ICR Attachment B - SDSI Application Form

OMB Control Number 2070-NEW; EPA ICR Number 2261.01

ICR ATTACHMENT B

S afer Detergents

Stewardship Initiative

Instructions for Application Form

EPA developed the Safer Detergents Stewardship Initiative (SDSI) to recognize environmental leaders who voluntarily commit to the use of safer surfactants. Leading product manufacturers have made great progress in developing safer, highly effective cleaners. These manufacturers believe that producing the safest products possible is important to their role as stewards of the environment and public health. A number of U.S. corporations have acted in advance of SDSI to use safer surfactants in their entire product lines.

Safer surfactants are surfactants that break down quickly to non-polluting compounds⁰. CleanGredients is a resource for information on safer surfactants (www.cleangredients.org).

• Candidates should complete this application and have it signed by a company authority (e.g., CEO or vice president for health and environment).

• Candidates should post a statement on their website describing the actions that qualify them for recognition under SDSI.

• EPA reserves the right to request at any time, on a confidential basis, appropriate documentation (including but not limited to bills of lading, invoices, material safety data sheets, and list of ingredients) to confirm that candidates have achieved the appropriate criteria for recognition. If documentation is requested but not received within a reasonable time, EPA may deny or withdraw recognition from that candidate.

There are two categories for recognition under SDSI: Champion and Partner.

• Champion is the highest level of recognition offered under SDSI. At this level, the participant is invited to the SDSI Awards ceremony, listed on the EPA SDSI website as a champion, and may use a special logo in their literature to help explain their participation in the program.

• The Partner category provides recognition of significant accomplishment towards the use of safer surfactants. Partners will be listed on the EPA SDSI website and may be granted recognition as a Champion in the future, if appropriate. Partner recognition will sunset on the commitment date provided in Section 3 of the Application.

Guidelines for achieving Champion or Partner Status are provided in Table 1. Both Champions and Partners will receive a certificate of recognition from DfE. To be eligible for the awards ceremony, which will be held in the 2008, candidates for Champion status should submit their application by the date provided on the DfE website (http://www.epa.gov/dfe/pubs/projects/formulat/sdsi.htm).

Application Process: The application will be available online and may be filled out and submitted in hard copy or electronically to [email protected]. Unless you claim information as confidential, all applications received will be considered public information and no materials submitted will be returned. For security purposes, confidential information may not be submitted electronically. If you choose to send the application electronically, the signed signature page must be scanned in and reattached to the electronic application.

If you choose to submit a hard copy application, send your completed application to the appropriate address below. Please note that irradiation of federal mail may damage electronic media or other materials. It is highly recommended that a package delivery service be used, especially if you are sending a disk.

Submit this form to the following address:

US Environmental Protection Agency

Safer Detergent Stewardship Initiative (7406M)

Attn: DfE

Via regular/certified mail:

1200 Pennsylvania Ave., NW

Washington, DC 20460

Via overnight mail:

1201 Constitution Ave., NW

EPA East, Room 5326

Washington, DC 20004

Phone: 202-564-9910

Confirmation of Receipt: EPA will confirm receipt of applications, usually by email. If you have not received an acknowledgment within two weeks of sending your applications, please contact DfE Contact at [email protected] or 202-564-9910

Notification: Winners will be notified prior to the official public announcement. Awards will be presented to the primary sponsor of the application.

Questions: Questions about eligibility, nomination procedures, or the Safer Detergent Stewardship Initiative should be directed to DfE Contact of EPA’s Design for the Environment Program at [email protected] or 202-564-9910

Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, gathering information, posting information to the internet, and reviewing and completing the application. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

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 application to this address.

Participant Type	Table 1: Guidelines for Achieving:
	Champion Status	Partner Status
Chemical Manufacturers	Demonstrate that you only manufacture safer surfactants0 Document a strategy for ensuring that you manufacture only safer surfactants	Commit to producing only safer surfactants1 by a date that is reasonable for your circumstances Document a strategy for ensuring that you will manufacture only safer surfactants
Formulators	Demonstrate that you only use safer surfactants in products1,0,0 Document a strategy for ensuring that only safer surfactants are used in products	Commit to using only safer surfactants in your products1,3 by a date that is reasonable for your circumstances Document a strategy for ensuring that only safer surfactants will be used in products
Retailers / Distributors	Demonstrate that only safer surfactants are included in products2,3 intended for sale Document a strategy for ensuring that only safer surfactants are included in products3 intended for sale	Commit to sell only products3 containing safer surfactants by a date that is reasonable for your circumstances Document your active encouragement of the use of safer surfactants
Institutional Purchasers	Demonstrate that you only purchase products containing safer surfactants Document a strategy0 for ensuring that purchased products only contain safer surfactants	Commit to only use products3 that only contain safer surfactants by a date that is reasonable for your circumstances Document your active encouragement of the use of safer surfactants
Others (e.g., non-profits, unions, academia)	Demonstrate outstanding efforts0 to encourage the use of safer surfactants	Document your active encouragement of the use of safer surfactants

Safer Detergents Stewardship Initiative OMB No. 2070-[XXXX]

SECTION 1a: Enter requested information for the authorized representative	Organization Name
	Contact Name
	Address
	Address
	Phone		Fax
	Email
	Website
SECTION 1b: Indicate your type of organization		Chemical Manufacturer – Manufactures surfactants
		Formulator – Purchases and blends chemicals (including surfactants) to create an end-use product for retailers and/or distributors
		Retailer / Distributor – Sells products containing surfactants
		Institutional Purchaser – Purchases or specifies cleaning products for use in multiple facilities (e.g., janitorial service provider)
		Other – Influences use of surfactants (e.g., non-profit, trade association, academia)
SECTION 1c: Indicate the level of recognition for which you are applying (refer to the instructions for a description of Champion and Partner status for each organization type)		Champion (go to Section 2)
		Partner (go to Section 3)

Safer Detergents Stewardship Initiative Page 2 of 5

SECTION 2: Fill out this section if you are applying for recognition as a Champion	If you are a…	Demonstrate in SECTION 2a that…	And the go to…
	Chemical Manufacturer	You only manufacture safer surfactants	Section 2b
	Formulator	You only use safer surfactants in products	Section 2b
	Retailer / Distributor	Only safer surfactants are included in products intended for sale	Section 2c
	Institutional Purchasers	All the products you purchase contain only safer surfactants	Section 2c
	Other	You have made outstanding efforts to encourage the use of safer surfactants	Go to Section 4
SECTION 2a: Use this space to explain how you meet the above requirements. Please include supporting documents when appropriate and note these documents in your statement. You may attach extra sheets as needed.	_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

SECTION 2b (Chemical Manufacturers and Formulators only): Indicate or describe your product stewardship strategy for ensuring the manufacture or use of safer surfactants	 Use CleanGredients to choose surfactants Provide the URL for that section of your website describing the actions that qualify the company or organization for recognition under SDSI: _________________________________________________________________
	 Other, please describe: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Safer Detergents Stewardship Initiative Page 3 of 5

SECTION 2c (Retailers/ Distributors and Institutional Purchasers only): Document your strategy for ensuring that all of your purchased products contain only safer surfactants. You may attach extra sheets as needed.*	If you are a…	Document a strategy for ensuring that…
	Retailer / Distributor	Only safer surfactants are included in products intended for sale
	Institutional Purchaser	Purchased products contain only safer surfactants

* An example of a strategy would be the establishment of a policy that requires suppliers to provide products that contain only safer surfactants. This strategy may be evidenced by a letter that is sent to suppliers requiring them to provide products with only safer surfactants, or a comparable statement posted on a company’s website. The retailer / distributor will not be eligible for Champion recognition until it sells products with only safer surfactants.

Safer Detergents Stewardship Initiative Page 4 of 5

SECTION 3: Fill out this section if you are applying for recognition as a Partner	If you are a…	Document in SECTION 3a your commitment to…
	Chemical Manufacturer	Produce only safer surfactants
	Formulator	Use only safer surfactants in your products
	Retailer / Distributor	Only sell products that only contain safer surfactants
	Institutional Purchasers	Only purchase products that only contain safer surfactants
	Other (e.g., trade association, NGO, etc.)	encouragement of safer surfactants
SECTION 3a: Use this space to describe how you meet the above requirements.*	_________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________
	Provide the URL for that section of your website describing the actions that qualify you for recognition under SDSI: _________________________________________________________________

* You should describe your commitment to a complete transition to safer surfactants by a date that is reasonable for your circumstances. Please state this date explicitly and explain briefly why it is a reasonable date for your circumstances.⁰ Include supporting materials when appropriate and note these materials in your statement. You may attach extra sheets as needed.

Safer Detergents Stewardship Initiative Page 5 of 5

SECTION 4: Certification of Application

Please have the appropriate company authority (e.g., CEO, vice president for health and environment, division head, or other authorized signatory) sign here to verify the accuracy of the application’s content.

Signature of Authorizing Entity	Date
Printed Name and Title	Date

I hereby affirm that the contents of this application are true and accurate to the best of my knowledge, and that I am an authorized representative of the company or organization named above and am duly authorized to sign this application.

0 An example of a class of safer surfactants is linear alcohol ethoxylates (LAE). LAEs are toxic to aquatic life, but break down quickly to non-polluting compounds. Nonylphenol ethoxylates, commonly referred to as NPEs, are a surfactant class that does not meet the definition of a safer surfactant. Both NPEs and their breakdown products, such as nonylphenol, are toxic to aquatic life.

0 CleanGredients™ is a resource for information on safer surfactants.

0 The deadline for using only safer surfactants in third-party finished goods and Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA)-registered products is December 31, 2008.

0 Products include those whose use routinely results in their discharge to the environment (e.g., all-purpose cleaners, laundry detergents, pesticides, airplane de-icers, fire-fighting foams and gels).

0 An example of a strategy is a letter that is sent to suppliers requiring them to provide products with only safer surfactants. The retailer/distributor will not be eligible for Champion recognition until its sells products with only safer surfactants.

0 Examples of contributions that would qualify include those that have developed means for surfactant users to identify safer surfactants, those that have taken action to educate industry or the public about safer surfactants, and those that have encouraged business to move toward safer surfactants.

0 Please note that Partner recognition will sunset on the commitment date. After this date, companies will need to apply for Champion recognition.

EPA Form 6300-2 (x-xx)