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Lab # 163230

RW103 - Radon in Water Test Kit Registration

We do not accept payment online. Please submit proper payment when you send in your test kit.

Your First Name:	Your Last Name:
Your Street Address: Your City: Your State: Zip Code:
Your Email Address: (your report will be sent here)
Phone Number:

TEST LOCATION

Test Address:	City:
County:	NJ Municipality (if applicable):
State:	Zip Code:

TEST INFORMATION

Detector Serial #:	Detector Serial #:
Collection Date:	Collection Time:
Room Level: Basement 1st Floor 2nd Floor Other	Room Used For: Living Room Bedroom Other:
Were closed house conditions maintained during the test? Yes No
Is this for a real estate transaction? Yes No