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Date:---------------------------------------------------------------- Organization:-------------------------------------------------------- Streetand 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: ❑ ---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑---------------------------------------------------------------------- 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: ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- ❑---------------------------------------------------------------------- ❑ ---------------------------------------------------------------------- Contact person for more information about the risk assessment: Printed name: -------------------------------------------------------- ❑ ---------------------------------------------------------------------- Organization: -------------------------------------------------------- ❑---------------------------------------------------------------------- Streetand city:----------------------------------------------------- F1---------------------------------------------------------------------- State: ZIP: Phone number: ( )--------------------------- Attachment 3 Page 2 of 5