FS-5100-0035 Formulation Ingredient Content

USDA Forest Service FS-5100-35 (2/2012)

OMB 0596-0182

Foam Fire Suppressants - Formulation Disclosure Sheet

Ref: FSM 5160

Information on this form may be protected by the Trade Secrets Act and/or Exemption 4 of the Freedom of Information Act

Product Name:      

Formulation Identification:      

Submitting Company:      

Date Submitted:      

Submitted By:      

Signature:

Title of Submitter:      

Recommended Mix Ratio Range: 0.1% - 1.0% by weight of concentrate in water

Formulation Ingredients1

Proprietary?2 Yes/No

Manufacturer, Process, & Quality or Grade

C.A.S. Number or Other Technical Identification3

Percent by Weight in Wet Concentrate4

Percent by Weight in Solution at Recommended Use-level4

Patent or TM Number5

Remarks

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

Common chemical name or trade name. List all ingredients including water. If proprietary, explain basis under remarks. Chemical Abstract Services number or other accepted industry standard.

Sum of all percents in this column must total 100. If one or more patents apply to the use of this ingredient or total formulation, please attach a copy of the patent(s).

BURDEN AND NONDISCRIMINATION STATEMENTS

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0596-0182. The time required to complete this information collection is estimated to average 1.0 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call toll free (866) 632-9992 (voice). TDD users can contact USDA through local relay or the Federal relay at (800) 877-8339 (TDD) or (866) 377-8642 (relay voice). USDA is an equal opportunity provider and employer.