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Enter Title Here - Enter Title Here

     Printed: January 9, 2011

    Information Request NSF Green Chemistry Product Information

About NSF

    NSF International (NSF) is an independent, not-for-profit organization of scientists, engineers, technicians, educators, and analysts.

    NSF currently provides testing, certification, and audit services for more than 130,000 products in 82 countries worldwide. It is a

    trusted neutral non-governmental agency, serving government, industry, and consumers in achieving solutions to problems relating to

    public health and the environment since 1944. The mission of NSF is to provide clients and the general public with objective, high

    quality, timely, third-party certification services. Services include development of consensus standards, voluntary product testing and

    certification with policies and practices which protect the integrity of registered Marks, education and training, and research and

    demonstration, all relating to public health and the environmental sciences.

NSF Green Chemistry Program

    NSF’s Green Chemistry Program performs reviews of product formulations and individual ingredients for conformity with environmental standards and recognition programs including:

    ; The U.S. Environmental Protection Agency, Design For the Environment (EPA - DfE) Formulator Program ; The GreenBlue Institute, for listing on the CleanGredients? website

    ; Green Seal environmental standards

    ; Environmental Choice standards

How does the process work?

    ; Submittal of the information requested on this form will initiate the process to obtain a time and cost estimate for NSF review

    services.

    ; NSF will review the information for completeness and provide the written cost estimate and corresponding contract. ; Upon receipt of a signed contract, and a 50% deposit, NSF will initiate the review process. NSF will request the following

    information as needed to complete the reviews:

    ; Test data and other product information to confirm the formulation complies with the criteria of the respective

    standard or recognition program (e.g. product performance test data, biodegradation studies for each ingredient, acute

    aquatic toxicity data, human health toxicity data, etc.)

    ; Proprietary ingredient disclosure from your ingredient suppliers NSF will provide forms that can be forwarded to

    your suppliers. The forms will explain the nature of the request, and provide an opportunity to submit the information

    directly and confidentially to NSF.

    ; An MSDS for each product and each ingredient

Confidentiality

    Only NSF authorized personnel are permitted accesses to the information provided on this form. The security of this form and the

    information it contains is maintained through our confidential business information procedures and will not be revealed or provided to

    unauthorized employees within the applicant’s company, ingredient suppliers, or other parties without your company’s prior written consent. See Section 4 of this form for EPA review for DfE recognition and CleanGredients? reviews.

AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 1 of 5

     Printed: January 9, 2011

Information Request NSF Green Chemistry NSF USE ONLY Product Information

     DCC:

     Corporate #: _________________________

    Project #: ___________________________

    The information requested on this form is critical to the review of your product.

    Please complete this form completely prior to submission. Please call 651-493-4247 for assistance.

1. Company information:

    Company name Company contact

     Job Title

    Address Telephone number ( )

     FAX number ( )

     Email

2. Review type:

    Please check the type of review you are seeking:

     EPA DfE Recognition

     Please attach: Product performance data

     Product MSDS

     Ingredient MSDS’s

     CleanGredients? listing

     In order to list on CleanGredients? you must be a current supplier subscriber on www.cleangredients.org

    Please attach: Biodegradability data

     Aquatic toxicity data

     Human health & safety data

     Product MSDS

     Ingredient MSDS’s

     Other (explain) ________________________

    Please check additional testing you are seeking:

     Product performance testing. EPA’s DfE Program requires product performance testing in order to recognize safer products.

     Market leading product you would like NSF to evaluate your product against:

     Compostability testing. EPA’s DfE Program requires compostability testing on all disposable wipe products.

     Biodegradation testing. NSF offers biodegradation testing to support CleanGredients? reviews.

    AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 2 of 5

     Printed: January 9, 2011

3. Product Information: (please submit one page per formulation, use additional sheets as needed)

    Company Name

    Product trade name: Type of product (all purpose cleaner, glass cleaner, surfactant, etc.)

    pH of product (at point of sale): Production volume (lbs/yr)

    Check if: Consumer Product / Industrial/Institutional Product

    Check if: Product is an aerosol / Product is an EPA registered pesticide

    Check if product is sold as: Ready-to-Use Formulation / A concentrate , if a concentrate what is the dilution ratio?

    Type of material used in packaging (cardboard, HDPE, PETE, etc.) Percent recycled content in packaging %

    4. Product Formulation: (for sample form and instructions, please see the last page of this form)

    Ingredient Class Other supporting Check if (Surfactant, Fragrance, Supplier(s) (Include information: Number MSDS is % Chemical Name solvent, builder, chelator, Trade Name Alternate Suppliers) of ethoxylates, attached CAS No. Composition [2] pH adjustor…etc) [4] 1 Supplier per line average chain length, [8] [1] [7] [3] [5] polymer MW, etc. [6]

    Omission of information may significantly delay the completion of the review process.

    ALL INFORMATION CONTAINED ON THIS PAGE IS CONFIDENTIALAESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 3 of 5

     Printed: January 9, 2011

    4. Certification statement: (check one)

    DfE and CleanGredients? applicants:

     I hereby certify that, to the best of my knowledge, the information provided to NSF is accurate and complete. I understand that the information submitted may be used as a basis for reviewing/accepting other products which contain this material and/or the ingredients herein. I also understand and agree that the information I have provided on this form was requested for NSF’s Green Chemistry program, and that after review, this information and the review will be submitted to the EPA’s Design for the Environment Program.

All other review-type applicants:

     I hereby certify that, to the best of my knowledge, the information provided to NSF is accurate and complete. I understand that the information submitted may be used as a basis for reviewing/accepting other products which contain this material and/or the ingredients herein.

Signature Date

     For forms submitted electronically, check this box to indicate agreement to the applicable Certification Statement above (required).

Typed or printed name

    Position/Title

    5. Return instructions:

    To send by e-mail, completely fill out the form, and type your name and contact information in Section 4. Check the box indicating your agreement with the certification statement. Send your e-mail with attachments to

    amcdade@nsf.org.

To send by fax, completely fill out and sign the form, then fax to 734-827-6197. This fax number goes to a secure

    computer for Amy McDade, Green Chemistry Project Manager for NSF International.

    To send by U.S. mail or courier, insert completed form in an envelope marked "Confidential Business Information," seal in an outer envelope, and return to:

     Amy McDade

     Green Chemistry

    NSF International

    789 Dixboro Road

    Ann Arbor, MI. 48105

    USA

    AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 4 of 5

     Printed: January 9, 2011

Formulation information: What should I enter in each column?

    [1] The CAS number (Chemical Abstracts Service registry number) is a systematic numbering convention that uniquely

    identifies each chemical. You may be able to find this information on the MSDS for the ingredient. If the ingredient is

    a mixture of several chemicals, enter the word “mixture.” There are multiple resources available on the web and

    elsewhere for finding specific CAS numbers (e.g., http://chem.sis.nlm.nih.gov/chemidplus/cmplxqry.html). All CAS

    numbers are up to nine digits, which are separated into three groups by hyphens. The first part of the number, starting

    from the left, has up to six digits; the second part after the first hyphen has two digits. Finally, the third part of the CAS

    number following the last hyphen is single digit. For example, a CAS number may look 123456-12-1. If it is not in this

    format, it is not a valid CAS number. If you cannot determine a CAS number for an ingredient, leave this area blank.

[2] The chemical name for each component can be found on the MSDS.

[3] The ingredient class can refer to: surfactants, solvents, chelators, fragrances, preservatives/biocide, builders, hydrotropes,

    sequestrants, dispersants, sanitizer, dyes/colorants, enzyme/microorganisms, fragrances, and other.

    [4] The trade name is the unique name or identification number of the ingredient as you buy it from your supplier. This

    information can be obtained from your purchasing department.

    [5] The supplier is the company from whom you buy this ingredient. If you know that your supplier is a distributor, and

    you know the name of the company that manufactures the ingredient, please enter both company names here. Write (D)

    after the distributor’s name, and (M) after the manufacturer’s name. For each ingredient that you buy from more than

    one supplier, please enter each chemical name, trade name, supplier, and % on a separate line.

    [6] A single surfactant CAS number may represent a wide range of carbon chain length and/or number of ethoxylates.

    Polymers may have varying molecular weights and residual monomers. Detailed information on the specific chemical

    you are using will help NSF perform an accurate review of your ingredient.

    [7] The percentage in the ingredient must be completed for each component. The total of all components must always equal

    100%.

    [8] NSF requests ingredient MSDS’s wherever available, they help identify useful information regarding composition,

    physical and chemical properties, indicate types of test data that may be available, etc.

An example of a completed formulation is shown below:

    Ingredient Other supporting Class information: Supplier(s) (Include Check if [3] Number of % Chemical Name Trade Name Alternate Suppliers) MSDS is CAS No. ethoxylates, Composition [2] [4] 1 Supplier per line attached [1] average chain [7] [5] [8] length…etc. [6]

    68131-39-5 Alcohols, Surfactant Surfactant 1 Company A C12-15, 14.25 Ethoxylated Average 7EO

    67762-38-3 Methyl soyate Solvent Solvent 1 Company B C12-18 35.75

    Proprietary Proprietary Fragrance Rain Drops # Company C N/A 0.003 302710

    Proprietary Proprietary Dispersant Dispersant 1 Company D MW >27,000, 1.18

    acrylic <2ppm styrene

    polymer

    7732-18-5 Water Solvent N/A Company (or N/A balance municipality) E

AESOP 8284; ISSUE 3; STATUS-PUBLISHED; EFFECTIVE 15 AUG 2009 This document is the property of NSF International. Page 5 of 5

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