FS-5100-0035 Formulation Ingredient Content

Qualified Products List for Wildland Fire Chemicals

fs_5100_0035

Qualified Products List for Wildland Fire Chemicals

OMB: 0596-0182

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

OMB 0596-0182

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


     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     


  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 this 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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File Typeapplication/msword
File TitleManufacturer Submission Procedures for Qualification of
AuthorFSDefaultUser
Last Modified ByWolf Cota
File Modified2012-02-16
File Created2008-07-09

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