"*" indicates required fields Name of Facility* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Onsite Management CommitmentConsent To the extent reasonably possible, I commit to helping ensure that building conditions required to achieve reliable radon tests are met, as portrayed herein, by accepting the following responsibilities:1) Prior Notifications: Notices will be distributed, as appropriate, to all occupants and staff members and posted in publicly accessible areas such as in corridors, offices, & elevators. Notifications will be distributed no later than the day before testing or as required by local law. All occupants should be notified (as appropriate) even if their room is not one of the rooms being tested. 2) Access: Access will be made available to the entire building on the day of testing device deployment and on day of device retrieval. Access to areas not being tested may be need to evaluate such things as closed building condition and HVAC equipment. Name First Last Title SignatureBuilding Operations Staff CommitmentConsent To the extent reasonably possible, I commit to helping ensure that building conditions required to achieve reliable radon tests are met, as portrayed herein, by accepting the following responsibilities:1. Building Preparation: I accept responsibility that, no later than 12 hours prior to testing, each building scheduled for testing will be reviewed for: a) Any broken windows have been repaired or sealed. b) HVAC system(s) are operational. c) If HVAC systems include controls or dampers for variable outdoor air ventilation or variable air volume distribution (VAV), these controls have been reviewed and adjusted as needed. Name First Last Title SignatureHiddenCaptchaCAPTCHA