6100-09 Quarterly Reporting Form - Licensed Certficiation Provid

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Section I: General Information

Provider Quarterly Reporting Form

Reporting Year and Quarter Year * 2012
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Quarter * Please select... 
Organization Name * Please select...
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Contact Name *
E-mail
Telephone
Format (xxx xxx xxxx)
Contact Update? 
 New primary contact for WaterSense
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E-mail and/or telephone update

Section II: Information on WaterSense Labeled New Homes
Total number of homes labeled this quarter:
Please enter a number
without commas.
Please share any common non-conformities or issues you've encountered during the past quarter:
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Section III: Information on Homes Inspected
To add information about additional homes, please use the "Add More Homes Inspected" link at the bottom
of the first record set.
Builder Name*: Please select...
Development Name (if applicable):
City:
State: Please select... 
Zip Code:
Number of Labeled Homes:
commas.
Inspection Protocol? Please select... 
Outdoor Option Used? Please select...
Add More Homes Inspected

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Please enter a number without

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*If the builder you have worked with is not on this list, please contact the WaterSense Helpline.

On the following page, you will be asked to review your responses. You must select "confirm" at the bottom of
the following page to submit your Quarterly Reporting Form to WaterSense.
Please note, you may need to try different printer settings or print as a PDF to print the full report for your
records. We apologize for any inconvenience.
Need assistance with this form?

OMB Control Number 2040-0272
Approval Expires 06/30/2013
EPA Form Number 6100-09. The public reporting and record keeping burden for this collection of information is estimated to average 10 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 Avenue, NW, Washington, D.C. 20460. Include the OMB control number in
any correspondence. Do not send the completed form to this address.