6100-09 Annual Reporting Form - Manufacturer WBIC Hard Copy

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

Irrigation Controller 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 Helpline at (866) 987-7367 to complete one.

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

Email: _______________________________________________________ Phone:_______________________________

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: Irrigation Controllers
A. Product Shipment Data
Include data for products shipped to or within the United States for the period between January 1, 2012, and December 31, 2012.
Please report the number of units (e.g., individual controllers) shipped rather than the number of models or model lines produced. For weather-based irrigation
controllers, please include data on add-on, plug-in, and standalone controllers.
Do NOT include replacements for parts damaged during shipping in any row below.
U.S. Total

(Please submit EXACT

shipment data; do not round.)

All Controllers
1

Claim as
confidential?
 Yes  No

Total number of clock timer controllers shipped?
Note: Clock timer controllers are not currently eligible for the WaterSense label.

2

 Yes  No

Total number of soil moisture sensors shipped?
Note: Soil moisture sensors are not currently eligible for the WaterSense label.

3

 Yes  No

Total number of weather-based controllers shipped?
Note: Count ALL weather-based controllers shipped, including both WaterSense labeled and
non-WaterSense labeled controllers.

4

 Yes  No

Total number of WaterSense labeled weather-based controllers shipped?

B. WaterSense Labeled Irrigation Controller Certification Information
Does your company own or plan to own a certification file?

 Yes  No

Is your company included as an additional company on a certification file?

 Yes  No

Certifying Body/Bodies

Certification File Number(s)

Additional Companies/Customers (if applicable)

Please include any clarifications regarding your data here:

2