EPA Form Number 6100-18 

The public reporting and record keeping burden for this collection of information is estimated to average eight hours per response. Send comments on the Agencaccuracy 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 New Certified Product Notification Form to this address. 

New Certified Prod

 WaterSense® Labeled Flushing Urinal 

EPA WaterSense Program Partners: Please complete and submit this form within two weeks of notification from a certifying bodmodel has received the WaterSense label. By submitting this form, the manufacturer partner agrees to continue to uphold the reqpartnership agreement. Section I: General Information Manufacturer Name: __________________________________________________________________ (This name should match what is on the certification file for WaterSense labeled flushing urinals and your EPA partnership agreemContact 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 Web registry. Please only include information purchaseInstructions: 

• Please only include information for one product type per line. Indicate the product type and flushing device (if applicable) • Check “Urinal System” if you sell a urinal as a complete system (i.e., both the fixture and flushing device) under a single m

• Check “Urinal Flushing Device” if the product, which can be either a pressurized flushing device or flush tank (gravity type

independently 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 fl

• The rated flush volume is the product’s maximum flush volume, as specified by the manufacturer, verified through testing

WaterSense Specification for Flushing Urinals. Include the rated flush volume for each product model and type. 

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume 

□ Urinal system □ Urinal flushing device □ Urinal fixture 
Submit this form (rewriteable PDF) to WaterSense via: Fax: (703) 841-1440Mail: WaterSense, c/o ERG, 2300 Wilson Blvd., Suite 350, Arlington, VA 22201 

Electronically: If you have Adobe Acrobat Standard or Professional, you can fill out the form electronically and e-mail it to: water

Reader users must print forms after completing and fax or mail them. Contact the WaterSense Helpline at (866) 987-7367 if you h

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume (g

□ Urinal system □ Urinal flushing device □ Urinal fixture 

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume (g

□ Urinal system □ Urinal flushing device □ Urinal fixture 

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume (g

□ Urinal system □ Urinal flushing device □ Urinal fixture 

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume (g

□ Urinal system □ Urinal flushing device □ Urinal fixture 

Product 

Brand Name Model Name Product Type (Please check one) Model Number Rated Flush Volume (g

□ Urinal system □ Urinal flushing device □ Urinal fixture 

Please copy this side and submit additional sheets as needed.