6100-11 New Certified Product Notification Form: Tank-Type High-

OMB Control Number 2040-XXXX
Approval Expires xx/xx/xxxx

New Certified Product Notification Form

Tank-Type High-Efficiency Toilet
EPA WaterSenseSM Program Partners: Please complete and submit when a new product or product
model has been certified.
Section I: General Information
Manufacturer Name 1 : __________________________________________________________________
Contact Name (for questions from the EPA WaterSense Team regarding this form)
Name: ________________________________

Telephone: ______________________________

Fax:

E-mail:

________________________________

______________________________

Section II: Product Information
Please complete for each newly certified product:

Product 1
Brand Name

Model Name

Model Number

Product URL*

(tank/bowl)

Flush Type
(single, dual, other)

Rated Flush
Volume (gal)

Flush Mechanism
(gravity, PA, other)

For EPA Records Only (This information will not be posted on Web site)
Name of Certifying Body

Certification File Number

Certification Date

Product 2
Brand Name

Model Name

Model Number

Product URL*

(tank/bowl)

Flush Type
(single, dual, other)

Rated Flush
Volume (gal)

Flush Mechanism
(gravity, PA, other)

For EPA Records Only (This information will not be posted on Web site)
Name of Certifying Body

Certification File Number

Certification Date

*Web page must contain WaterSense label

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Please use the same name used on your partnership agreement. If you do not yet have a partnership agreement, please contact
the WaterSense program to complete one.

EPA Form Number 6100-11

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Product 3
Brand Name

Model Name

Product URL*

Model Number
(tank/bowl)

Flush Type
(single, dual, other)

Rated Flush
Volume (gal)

Flush Mechanism
(gravity, PA, other)

For EPA Records Only (This information will not be posted on Web site)
Name of Certifying Body

Certification File Number

Certification Date

*Web page must contain WaterSense label

Mail this form to:
EPA WaterSense Program
c/o ERG
2200 Wilson Boulevard
Suite 400
Arlington, VA 22201

OR

Fax this form to:
EPA WaterSense Program
c/o ERG
(703) 841-1440

For more information please call the WaterSense Helpline at (866) WTR-SENSE or visit
.

The public reporting and recordkeeping burden for this collection of information is estimated to average 21 hours per
response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and
any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to
the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW,
Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed New Certified
Product Notification Form to this address.

EPA Form Number 6100-11

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