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<br />n---------------------------------------------------------------------- <br />Person who prepared this summary notice: <br />Printed name:-------------------------------------------------------- <br />u---------------------------------------------------------------------- <br />Signature:----------------------------------------------------------- <br />U Date:---------------------------------------------------------------- <br />Q---------------------------------------------------------------------- <br />Organization:-------------------------------------------------------- <br />[J---------------------------------------------------------------------- <br />Street and city:----------------------------------------------------- <br />0---------------------------------------------------------------------- <br />State: ZIP: Phone number: (_____)--------------------------- <br />~---------------------------------------------------------------------- <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) <br />presumption applies to: <br />[---------------------------------------------------------------------- <br />[J--------------------------------------------------------------------__ <br />~J--------------------------------------------------------------________ <br />Type of presumption (check all that apply) : <br />(a) _ Lead-based paint is presUllled to be <br />(b) _ Lead-based paint hazard(s) is (are) <br />present. <br />SUJIIIIlary of presumption. List at least the housing unit numbers and <br />common areas (for multif_ily housing), bare soil locations, dust- <br />lead locations, and/or building components (including type of roOlll <br />or space, and the material underneath the paint), and types of lead- <br />based paint hazards presumed to be present: <br />C,-----------------------------------------------------------___________ <br />1]--------------------------------------------------____________________ <br />~---------------------------------------------------------------------- <br />~---------------------------------------------------------------------- <br /> <br />this notice of <br /> <br />present. <br />presUllled <br /> <br />to be <br /> <br />[,---------------------------------------------------------------------- <br />~I-----------------------------------------------------_________________ <br />.J-------------------------------------------------------_______________ <br /> <br />c-----------------------------------------------------_________________ <br /> <br />I~-----------------------------------------------------_________________ <br />u-----------------------------------------------------------___________ <br /> <br />~---------------------------------------------------------------------- <br /> <br />I -------------------------------------_________________________________ <br /> <br />IJ----------------------------------------______________________________ <br /> <br />D-----------------------------------------------------------___________ <br />~---------------------------------------------------------------------- <br /> <br />1,-----------------------------------------------------_________________ <br /> <br />G--------------------------------------------------------------------__ <br />Contact person for more information about the presumption: <br />Attachment 3 <br />Page 3 of 5 <br />