MW-RN-2020 (1)

Protocol for the Collection, Transfer and ANSI/AARST MW-RN 2020 Measurement of Radon in Water 39 Exhibit 1 Example — Water Sample Collection Form Property address ___________________________________________________________________ ___________________________________________________________________ Owner/Client Name __________________________ Phone _______________ Email ____________ _________________________________________________________________ Person collecting the water sample Name _______________________ Phone _______________ Email _____________ Certification # _________________ Certification Authority _____________________ Company ____________________ Phone _______________ Email _____________ Certification # _________________ Certification Authority _____________________ Laboratory processing the water sample Name _______________________ Phone _______________ Email _____________ Certification # _________________ Certification Authority ______________ Radon Information Sources State Office ___________________ Phone _______________ Website ___________ Other _______________________ Phone _______________ Website ___________ Test purpose: q Initial test, q confirmatory test, q seasonal test, q post-mitigation test, q other ________________ Sampling method: q Filled bowl or bucket—Immersed bottle, q Upright funnel—Bottle, q Upright funnel—Immersed bottle, q Upright funnel— Syringe, q Filled bowl or bucket— Syringe, q other _____________________ Sample Location #1 ____________________________________________________Date ________ Time _________ ________________________________ Sample ID #1 ___________ Sample ID #2 __________ A description of water treatment and/or storage tanks prior to the sampling spigot ______________________________________________________________________________ To assure fresh water, either A) Water temperature measurement device ______________________________________ Water temperature immediately before sample collection: ________˚ Water temperature immediately after sample collection: ________˚ Or B) The method used (such as measured or calculated volume of water) __________________________________________________________ Water volume expelled prior to collection ____________________________________________ Extenuating factors (aerators, treatment equipment, vacant, etc.) ______________________________________________________________________________ ______________________________________________________________________________

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