EPA Form Number 6100-18The public reporting and record keeping burden forthis collection of information is estimated to average eight hours per response. Send comments on theAgency's need for this information, theaccuracy of the provided burden estimates, and anysuggested methods for minimizing respondent burden,including through the use of automated collectiontechniques to the Director, CollectionStrategies Division, U.S. Environmental ProtectionAgency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number inany correspondence. Do not send thecompleted New Certified Product Notification Form to this address.1OMB Control Number 2040-0272Approval Expires 01/31/2010New Certified Product Notification FormWaterSense®Labeled Flushing UrinalEPA WaterSense Program Partners:Please complete and submit this form within two weeks of notification from a certifying body that your product or productmodel has received the WaterSense label. By submitting this form, the manufacturer partner agrees to continue to uphold the requirements of its manufacturerpartnership agreement.Section I: General InformationManufacturer Name: __________________________________________________________________(This name should match what is on the certification file for WaterSense labeled flushing urinals and yourEPA partnership agreement.)Contact Name (for questions from the EPA WaterSense Team regarding this form)Name: ________________________________ Telephone: ______________________________Fax: ________________________________ E-mail: ______________________________Section II: Certification Information(This information will not be posted on the WaterSense Web registry.)Name of Certifying Body: __________________________________________ Certification File Number: _______________________________________Section III: Product Information(This information will appear on the WaterSense Webregistry. Please only include information purchasers will see on product packaging.)Instructions:•Please only include information for one product typeper line. Indicate the product type and flushing device(if applicable) for each product model.•Check “Urinal System” if you sell a urinal as a complete system (i.e., both the fixture and flushing device)under a single model number.•Check “Urinal Flushing Device” if the product, which canbe either a pressurized flushing device or flush tank (gravity type) flushing device, is soldindependently of the urinal fixture.•Check “Urinal Fixture” if the product is the china/plastic/stainless steel piece only and is sold independently of the urinal flushing device.•The rated flush volume is the product’s maximum flush volume, as specified by the manufacturer, verifiedthrough testing, and in compliance with theWaterSense Specification for Flushing Urinals. Include the rated flush volume for each product model and type.ProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicable2Submit this form (rewriteable PDF) to WaterSense via:Fax:(703) 841-1440Mail:WaterSense, c/o ERG, 2300 Wilson Blvd., Suite 350,Arlington, VA 22201Electronically:If you have Adobe Acrobat Standard or Professional,you can fill out the form electronically and e-mail itto:watersense@epa.gov. AcrobatReader users must print forms after completing and fax or mail them. Contact the WaterSense Helpline at(866) 987-7367 if you have any questions.ProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicableProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicableProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicableProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicableProductBrand Name Model NameProduct Type(Please check one)Model Number Rated Flush Volume(gal)Flushing Device Type□Urinal system□Urinal flushing device□Urinal fixture□Pressurized flushing device□Flush tank (gravity type)□Not applicablePlease copy this side and submit additional sheets asneeded.