Request Testing / Agreement (beginning 11/20/2020)

Request Testing / Agreement

This is to be completed by person responsible for payment for services requested.
Preferred date and time for water sample(s) to be taken? Typical hours are between 9am-1pm Monday through Thursday (except Holidays).*

MonthDayYear
DateHourMinutesAM/PM Option
Location - Street Address*
City and Zip Code*
How are we to get in?*
If you will not be there, give contact info of person who will be there to let technician in and pay fees.
Testing to be Performed
Radon Test
Price Quoted (enter NA if not applicable) *
.
If radon test is will be done, please note:

** Power to home must remain on during duration of radon test

** Do not unplug, move, or disturb the Radon Detector

** Keep windows and doors closed except to enter / exit home
Water Test (s) Requested*
.
Price Quoted (enter NA if not applicable) *
.
Comments / Additional Info
If this is for re-finance, provide Lender contact info (Name - Phone Number - Email)
CUSTOMER INFO
CUSTOMER Name(s)*
Customer's Current Mailing Address*
Currrent Mailing Address (House or PO BoxNumber, Street, & Zip)
CUSTOMER Phone Number*
Customer Cell Number*
Customer's E-mail*
Will Customer be there?*
.
Location of Key / Lockbox / Supra if no one will be there
REALTOR Info
REALTOR (if applicable)
Realtor's Cell Number
Realtor E-mail
Provide if Results to be Sent to Realtor
Person Ordering Testing*
Phone Number*
E-mail*
By typing your name and /or signing below, you are argreeing you are the person responsible for payment for services requested at "Time of Service", when water sample taken.

**Forms of payment accepted: cash, cashier's check, or money order made out to Dayle Guffey. (Personal checks and credit cards are NOT accepted).
Type Name*
Responsible Party
Signature of Responsible Party

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