This government document is issued by Department of Environmental Protection for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:gul-_xwuyho&q=http://files.dep.state.pa.us/PublicParticipation/Public%2520Participation%2520Center/PubPartCenterPortalFiles/Environmental%2520Quality%2520Board/2018/June%252019/7-499_Radiological_Health_Final/05A_7-499_Final%2520Rad%2520Health_Forms.pdf&sa=U&ved=2ahUKEwilvbvUqtX8AhUuUqQEHT2ZBO04MhAWegQIBhAB&usg=AOvVaw1l2ML5JZ3U8jHZY-nt17sr