6100-11 New Certified Product Toilet

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

New Certified Product Notification Form

Tank-Type High-Efficiency Toilet
EPA WaterSense® Program Partners: Please complete and submit 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 their manufacturer
partnership agreement.
Section I: General Information
Manufacturer Name1: __________________________________________________________________
Contact Name (for questions from the EPA WaterSense Team regarding this form)
Name: ________________________________

Telephone: ______________________________

Fax:

E-mail:

________________________________

______________________________

Section II: Product Information
Product
Brand Name

Model Name

Model Number
2

HET

Bowl

Flush Type
Tank

(single, dual, other)

Rated Flush Volume (gal)
Single or
Average

Min

Max

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 URL

(mm/dd/yy)

(if available)

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.
1
2

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.
Please use this column if you have either a single model number or a combination model number (for both the bowl and tank).

EPA Form Number 6100-11
The public reporting and record keeping burden for this collection of information is estimated to average 8 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.

Product
Brand Name

Model Name

Model Number
HET2

Bowl

Flush Type
Tank

(single, dual, other)

Rated Flush Volume (gal)
Single or
Average

Min

Max

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 URL

(mm/dd/yy)

(if available)

Product
Brand Name

Model Name

Model Number
HET2

Bowl

Flush Type
Tank

(single, dual, other)

Rated Flush Volume (gal)
Single or
Average

Min

Max

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 URL

(mm/dd/yy)

(if available)

Product
Brand Name

Model Name

Model Number
2

HET

Bowl

Flush Type
Tank

(single, dual, other)

Rated Flush Volume (gal)
Single or
Average

Min

Max

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 URL

(mm/dd/yy)

(if available)

Product
Brand Name

Model Name

Model Number
HET

Bowl

Flush Type
Tank

(single, dual, other)

Rated Flush Volume (gal)
Single or
Average

Min

Max

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

Certification File Number

Please copy this side and submit additional sheets as needed.

Certification Date

Product URL

(mm/dd/yy)

(if available)

Flush Mechanism
(gravity, PA, other)