FS-5100-0035 Formulation Ingredient Content

Qualified Products List for Wildland Fire Chemicals

fs_5100_0035_Feb-2012

Qualified Products List for Wildland Fire Chemicals

OMB: 0596-0182

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USDA Forest Service FS-5100-35 (2/2012)

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 Company:      

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 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

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