FS-5100-0037 Long-Term Retardant-Formulation Disclosure Sheet

USDA Forest Service FS-5100-37 (2/2012)

OMB 0596-0182

Long-Term Retardant - 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 Use Level (enter amount and check applicable box):       pounds of concentrate/gallon of water OR gallons of concentrate/gallon of 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
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
     		     	     		     			     	     	     	     
Common chemical name or trade name. List all ingredients including water. If proprietary, explain basis under remarks. Chemical Abstract Services number or other accepted industry standard.							Sum of all percents in column must total 100. 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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