Form FS-5100-37 Long-Term Retardant - Formulation Disclosure Sheet

Qualified Products List for Long-Term Retardant Fire Suppressants

fs_5100_0037

Qualified Products List for Long-Term Retardant Fire Suppressants

OMB: 0596-0184

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USDA Forest Service FS-5100-37 (10/2008)

OMB 0596-0184

Long-Term Retardant - Formulation Disclosure Sheet

(Ref: FSM 5160)

Information on this form may be protected by the Trade Secrets Act and/or Exemption 4 of the Freedom of Information Act


Product Name:      

Formulation Identification:      

Submitting Co.:      

Date Submitted:      

Submitted By:      

Signature:

Title of Submitter:      

Recommended Use Level (enter amount and check applicable box):       pounds of concentrate/gallon of water OR gallons of concentrate/gallon of water


Formulation Ingredients1

Proprietary?2

Yes/No

Manufacturer, Process, & Quality or Grade

C.A.S. Number or Other Technical Identification3

Percent by Weight in Wet or Dry Concentrate4

Percent by Weight in Solution at Recommended Use-level4

Patent or TM Number5

Remarks


     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


  1. Common chemical name or trade name. List all ingredients including water.

  2. If proprietary, explain basis under remarks.

  3. Chemical Abstract Services number or other accepted industry standard.


  1. Sum of all percents in column must total 100.

  2. If one or more patents apply to the use of this ingredient or total formulation, please attach a copy of the patent(s).



BURDEN AND NONDISCRIMINATION STATEMENTS

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0182. The time required to complete this information collection is estimated to average 45 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

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To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.

File Typeapplication/msword
File TitleManufacturer Submission Procedures for Qualification of
AuthorFSDefaultUser
Last Modified ByFSDefaultUser
File Modified2008-10-17
File Created2008-07-09

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