EPA Form Number 6100-11The public reporting and record keeping burden for this collectionof information is estimatedto average 8 hours per response.Send comments on the Agency's need for this information, the accuracyof the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to theDirector, Collection StrategiesDivision, U.S. Environmental ProtectionAgency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send thecompleted New Certified Product Notification form to this address.OMB Control Number 2040-0272Approval Expires 01/31/2010New Certified Product Notification FormTank-Type High-Efficiency ToiletEPA WaterSense®Program Partners:Please complete and submit within two weeks of notification from a certifying body that your product or product modelhas receivedthe WaterSense label. By submitting this form, the manufacturer partner agrees to continue to uphold the requirements of their manufacturerpartnership agreement.Section I: General InformationManufacturer Name1: __________________________________________________________________Contact Name (for questions from the EPA WaterSense Team regarding this form)Name: ________________________________ Telephone: ______________________________Fax: ________________________________ E-mail: ______________________________Section II: Product InformationProductModel NumberRated Flush Volume(gal)Brand NameModel NameHET2Bowl TankFlush Type(single, dual, other)Single orAverageMin MaxFlush Mechanism(gravity, PA, other)For EPA Records Only (This information will not be posted on Web site)Name of Certifying BodyCertification File NumberCertification Date(mm/dd/yy)Product URL(if available)Submit this form (rewriteablePDF) 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 it to:watersense@epa.gov. AcrobatReader users must print forms after completing and fax or mailthem. Contact the WaterSense Helpline at 866 987-7367 if you have any questions.1Please 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.2Please use this column if you have either a single model number or a combinationmodel number (for both the bowl and tank).ProductModel NumberRated Flush Volume(gal)Brand NameModel NameHET2Bowl TankFlush Type(single, dual, other)Single orAverageMin MaxFlush Mechanism(gravity, PA, other)For EPA Records Only (This information will not be posted on Web site)Name of Certifying BodyCertification File NumberCertification Date(mm/dd/yy)Product URL(if available)ProductModel NumberRated Flush Volume(gal)Brand NameModel NameHET2Bowl TankFlush Type(single, dual, other)Single orAverageMin MaxFlush Mechanism(gravity, PA, other)For EPA Records Only (This information will not be posted on Web site)Name of Certifying BodyCertification File NumberCertification Date(mm/dd/yy)Product URL(if available)ProductModel NumberRated Flush Volume(gal)Brand NameModel NameHET2Bowl TankFlush Type(single, dual, other)Single orAverageMin MaxFlush Mechanism(gravity, PA, other)For EPA Records Only (This information will not be posted on Web site)Name of Certifying BodyCertification File NumberCertification Date(mm/dd/yy)Product URL(if available)ProductModel NumberRated Flush Volume(gal)Brand NameModel NameHET Bowl TankFlush Type(single, dual, other)Single orAverageMin MaxFlush Mechanism(gravity, PA, other)For EPA Records Only (This information will not be posted on Web site)Name of Certifying BodyCertification File NumberCertification Date(mm/dd/yy)Product URL(if available)Please copy this side and submit additional sheets as needed.