Form FS-5100-35 Formulation Ingredient Content

USDA Forest Service FS-5100-35 (10/2008)

OMB 0596-0183

Foam Fire Suppressants - 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 Mix Ratio Range: 0.1% - 1.0% by weight of concentrate in 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

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Common chemical name or trade name. List all ingredients including water. If proprietary, explain basis under remarks. Chemical Abstract Services number or other accepted industry standard.

Sum of all percents in this column must total 100. 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

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