EPA Form 6300

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### ICR No. **2261 .**  **03 ; OMB Control No. 2070** 
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**ATTACHMENT B**  **DfE Formulator Program: Product Information Form**



### OMB Control No. 2070
**- 0171**  **Approval expires 05/31/2014**  The public reporting and recordkeeping burden for this collection of information is estimated to average 10 hours per respons e, including the time for reviewing instructions, gathering information, posting information to the internet, and reviewing and com pleting the application. 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 th e 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 application to this address.EPA Form 6300

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# Safer Detergents **Stewardship Initia ti** **ve Instructions for Application Form** 

EPA developed the Sa fe r Detergents Ste wardship Initiative (SDSI) to recognize environmental leaders wh o voluntarily commit to the use of sa fe r surf actants. Leading product manuf acturers have made great progress in developing sa fe r, highly eff

ective cleane rs. These manuf ac turers believe that producing the sa fe st products possible is important to their role as ste wards of the environment and public health. A number of U.S. corporations have acted in advance of SDSI to use sa fe r sur factants in their entire product lines.
Safer surfactants are surfactants that break down quickly to non

- polluting compounds 1

. DfE’s Safer Chemical Ingredients List contains surfactants that meet DfE’s criteria for safer chemicals ( http://www.epa.gov/dfe/saferingredients. htm ). CleanGredients  is also a resource for information on safer surfactants (www.cleangredients.org). To be eligible for recognition under SDSI, candidates should do the following: o Complete this application and have it signed by a company authority (e.g., CEO or vice president for health and environment). o Post a statement on their website describing the actions that qualify them for recognition under SDSI. EPA reserves the right to request at any time, on a confidential basis, appropriate documentation (including but not limited to bills of lading, invoices, material safety data sheets, and list of ingredients) to confirm that candidates have achieved the ap propriate criteria for recognition. If documentation is requested but not received within a reasonable time, EPA may deny or withdraw recognition from that candidate.

1 An example of a class of safer surfactants is linear alcohol ethoxylates (LAE). LAEs are toxic to aquatic life, but break down quickly to non

- polluting compounds. Nonylphenol ethoxylates, commonly referred to as NPEs, are a surfactant class that does not meet the definition of a safer surfactant. Both NPEs and their breakdown products, such as nonylphenol, are toxic to aquatic life. There are two categories for recognition under SDSI: Champion and Partner.



###  **Champion** is the highest level of recognition offered under SDSI. At this level, the participant is listed on the EPA SDSI website as a champion and may use a special logo in their literature to help explain their participation in the program.



###  The **Partner** category p rovides recognition of significant accomplishment towards the use of safer surfactants. Partners will be listed on the EPA SDSI website and may be granted recognition as a Champion in the future, if appropriate. Partner recognition will sunset on the comm itment date provided in Section 3 of the Application. Guidelines for achieving Champion or Partner Status are provided in Table 1. Both Champions and Partners will receive a certificate of recognition from DfE

. Application Process : The application is available online and may be filled out and submitted in hard copy by mail or scanned and emailed to SDSI@epa.gov. Unless you claim information as confidential , all applications received will be considered public information and no mater ials submitted will be returned. For security purposes, confidential information should not be submitted electronically. If you choose to send the applicationEPA Form 6300

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electronically, the application and signed signature page must be scanned and sent to SDSI@epa.g ov. If you choose to submit a hard copy application, sen d your completed application via regular / certified mail or overnight mail to the following address: Safer Detergent Stewardship Initiative Attn: Laura Romano 4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814

- 5341 301

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- 5289 Conf irmation of

Receipt: EPA will confirm receipt of applications, usually by email. If you have not received an acknowledgment within two weeks of sending your applications, please contact David Difiore at SDSI@epa.gov or 202

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- 8786 Notif ication: Winners will be notified prior to the official public announcement. Awards will be presented to the primary sponsor of the application. Questions: Questions about eligibility, nomination procedures, or the Safer Detergent Stewardship Initiative should be directed to David Difiore of EPA’s Design for the Environment Program at SDSI@epa.gov or 202

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**Paperwork Burden Estimate** The public reporting and recordkeeping burden for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, gathering information, posting information to the internet, and reviewing and completing the appl ication. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2070

- 0171. Approval expires on 05 /31/2014. 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, Col lection 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 application to**  **this address.**EPA Form 6300

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**Additional n otes about Table 1**  **guidelines :** 
 DfE’s Safer Chemical Ingredients List and CleanGredientsTM are resource s for information on safer surfactants.

 Products include those whose use routinely results in their discharge to the environment (e.g., all

- purpose cleaners, laundry detergents, pesticides, airplane de

- icers, fire

- fighting foams and gels).

 An example of a strategy is a letter that is sent to suppliers requiring them to provide products with only safer surfactants. The retailer/distributor or institutional purchaser will not be eli gible for Champion recognition until only safer surfactants are sold or purchased.

 Examples of efforts that would qualify include developing means for surfactant users to identify safer surfactants, taking action to educate industry or the public about saf er surfactants, and encouraging business to move toward safer surfactants. **Par ticipant**  **Type** 

### Table 1: Guidelines for Achieving: **Champion Status Partner Status** 

Chemical Manufacturers 

###  Demonstrate that you only manufacture safer surfactants


###  Document a strategy for ensuring that you manufacture only safer surfactants 

###  Commit to manufacturing only safer surfactants by a date that is reasonable for your circumstances


###  Document a strategy for ensuring that you will manufacture only safer surfactants

Formulators 

###  Demonstrate that you only use safer surfactants in products


###  Document a strategy for ensuring that only safer surfactants are used in products 

###  Commit to using only safer surfactants in your products by a date that is reasonable for your circumstances


###  Document a strategy for ensuring that only safer surfactants will be used in products

Retailers / Distributors 

###  Demonstrate that only safer surfactants are included in products intended for sale


###  Document a strategy for ensuring that only safer surfactants are included in products intended for sale 

###  Commit to sell only products cont aining safer surfactants by a date that is reasonable for your circumstances


###  Document your active encouragement of the use of safer surfactants

Institutional Purchasers 

###  Demonstrate that you only purchase products containing safer surfactants


###  Document a strategy for ensuring that purchased products only contain safer surfactants 

###  Commit to only use products that only contain safer surfactants by a date that is reasonable for your circumstances


###  Document your active encouragement of the use of safer surfacta nts

Others (e.g., non - profits, unions, academia) 

###  Demonstrate outstanding efforts to encourage the use of safer surfactants 

###  Document your active encouragement of the use of safer surfactantsEPA Form 6300

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SECTION 1a: Enter requested information for the authorized representative Organization Name

Contact Name

Address

Address

Phone Fax

Email

Website
SECTION 1b: Indicate your type of organization Chemical Manufacturer

– Manufactures surfactants Formulator

– Purchases and blends chemicals (including surfactants) to create an end

- use product for retailers and/or distributors Retailer / Distributor

– Sells products containing surfactants Institutional Purchaser

– Purchases or specifies cleaning products for use in multiple facilities (e.g., janitorial service provider) Other

– Influences use of surfactants (e.g., non

- profit, trade association, academia)
SECTION 1c: Indicate the level of recognition for which you are applying (refer to the instructions for a description of Champion and Partner status for each organization type) Champion (go to Section 2) Partner (go to Section 3)EPA Form 6300

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SECTION 2: Fill out this section if you are applying f

or recognition as a Champion If you are a... Demonstrate in SECTION 2a that... And the n go to... Chemical Manufacturer You only manufacture safer surfactants Section 2b Formulator You only use safer surfactants in products Section 2 b Retailer / Distributor Only safer surfactants are included in

products intended for sale Section 2 c Institutional Purchasers All the products you purchase contain only

safer surfactants Section 2 c Other You have made outstanding efforts to

encourage the use of safer surfactants Go to Section 4

SECTION 2a: Use this space to explain how you meet the above requirements. Please include supporting documents when appropriate and note these documents in your statement. You may attach extra sheets as needed. To be eligible for recognition, candidates should post a statement on their website stating that they manufacture, use, or purchase products containing only safer surfactants. Use this space to provide the URL for that section of your website des cribing the actions that qualify you for recognition:EPA Form 6300

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SECTION 2b (Chemical Manufacturers and Formulators only): Indicate or describe your product stewardship strategy for ensuring the manufacture or use of safer surfactants Use DfE’s Safer Chemical Ingredients List or CleanGredients TM to choose surfactants

Other, please describe 2 :

SECTION 2c (Retailers/ Distributors and Institutional Purchasers only): Document your strategy for ensuring that all of your purchased products contain only safer surfactants. You may attach extra sheets as needed .* If you are a... Document a strategy for ensuring that... Retailer / Distributor Only safer surfactants are included in products intended for sale

Institutional Purchaser Purchased products contain only safer surfactants

* An example of a strategy would be the establishment of a policy that requires suppliers to provide products that contain only safer surfactants. This strategy may be evidenced by a letter that is sent to suppliers requiring them to provide products with only safer surfactants, or a comparable statement posted on a company’s website. The retailer / distributor will not be eligible for Champion recognition until it sells products with only safer surfactants.

2 For SDSI recogniti on, your strategy description should include an explanation of your due diligence in selecting safer surfactants. Along with the non

- use of NPE surfactants, examples of due diligence include : Only using surfactants from DfE’s Safer Chemical Ingredients List ( http://www.epa.gov/dfe/saferingredients.htm ); only using surfactants from CleanGredients TM (www.cleangredients.org); only using surfactants that meet the DfE or CleanGredients surfactant screens (see DfE screen at http://www.epa.gov/dfe/pubs/projects/gfcp/index.htm); or only using surfactants that meet criteria similar to the DfE or CleanGredients TM screens (e.g., the EU Detergents Directive). In addition, a description of in

- house criteria that ensures the use of safer surfactants may also qualify as d ue diligence.EPA Form 6300

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SECTION 3: Fill out this section if you are applying f or recognition as a Partner If you are a... Document in SECTION 3a your commitment to...
Chemical Manufacturer Produce only safer surfactants
Formulator Use only safer surfactants in your products Retailer / Distributor Only sell products that only contain safer surfactants
Institutional Purchasers Only purchase products that only contain safer surfactants
Other (e.g., trade association, NGO, etc.) encouragement of safer surfactants

SECTION 3a: Use this space to describe how you meet the above requirements. * To be eligible for recognition, candidates should post a statement on their website stating their commitment to completely transitioning to safer surfactants. Use this space to provide the URL for that section of your website describing the actions that qualify you for recognition:

* You should describe your commitment to a complete transition to safer surfactants by a date that is reasonable for your circumstances. Please state this date explicitly and explain briefly why it is a reasonable date for your circumstances. 3 Include supporting materials when appropriate and note these materials in your statement. You may attach extra sheets as needed.

3 Please note that Partner recognition will sunset on the commitment date. After this date, companies will need to apply for Champion recognition.EPA Form 6300

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SECTION 4: Certification of Application Please have the appropriate company authority (e.g., CEO , vice president for health and environment , division head, or other authorized signatory) sign here to verify the accuracy of the application’s content.

Signature of Authorizing Entity Date

Printed Name and Title Date I hereby affirm that the contents of this application are true and accurate to the best of my knowledge, and that I am an authorized representative of the company or organization named above and am duly authorized to sign this applicatio n.