6100-18 New Certified Product Urinal

OMB Control Number 2040-0272
Approval Expires 01/31/2010

New Certified Product Notification Form

WaterSense® Labeled Flushing Urinal
EPA WaterSense Program Partners: Please complete and submit this form within two weeks of notification from a certifying body that your product or product
model has received the WaterSense label. By submitting this form, the manufacturer partner agrees to continue to uphold the requirements of its manufacturer
partnership agreement.
Section I: General Information
Manufacturer Name: __________________________________________________________________
(This name should match what is on the certification file for WaterSense labeled flushing urinals and your EPA partnership agreement.)
Contact Name (for questions from the EPA WaterSense Team regarding this form)
Name: ________________________________

Telephone: ______________________________

Fax:

E-mail:

________________________________

______________________________

Section II: Certification Information (This information will not be posted on the WaterSense Web registry.)
Name of Certifying Body: __________________________________________ Certification File Number: _______________________________________
Section III: Product Information (This information will appear on the WaterSense Web registry. Please only include information purchasers will see on product packaging.)
Instructions:
• Please only include information for one product type per line. Indicate the product type and flushing device (if applicable) for each product model.
• Check “Urinal System” if you sell a urinal as a complete system (i.e., both the fixture and flushing device) under a single model number.
• Check “Urinal Flushing Device” if the product, which can be either a pressurized flushing device or flush tank (gravity type) flushing device, is sold
independently of the urinal fixture.
• Check “Urinal Fixture” if the product is the china/plastic/stainless steel piece only and is sold independently of the urinal flushing device.
• The rated flush volume is the product’s maximum flush volume, as specified by the manufacturer, verified through testing, and in compliance with the
WaterSense Specification for Flushing Urinals. Include the rated flush volume for each product model and type.
Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

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EPA Form Number 6100-18
The public reporting and record keeping burden for this collection of information is estimated to average eight 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.

Submit this form (rewriteable PDF) to WaterSense via:
Fax: (703) 841-1440
Mail: WaterSense, c/o ERG, 2300 Wilson Blvd., Suite 350, Arlington, VA 22201
Electronically: If you have Adobe Acrobat Standard or Professional, you can fill out the form electronically and e-mail it to: [email protected]. Acrobat
Reader users must print forms after completing and fax or mail them. Contact the WaterSense Helpline at (866) 987-7367 if you have any questions.
Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

Product
Brand Name

Model Name

Product Type
(Please check one)

Model Number

Rated Flush Volume (gal)

Flushing Device Type

□ Urinal system

□ Pressurized flushing device

□ Urinal flushing device

□ Flush tank (gravity type)

□ Urinal fixture

□ Not applicable

Please copy this side and submit additional sheets as needed.

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