Download DOH-5028, Radon Resistant New Construction Report

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Radon Resistant New Construction Report
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Environmental Radiation Protection
547 River Street, Room 530
Troy, NY 12180-2216
Name: _________________________________________________________________________________________________
Company Name: ________________________________________________________________________________________
Street Address: __________________________________________________________________________________________
Year: ______________________________
Period:
January-June
July-December
(report due 30 days following end of the semi-annual period)
City: __________________________________________________________________________________________________
State: __________________________________________________________________ Zip Code: ______________________
Email: _________________________________________________________________ Phone #________________________
(if necessary)
Date of the
Construction
Zip Code
Town
or
City
County
Passive System
Radon Concentration
(pCi/L)
* EXAMPLE: Residential (ranch, 2 story colonial, etc) or Commercial (school, apartment building, etc)
Page 1 of 2
DOH-5028 (2/11)
Type of Building
or house*
Active System
Radon Concentration
(pCi/L)
(if necessary)
Date of the
Construction
Zip Code
Town
or
City
County
Passive System
Radon Concentration
(pCi/L)
* EXAMPLE: Residential (ranch, 2 story colonial, etc) or Commercial (school, apartment building, etc)
Page 2 of 2
DOH-5028 (2/11)
Type of Building
or house*
Active System
Radon Concentration
(pCi/L)
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