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<br />Date:---------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />Street and city:----------------------------------------------------- <br />State: ZIP: -------------------------------------------------- <br />Phone nnmher: (==:=)------------------------------------------------- <br /> <br />Appendix B--Samp~e Summary Risk Assessment Notice Format <br /> <br />Note: This fol.l.owing appendix wil.l. not appear in the Code of <br />Federal. Regul.ations <br /> <br />SUJIIJlULry Notice of Lead-Based Paint Risk Assessment <br /> <br />Address/l.ocation of property or structure(s) this summary notice <br />appl.ies to: <br />J--------------------------------------------------------------________ <br /> <br />[c-----------------------------------------------------------___________ <br />0-----------------------------------------------------------___________ <br />Lead-based paint risk assessment description: <br />Date(s) of risk assessment:-------------------------------------_____ <br /> <br />SnmmAry of risk assessment resul.ts (check all. that appl.y) : <br />(a) _ No l.ead-based paint hazards were found. <br />(b) Lead-based paint hazards were found. <br />(c) - A brief summary of the findings of the risk assessment <br />is provided""bel.ow (required if any l.ead-based paint hazards were <br />found) . <br /> <br />SUIIIIIlary of types and l.ocations of l.ead-based paint hazards. List at <br />l.east the housing unit nuabers and common areas (for mul.tifamil.y <br />housing), bare soil. l.ocations, dust-l.ead l.ocations, and/or buil.ding <br />components (incl.uding type of roOlll or space, and the material. <br />underneath the paint), and types of l.ead-based paint hazards found: <br />C--------------------------------------------------------______________ <br />0-----------------------------------------------------_________________ <br />u-------------------------------------------------_____________________ <br />0---------------------------------------------------___________________ <br />0--------------------------------------------------____________________ <br />u-------------------------------------------------_____________________ <br />0-----------------------------------------------------_________________ <br />j---------------------------------------------------------------------- <br />C-----------------------------------------------------_________________ <br /> <br />L~-------------------------------------------------_____________________ <br />[!---------------------------------------------------------------------- <br />]---------------------------------------------------------------------- <br /> <br />Contact person for more information about the risk assessment: <br />Printed name:------------------------------------------______________ <br />L-----------------------------------------------------_________________ <br />Organization:------------------------------------------______________ <br /> <br />! ;---------------------------------------------------------------------- <br /> <br />Street and city:------------------------------------_________________ <br />~-----------------------------~---------------------------------------- <br /> <br />State: <br /> <br />ZIP: <br /> <br />Phone number: (____)--------------------------- <br />Attachment 3 <br />Page 2 of 5 <br />