D------------------------------------__________________________________ [---------------------------------------------------------------------- D----------------------------------____________________________________ D---------------------------------_____________________________________ D-----------------------------------___________________________________ D-------------------------------_______________________________________ D-----------------------------------___________________________________ ---------------------------------------------------------------------- D---------------------------------_____________________________________ D----------------------------------____________________________________ D-------------------------------_______________________________________ Contact person for more information about the risk assessment: Printed name:----------------------------____________________________ D----------------------------__________________________________________ Organization:-----------------------_________________________________ D-----------------------------_________________________________________ Street and city:---------------------------__________________________ D---------------------------___________________________________________ State: ZIP: Phone number: (____)--------------------------- Attachment 3 Page 2 of 5