OMB Control Number 2040

- 0272

Approval Expires 0 6/ 30/201 3



# Retailer/Distributor Annual Reporting 2013

WaterSense ® Retailer/Distributor Partners: Please complete and submit this form to U.S. Environmental Protection Agency (EPA) contractor Eastern

Research Group, Inc. (ERG) by February 1 5, 201 3.

Note on C onfidentiality of D ata: Sensitive business information may be claimed confidential under 40 CFR Part 2, Subpart B. ERG has an EPA

- approved

security plan in place to protect confidential business information from unauthorized disclosure. All data submitted as confidential will be handled as such. All

data will be presented to EPA in aggregate.



### Please send a completed hard copy of this form to the address below by February 1 5 , 201 3

.

Mail: EPA WaterSense Annual Reporting, c/o ERG Phone : Call (866) 987

- 7367 if you have any questions about

2300 Wilson Boulevard, Suite 350 how to complete or submit this form.

Arlington, VA 22201

D o NOT submit this form via email or fax.

Section I: General Information

Retailer/Distributor Name on Partnership Agreement :

___________________________________________________________ If you do not yet have a partnership agreement, please contact the WaterSense Helpline at (866) 987

- 7367 to complete one

.



### Contact Name (for questions regarding this form) :

______________________________________________________________ Please provide a U.S. contact

, if possible.



### E mail:

________________________________________________________ P hone :

_______________________________

Please continue to the next page.

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 need for

this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the

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

correspondence. Do not send the completed annual data form to this address.Retailer/Distributor Name on Partnership Agreement:

_________________________________________________________________________________



### Section II : Tank

- Type Toilets

Please provide the following information for all tank

- type toilets sold in the United States for the period between January 1, 20 12 , and December 31, 20 12 . If

you r company does not sell or distribute toilets, please leave this section blank.

P lease report the number of units ( e.g., individual toilets) sold rather than the number of models or model lines sold

.

For the purpose of annual reporting, a combination toilet is defined as a tank and bowl that are sold together as a unit (may be one

- piece or two -p iece). To

avoid double counting, only report product sales data in the “ Tanks ” and “ Bowls ” columns if these components are NOT already counted as part of

a product in the Combination column.

U.S. Total

Tanks Bowls

Combination All Tank

- Type Toilets (Please submit EXACT sales data; do not round .)

combination) combination) Claim as confidential?

(NOT sold as part of a (NOT sold as part of a

 Yes  No

 Yes  No

 Yes  No 1.

2.

3. Total number of tank

- type toilets sold?

Note: Count ALL tank

- type toilets sold

, including both WaterSense labeled and

non

- WaterSense labeled toilets.

Total number of high

- efficiency tank

- type

toilets sold with an effective flush volume

of 1.28 gpf or less?

Notes: Count both WaterSense labeled

and non

- WaterSense labeled toilets that

meet th is criterion.

Total number of WaterSense labeled tank

type toilets sold ?



### Please include any clarifications regarding your data here :

2Retailer/Distributor Name on Partnership Agreement:

_________________________________________________________________________________



### Section III : Lavatory Faucets

P lease provide the following information for all lavatory faucets sold in the United States for the period between January 1, 20 12, and December 31, 20 12 . If

you r company does not sell or distribute faucets, please leave this section blank.

Please report the number of units (e.g., individual faucets) sold rather than the number of models or model lines sold . Please only include data on lavatory

faucets sold for private use (e .g., for installation in homes or hotel/hospital guest rooms).

Do NOT include the following in any row below:



### • F aucets sold for commercial use (e.g., public restrooms, typically with flow rates of 0.5 gpm or less ).



### • Faucets sold for kitchen sink use

.



### • D ata on lavatory faucet accessories (e.g., faucet flow restrictors, flow regulators, aerator devices, and laminar devices). Complete Section IV : Lavatory

Faucet Accessories if you are reporting sales of lavatory faucet accessories

.

All Lavatory Faucets U.S. Total

(Please submit EXACT sales data ; do not round

. ) Claim as confidential?

1.

2.

3. Total number of lavatory faucets sold ?

Note: Count ALL lavatory faucets sold , including

both WaterSense labeled and non

- WaterSense

labeled lavatory faucets.

Total number of high

- efficiency lavatory faucets

sold with a certified flow rate that falls between a

minimum of 0.8 gpm at 20 psi and a maximum of

1.5 gpm at 60 psi?

Note: Count both WaterSense labeled and non

WaterSense labeled lavatory faucets that meet

these criteria.

Total number of WaterSense labeled lavatory

faucets sold ?  Yes  No

 Yes  No

 Yes  No



### Please include any clarifications regarding your data here :

3Retailer/Distributor Name on Partnership Agreement:



### Section IV : Lavatory Faucet Accessories

Please provide the following information for all lavatory faucet accessories sold in the United States for the period between January 1, 20 12, and

December 31, 20 12 . If you r company does not sell or distribute lavatory faucet accessories , please leave this section blank.

Please report the number of units ( e.g., individual faucet accessories) sold rather than the number of models or model lines sold

. When multiple products in this

product category are sold together as part of a kit, please count the individual units. Please only include data on lavatory faucet accessories sold for private

use (e.g., for installation in homes or hotel/hospital guest rooms).

Do NOT include the following in any row below:



### • F aucet accessories sold for commercial use (e.g., public restrooms , typ ically with flow rates of 0.5 gpm or less ).



### • Faucet accessories sold for kitchen sink use.



### • D ata on lavatory faucets . Complete Section III : Lavatory Faucets if you are reporting sales of lavatory faucets

.

1. Total number of lavatory faucet accessories sold?

Note: Count ALL lavatory faucet accessories sold,

including both WaterSense labeled and non

WaterSense labeled lavatory faucet accessories. All Lavatory Faucet Accessories U.S. Total

(Please submit EXACT sales data ; do not round

. )

 Yes  No Claim as confidential?

2. Total number of lavatory faucet accessories with a

certified flow rate that falls between a minimum of

0.8 gpm at 20 psi and a maximum of 1.5 gpm at 60

psi sold?

Note: Count both WaterSense labeled and non

WaterSense labeled lavatory faucet accessories

that meet these criteria.  Yes  No

3. Total number of WaterSense labeled lavatory faucet

accessories sold?  Yes  No



### Please include any clarifications regarding your data here :

4Retailer/Distributor Name on Partnership Agreement:

_________________________________________________________________________________



### Section V: Flushing Urinals

Please provide the following information for all flushing urinal valves sold in the United States for the period between January 1, 201 2, and December 31,

201 2 . If you r company do es not sell or distribute flushing urinals, please leave this section blank.

Please report the number of units (e.g., individual flushing urinals) shipped rather than the number of models or model lines sold. For the purposes of annual

reporting, a urinal system is a valve and fixture that are sold together as a unit. To avoid double counting, only report product sales data in the “ Flushing

Urinal Valves ” and “ Flushing Urinal Fixtures ” columns if these compon ents are NOT already counted as a product in the “ Flushing Urinal Systems ”

column.

1. Total number of flushing urinals sold ?

Note: Count ALL flushing urinals sold

, including both WaterSense labeled and

non

- WaterSense labeled flushing urinals. All Flushing Urinals U.S. Total

(Please submit EXACT sales data ; do not round

. )

Flushing Urinal

Systems Flushing Urinal Valves

(NOT sold as part of a

system) Flushing Urinal Fixtures

(NOT sold as part of a

system)

 Yes  No Claim as c onfidential?

2.

3. Total number of high

- efficiency flushing

urinals sold with average maximum water

consumption of 0.5 gpf or less?

Note: Count both WaterSense labeled

and non

- WaterSense labeled flushing

urinals that meet th is criteri on

.

Total number of WaterSense labeled

flushing urinals sold ?  Yes  No

 Yes  No



### Please include any clarifications regarding your data here :

5Retailer/Distributor Name on Partnership Agreement:

_________________________________________________________________________________



### Section VI: Showerheads

Please provide the following information for all showerheads sold in the United States for the period between January 1, 201 2, and December 31, 201 2 . If

you r company does not sell or distribute showerheads, please leave this section blank.

Please report the number of units (e.g., individual showerheads ) sold rather than the number of models or model lines sold

. Please count showerheads

packaged in trim kits as one showerhead. Please only include data on fixed or hand

- held showerheads sold

.

Do NOT includ e data on any of the following in the rows below:



### • B ody sprays , which are defined as “a shower device for spraying water onto a bather other than from the overhead position .”



### • Multiple showerheads

, unless the showerheads are provided in combination in a single device intended to be connected to a single shower outlet

.

1. All Showerheads

Total number of showerheads sold?

Note: Count ALL showerheads sold, including both

WaterSense labeled and non

- WaterSense labeled

showerheads

. U.S. Total

(Please submit EXACT sales data ; do not round

. )

 Yes  No Claim as confidential?

2. Total number of showerheads with a maximum flow

rate of 2.0 gpm or less sold?

Note: Count both WaterSense labeled and non

WaterSense labeled showerheads that meet this

criterion.  Yes  No

3. Total number of WaterSense labeled showerheads

sold?  Yes  No



### Please include any clarifications regarding your data here :

61

2

3

4 Retailer/Distributor Name on Partnership A g r eement:

_________________________________________________________________________________



### Section V I I: Irrigation Controllers

Please provide the following information for irrigation controllers sold in the United States for the period between January 1, 2012, and December 31, 2012.

If you r company do es not sell or distribute irrigation controllers, please leave this section blank.

Please report the number of units (e.g., individual controllers ) sold rather than the number of models or model lines sold. For weather

- based irrigation

controllers, please include data on add

- on, p lug

- in, and standalone controllers.

All Controllers

data ; do not round. ) confidential? U.S. Total

(Please submit EXACT sales Claim as

Total number of clock timer controllers sold?

Note: Clock timer controllers are not currently eligible for the WaterSense label.

Total number of soil moisture sensors sold?

Note: Soil moisture sensors are not currently eligible for the WaterSense label.

Total number of w eather

- based controllers sold?

Note: Count ALL weather

- based controllers sold, i ncluding both WaterSense labeled and non

Water Sense labeled controllers.

Total number of WaterSense labeled weather

- based controllers sold ?  Yes  No

 Yes  No

 Yes  No

 Yes  No



### Please include any clarifications regarding your data here :

7