OMB Control Number 2040-0272Approval Expires 01/31/2010Retailer/Distributor Annual ReportingEPA WaterSense®Program Partners:Please complete and submit to EPA contractor, Eastern Research Group (ERG) by March 2, 2009.Note on confidentiality of data:Sensitive business information may be claimed confidential under 40 CFR Part 2, Subpart B. ERG has an EPA-approvedsecurity plan in place to protect confidential business information from unauthorized disclosure. All data submitted as confidential will be handled as such.Retailer/Distributor Name1: __________________________________________________________________Section I: General InformationName: ________________________________ Telephone: ________________________E-mail:Contact Name (for questions regarding this form)Section II: Product InformationA.Tank-Type ToiletsProvide the following information foralltoiletssold in the United Statesbetween January 1, 2008 and December 31, 2008. If you do not sell or distributeWaterSense labeled toilets, please leave this section blank.All Tank-Type ToiletsU.S. TotalAverage PriceConfidential?Total number of toilets sold?YesNoTotal number of toilets withan effective flush volumeof 1.28 gallons per flush (gpf) or less sold?YesNoTotal number of WaterSense labeled toilets sold?YesNoB.Bathroom Sink FaucetsProvide the following information forallbathroom sink faucetssold in the U.S.between January 1, 2008 and December 31, 2008.Do notinclude in thissection any data for lavatory faucet accessories2(e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar devices) (see Question C). If you donot sell or distribute WaterSense labeled faucets, please leave this section blank.All Lavatory FaucetsU.S. TotalAverage PriceConfidential?Total number lavatory faucets sold?YesNoTotal number of lavatory faucets sold with a certifiedflow rate between 1.0 and 1.5 gallons per minute(gpm)?YesNoTotal number of WaterSense labeled bathroom sinkfaucets sold?YesNo1Please use the same name used on your partnership agreement. If you do not yet have a partnership agreement, please contact the WaterSense program to complete one.2Accessory, as defined in ASME 112.18.1/CSA B125.1, means a componentthat can, at the discretion of the user, be readily added, removed, or replaced, and that, when removed, will not preventthe fitting from fulfilling its primary function. For the purpose of this specification,an accessory can include, but is not limited to, lavatory faucet flow restrictors, flow regulators, aerator devices, andlaminar devices.C.Lavatory Faucet AccessoriesProvide the following information forall lavatory faucet accessories2(e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar devices)soldbetween January 1, 2008 and December 31, 2008. Pleasedo notinclude any data on lavatory faucets here (see Question B). If you do not sell or distributeWaterSense labeled faucet accessories,please leave this section blank.All Lavatory Faucet AccessoriesU.S. TotalAverage PriceConfidential?Total number of lavatory faucet accessories sold?YesNoTotal number of lavatory faucet accessories sold with acertified flow rate between 1.0 and 1.5 gpm?YesNoTotal number of WaterSense labeled lavatory faucetaccessories sold?YesNoSection III: WaterSense Labeled Product AvailabilityInformation on WaterSense's impact on the marketplace is vitalto the continued success of the program. Please provide data onproduct availability andpromotion.b.If yes, please estimate the number of consumers reached:______________________________________________________________________1.a.Are you promoting the WaterSense labeled products you sell to consumers or other stakeholders?YesNoc.If yes, please indicate how you are promotingWaterSense labeled products (please provide samples):In-store promotions, such as displays and other signageAds and circularsBrochures, other marketing materialsRebate programs (usually in conjunction with local utilities)Web siteOther: _____________________________________________________________________________________________________________d.If yes, are you working with other types of WaterSense partners (e.g., utilities or manufacturers) to promote WaterSense labeled products to consumers?2.In which of your facilities can consumers find WaterSense labeled products? Please list markets (e.g., Los Angeles, Denver).2Accessory, as defined in ASME 112.18.1/CSA B125.1, means a componentthat can, at the discretion of the user, be readily added, removed, or replaced, and that, when removed, will not preventthe fitting from fulfilling its primary function. For the purpose of this specification,an accessory can include, but is not limited to, lavatory faucet flow restrictors, flow regulators, aerator devices, andlaminar devices.EPA Form Number 6100-09The public reporting and record keeping burden for this collection ofinformation is estimated toaverage 18 hours per response. Send comments on the Agency's need for this information, theaccuracy of the provided burden estimates, and any suggested methods for minimizing respondentburden, including through the use of automated collection techniques to the Director, CollectionStrategies Division, U.S. EnvironmentalProtection Agency (2822T), 1200 PennsylvaniaAve., NW, Washington, D.C. 20460. Includethe OMB control number in any correspondence. Do not send thecompleted annual data form to this address.Section IV: WaterSense Program FeedbackIn the interest of serving you better, EPA would like to learn more about your opinions regarding the WaterSense program and information needs. Pleasecomplete the following section to provide feedback to EPA.1.On a scale of 1 to 5 (5 = most valuable), how valuable do you find the WaterSense program?Value: ________How had WaterSense added value?2.Please provide suggestions for improving the WaterSense program (e.g., general tools/materials, communications, Helpline, Web site, etc):Please Submit by March 2, 2009Mail:EPA WaterSense AnnualReportingc/o ERG14555 Avion Parkway, Suite 200Chantilly, VA 20151Contact the WaterSense Helpline at (866) 987-7367 if you have any questions about how to complete this form or submission instructions.EPA Form Number 6100-09The public reporting and record keeping burden for this collection ofinformation is estimated toaverage 18 hours per response. Send comments on the Agency's need for this information, theaccuracy of the provided burden estimates, and any suggested methods for minimizing respondentburden, including through the use of automated collection techniques to the Director, CollectionStrategies Division, U.S. EnvironmentalProtection Agency (2822T), 1200 PennsylvaniaAve., NW, Washington, D.C. 20460. Includethe OMB control number in any correspondence. Do not send thecompleted annual data form to this address.