6100-09 Annual Reporiting Form Retailer

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

Retailer/Distributor Annual Reporting

EPA WaterSense® Program Partners: Please complete and submit to EPA contractor, Eastern Research Group (ERG) by March 2, 2009.
Note on confidentiality of data: Sensitive business information may be claimed confidential under 40 CFR Part 2, Subpart B. ERG has an EPA-approved
security plan in place to protect confidential business information from unauthorized disclosure. All data submitted as confidential will be handled as such.

Section I: General Information
Retailer/Distributor Name 1 : __________________________________________________________________
Contact Name (for questions regarding this form)
Name:

________________________________ Telephone:

________________________E-mail:

Section II: Product Information
A.

Tank-Type Toilets

Provide the following information for all toilets sold in the United States between January 1, 2008 and December 31, 2008. If you do not sell or distribute
WaterSense labeled toilets, please leave this section blank.

All Tank-Type Toilets
Total number of toilets sold?
Total number of toilets with an effective flush volume
of 1.28 gallons per flush (gpf) or less sold?
Total number of WaterSense labeled toilets sold?

B.

U.S. Total

Average Price

Confidential?

… Yes … No
… Yes … No
… Yes … No

Bathroom Sink Faucets

Provide the following information for all bathroom sink faucets sold in the U.S. between January 1, 2008 and December 31, 2008. Do not include in this
section any data for lavatory faucet accessories 2 (e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar devices) (see Question C). If you do
not sell or distribute WaterSense labeled faucets, please leave this section blank.
All Lavatory Faucets
Total number lavatory faucets sold?
Total number of lavatory faucets sold with a certified
flow rate between 1.0 and 1.5 gallons per minute
(gpm)?
Total number of WaterSense labeled bathroom sink
faucets sold?

U.S. Total

Average Price

Confidential?

… Yes … No
… Yes … No
… Yes … No

1

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.
Accessory, as defined in ASME 112.18.1/CSA B125.1, means a component that can, at the discretion of the user, be readily added, removed, or replaced, and that, when removed, will not prevent
the fitting from fulfilling its primary function. For the purpose of this specification, an accessory can include, but is not limited to, lavatory faucet flow restrictors, flow regulators, aerator devices, and
laminar devices.

2

C.

Lavatory Faucet Accessories

Provide the following information for all lavatory faucet accessories 2 (e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar devices) sold
between January 1, 2008 and December 31, 2008. Please do not include any data on lavatory faucets here (see Question B). If you do not sell or distribute
WaterSense labeled faucet accessories, please leave this section blank.
All Lavatory Faucet Accessories
Total number of lavatory faucet accessories sold?
Total number of lavatory faucet accessories sold with a
certified flow rate between 1.0 and 1.5 gpm?
Total number of WaterSense labeled lavatory faucet
accessories sold?

U.S. Total

Average Price

Confidential?

… Yes … No
… Yes … No
… Yes … No

Section III: WaterSense Labeled Product Availability
Information on WaterSense's impact on the marketplace is vital to the continued success of the program. Please provide data on product availability and
promotion.

1. a. Are you promoting the WaterSense labeled products you sell to consumers or other stakeholders?
… Yes … No
b. If yes, please estimate the number of consumers reached: ______________________________________________________________________
c. If yes, please indicate how you are promoting WaterSense labeled products (please provide samples) :
… In-store promotions, such as displays and other signage
… Ads and circulars
… Brochures, other marketing materials
… Rebate programs (usually in conjunction with local utilities)
… Web site
… Other: _____________________________________________________________________________________________________________

d. If yes, are you working with other types of WaterSense partners (e.g., utilities or manufacturers) to promote WaterSense labeled products to consumers?

2

2.

In which of your facilities can consumers find WaterSense labeled products? Please list markets (e.g., Los Angeles, Denver).

Accessory, as defined in ASME 112.18.1/CSA B125.1, means a component that can, at the discretion of the user, be readily added, removed, or replaced, and that, when removed, will not prevent
the fitting from fulfilling its primary function. For the purpose of this specification, an accessory can include, but is not limited to, lavatory faucet flow restrictors, flow regulators, aerator devices, and
laminar devices.
EPA Form Number 6100-09
The public reporting and record keeping burden for this collection of information is estimated to average 18 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 annual data form to this address.

Section IV: WaterSense Program Feedback
In the interest of serving you better, EPA would like to learn more about your opinions regarding the WaterSense program and information needs. Please
complete the following section to provide feedback to EPA.

1.

On a scale of 1 to 5 (5 = most valuable), how valuable do you find the WaterSense program?
Value: ________
How had WaterSense added value?

2.

Please provide suggestions for improving the WaterSense program (e.g., general tools/materials, communications, Helpline, Web site, etc):

Please Submit by March 2, 2009
Mail: EPA WaterSense Annual Reporting
c/o ERG
14555 Avion Parkway, Suite 200
Chantilly, VA 20151
Contact the WaterSense Helpline at (866) 987-7367 if you have any questions about how to complete this form or submission instructions.

EPA Form Number 6100-09
The public reporting and record keeping burden for this collection of information is estimated to average 18 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 annual data form to this address.