Facility InformationFacility NameFacility 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 Client AuthorizationsPlease ensure all contacts and authorizations are provided prior to testing events.Staff authorized for responding to occupant and public inquiries regarding the radon testing:Title/NamePhone Add RemovePerson(s) authorized to receive radon report data and any incremental reports:Title/NamePhone Add RemoveClient or Authorized Agent Name: First Last Client or Authorized Agent SignatureFacility Staff Contact InformationManager/Facility POC Name First Last Manager/Facility POC Email Manager/Facility POC PhoneMaintenance POC Name First Last Maintenance POC Email Maintenance POC Phone(For apartment access, an employee of the management company is needed to escort the radon professional at all times.) Dwelling Access Name First Last Email PhoneOther Contact Name First Last Other Title/PositionOther Contact Email Other Contact Phone