Retailer/Distributor Annual Reporting 

EPA WaterSense

® Program Partners: Please complete and submit to EPA contractor, Eastern Research Group (ERG) by Marc

Note on confidentiality of data: Sensitive business information may be claimed confidential under 40 CFR Part 2, Subpart B. Esecurity plan in place to protect confidential business information from unauthorized disclosure. All data submitted as confidential Retailer/Distributor Name1: __________________________________________________________________ 

Section I: General Information Name: ________________________________ Telephone: ________________________E-mail: Contact Name (for questions regarding this form) Section II: Product Information A. Tank-Type Toilets Provide the following information for all toilets sold in the United States between January 1, 2008 and December 31, 2008. If yo

WaterSense labeled toilets, please leave this section blank. 

All Tank-Type Toilets U.S. Total Average Price Total number of toilets sold? Total number of toilets with an effective flush volume of 1.28 gallons per flush (gpf) or less sold? Total number of WaterSense labeled toilets sold? 

B. Bathroom Sink Faucets Provide the following information for all bathroom sink faucets sold in the U.S. between January 1, 2008 and December 31, 2008

section any data for lavatory faucet accessories2 (e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar device

not sell or distribute WaterSense labeled faucets, please leave this section blank. 

All Lavatory Faucets U.S. Total Average Price Total number lavatory faucets sold? Total number of lavatory faucets sold with a certified flow rate between 1.0 and 1.5 gallons per minute (gpm)? Total number of WaterSense labeled bathroom sink faucets sold? 

1 Please use the same name used on your partnership agreement. If you do not yet have a partnership agreement, please contact the WaterSense program to co2 Accessory, as defined in ASME 112.18.1/CSA B125.1, means a component that can, at the discretion of the user, be readily added, removed, or replaced, and t

the 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 

laminar devices.
 
C. Lavatory Faucet Accessories 

Provide the following information for all lavatory faucet accessories2 (e.g., faucet flow restrictors, flow regulators, aerator device

between January 1, 2008 and December 31, 2008. Please do not include any data on lavatory faucets here (see Question B). If y

WaterSense labeled faucet accessories, please leave this section blank. 

All Lavatory Faucet Accessories U.S. Total Average Price 

Total number of lavatory faucet accessories sold? 

Total number of lavatory faucet accessories sold with a certified flow rate between 1.0 and 1.5 gpm? Total number of WaterSense labeled lavatory faucet accessories sold? 

Section III: WaterSense Labeled Product Availability Information on WaterSense's impact on the marketplace is vital to the continued success of the program. Please provide data on 

promotion. 

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? 

 Yes  No 

c. If yes, please indicate how you are promoting WaterSense labeled products (please provide samples) : 

 In-store promotions, such as displays and other signage 

 Ads and circulars 

 Brochures, other marketing materials 

 Rebate programs (usually in conjunction with local utilities) 

 Web site 

 Other: _________________________________________________________________________________________

d. If yes, are you working with other types of WaterSense partners (e.g., utilities or manufacturers) to promote WaterSense la

2. In which of your facilities can consumers find WaterSense labeled products? Please list markets (e.g., Los Angeles, Denve

2 Accessory, as defined in ASME 112.18.1/CSA B125.1, means a component that can, at the discretion of the user, be readily added, removed, or replaced, and t

the 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 

laminar devices. 

EPA Form Number 6100-09 The public reporting and record keeping burden for this collection of information is estimated to average 18 hours per response. Send comments on the Agency's 

accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection tech

Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in 

completed annual data form to this address. 
Section IV: WaterSense Program Feedback 

In the interest of serving you better, EPA would like to learn more about your opinions regarding the WaterSense program and infcomplete 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

Please Submit by March 2, 2009 Mail: EPA WaterSense Annual Reporting 

c/o ERG 14555 Avion Parkway, Suite 200 Chantilly, VA 20151 

Contact the WaterSense Helpline at (866) 987-7367 if you have any questions about how to complete this form or submission ins

EPA Form Number 6100-09 The public reporting and record keeping burden for this collection of information is estimated to average 18 hours per response. Send comments on the Agency's accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection tech

Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in 

completed annual data form to this address.