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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: J----------------------------------------------________________________ J-------------------------------------------___________________________ J--------------------------------------------__________________________ 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: J-----------------------------------------_____________________________ J----------------------------------------______________________________ 0------------------------------------__________________________________ ---------------------------------------------------------------------- ---------------------------------------------------------------------- J---------------------------------------_______________________________ J----------------------------------____________________________________ C--------------------------------------________________________________ J-------------------------------------_________________________________ J-----------------------------------___________________________________ J----------------------------------____________________________________ J-------------------------------------_________________________________ Contact person for more information about the risk assessment: Printed name:--------------------------------________________________ 0-----------------------------------___________________________________ Organization:-----------------------------___________________________ 0-------------------------------_______________________________________ Street and city:--------------------------------_____________________ u------------------------------________________________________________ State: ZIP: Phone number: (____)--------------------------- Attachment 3 Page 2 of5