6100-09 Annual Reporting Form - Manufacturer Plumbing Hard Copy

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OMB Control Number 2040-0272
Approval Expires 06/30/2013

Manufacturer Annual Reporting 2013
WaterSense® Manufacturer Partners: Please complete and submit this form to U.S. Environmental Protection Agency (EPA) contractor Eastern Research
Group, Inc. (ERG) by February 15, 2013.
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. All
data will be presented to EPA in aggregate.

Please send a completed hard copy of this form to the address below by February 15, 2013.
Mail: EPA WaterSense Annual Reporting, c/o ERG
2300 Wilson Boulevard, Suite 350
Arlington, VA 22201

Phone: Call (866) 987-7367 if you have any questions about
how to complete or submit this form.

Do NOT submit this form via email or fax.
ALL WaterSense manufacturer partners that joined WaterSense before January 1, 2013 should complete and submit
Sections I and II of this reporting form and any required product-specific sections, regardless of whether your products
have earned the WaterSense label.

Section I: General Information
Manufacturer Name on Partnership Agreement:

If you do not yet have a partnership agreement, please contact the WaterSense program to complete one.

Contact Name (for questions regarding this form):
Please provide a U.S. contact if possible.

E-mail:

Phone:
Next Page

EPA Form Number 6100-09. The public reporting and record keeping burden for this collection of information is estimated to average five 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 found in the top right
corner of this page in any correspondence. Do not send the completed annual reporting form to this address.

Manufacturer Name on Partnership Agreement:

Section II: Product Shipment Information Form Instructions
Please answer questions 1 and 2 in the “Classification” column below. Your company’s classification will determine which product-specific
sections of this reporting form should be completed.
Note: If your company is responsible for the certification of products, but your products have not yet earned the
WaterSense label, you should check “Yes” in Row 1 below and report the total number of products shipped for that
category. WaterSense uses the total product shipment data reported in this form to estimate the water savings and
impact associated with WaterSense labeled products.
Lavatory Faucet Accessories
Classification

1. Does your
company own or
plan to own a
certification file?
2. Is your company
included as an
additional
company on a
certification file?

Tank-Type
Toilets

Yes

Lavatory Faucets

Yes

(e.g., faucet flow restrictors, flow regulators, aerator
devices, and laminar devices)

Shipped as
components for use
in lavatory faucets

Shipped for sale as
individual
aftermarket devices

Yes

Yes

Flushing Urinals

Yes

•
•

Yes

No

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Classification Table
Either “Yes” or “No” must be marked for each product category in each classification row for the period between
January 1, 2012, and December 31, 2012.

•

Showerheads

In an effort to prevent double counting products, WaterSense will only count product shipment data from
certification file owners. Additional companies should remind the certification file owner to submit a WaterSense
Manufacturer Annual Reporting Form.
If you checked “Yes” in response to both questions for a product category, please complete the productspecific section for that product category as indicated in the table above, but ONLY include shipment data on
products for which you are the certification file owner, NOT an additional company.
If you checked “No” in response to both questions for a product category, you do not need to complete the
product-specific section for that product category.

Confirm

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