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					                                                                                APPLICANT PRODUCT SUBMITTAL FORM
                                                                                Classification to ANSI/NSF Standard 42 & 53


                                        Please provide File, Volume, and Section Info and           UL File #:                Volume, Section:
Do you have a current           YES
                                        Indicate any changes to Company Info, below
UL File for this
submittal?                      NO      Please complete the Company Information, below

                                                    COMPANY INFORMATION
APPLICANT: The company or individual who applies to UL for the investigation of a component, product or system. This party
contractually assumes the financial obligation for the cost of the investigation and Follow-Up Service, and thereby exercises the rights to
information obtained as a result of the investigation.
COMPANY NAME:
STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE:                                               FAX:                                      EMAIL:
CLASSIFIED COMPANY: The company under which the Applicant wishes the Classification of a certified product to appear in UL’ s
published records (i.e., the name of the company under which the product is sold)
  Classified Company             Alternate Classified Company (Classified               Multiple Classified Companies (Applicant and
  Info is same as             Company different from Applicant)                      Additional Classified Company)
  Applicant Info
COMPANY NAME:
STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE:                                               FAX:                                      EMAIL:
MANUFACTURER: The company responsible in full or in part for manufacturing the product submitted to UL for certification, including but
not limited to its compounding, molding, production in final form, packaging and labelling. A facility that repackages and re-labels a product
is also considered a Manufacturing location.
   Mfr Info is same as           Mfr Info is same as              New Manufacturer/ Location               Alternate Manufacturer/ Location
   Applicant Info                Classified Company
                                                                   Please Provide any Additional Manufacturing Location Info on Separate Page
                                 Info
COMPANY NAME:
STREET ADDRESS:
CITY, STATE:
PROVINCE, COUNTRY:
CONTACT NAME/TITLE:
TELEPHONE:                                                FAX:                                     EMAIL:

AGENT: A third party authorized to represent the Applicant in dealings with UL. Please note an agent must have an active Agency
Authorization on file.
AGENCY NAME:                                                             AGENCY CONTACT:
TELEPHONE:                                                FAX:                                      EMAIL:

     UL will refrain, without the Applicant’s prior written authorization, from voluntarily disclosing to third
     parties proprietary information which is obtained by UL in confidence from the Applicant and which is
     not already known to UL, already available to the public or subsequently acquired from other sources.
                                            RETURN COMPLETED FORM TO :
   UNDERWRITERS LABORATORIES INC.- ATTN: MARY RISPER, CUSTOMER SERVICE – 333 PFINGSTEN ROAD , NORTHBROOK, IL 60062
                       TELEPHONE: (847) 664-4911 FAX (847) 574-4005 EMAIL: water@us.ul.com


              Applicant                                           Page 1 of 6                                 «VariationNumber»
                                                                                                             Issued: January 5, 2005
                                      GENERAL PRODUCT INFORMATION – PART 1

                                           DRINKING WATER TREATMENT UNITS
PRODUCT NAME:

Catalog number, model number, trade name, etc. under which the product is sold. This will be the product designation under
which UL will list this product in its published records.


 MAXIMUM OPERATING TEMPERATURE, ºF(ºC):


 MAXIMUM WORKING PRESSURE, PSI(KPA):


 SERVICE FLOW RATE, GPM(LPM):                                    CAPACITY, GAL(L):


 UNIT VOLUME, GAL(L):                                       UNIT VOID VOLUME, GAL(L):


 DOES THE PRODUCT CONTAIN A PERFORMANCE INDICATOR?                                            YES                 NO


 WQA GOLD SEAL VALIDATION TO BE INCLUDED?                                 YES                 NO


  TESTING CYCLE:              50/50         10/90           MIN ON:               MIN OFF:                 (Specify if not used for all claims.)


 DESCRIPTION OF USE PATTERN (POUR THROUGH BATCH SYSTEM):


PERFORMANCE CLAIMS FOR STANDARD 42:


                Chloride                                          Additives (polyphosphates)                Particulate (Class I)
                pH (low)                                          Additives (silicates)                     Particulate (Class II)
                pH (high)                                         Manganese                                 Particulate (Class III)
                Iron                                              Sulfate                                   Particulate (Class IV)
                Phenol                                            Zinc                                      Particulate (Class V)
                TDS                                               Hydrogen Sulfide                          Particulate (Class VI)
                Taste/Odor/Chlorine - Aesthetic                   Foaming Agent
                Chloramine                                        Bacteriostasis

PERFORMANCE CLAIMS FOR STANDARD 53:


                Total Trihalomethanes*                              Selenium
                VOC’s (by surrogate)                                Mercury
                Fluoride                                            Cyst reduction using:                 live Cryptosporidium parvum oocysts
                Nitrate and Nitrite                                                                       polystyrene microspheres
                Lead                                                Turbidity Reduction
                Barium                                              Asbestos Reduction
                Cadmium                                             Arsenic (Pentavalent) with influent level at:               50 ppb
                Chromium (Hexavalent)                                                                                           300 ppb
                Chromium (Trivalent)                                Arsenic (Trivalent) with influent level at:                 50 ppb
                                                                                                                                300 ppb
                Copper
                Radon                                               Other (Please specify)

    * Although TTHMs are included as part of the VOC by surrogate test, in order to claim TTHM reduction as a separate claim, a separate reduction
    test may be required.



              Applicant                                             Page 2 of 6                                   «VariationNumber»
                                                                                                                 Issued: January 5, 2005
GENERAL PRODUCT TYPE:

         PLUMBED-IN SYSTEM WITHOUT RESERVOIR             BACKWASH FLOW RATE (IF APPLICABLE):
         OR FAUCET MOUNT SYSTEM
                                                         TANK HEIGHT (IF APPLICABLE):
         PLUMBED-IN SYSTEM WITH RESERVOIR

                                                         TANK DIAMETER (IF APPLICABLE):
         POUR-THROUGH BATCH SYSTEM

         POINT-OF-ENTRY                                  PRESSURE DROP (POINT-OF-ENTRY):

         REFRIGERATOR FILTER WITHOUT                     FLOW CONTROL PROVIDED WITH UNIT:                    YES            NO
         INTEGRAL FLOW CONTROL

         REFRIGERATOR FILTER WITHOUT                     DIVERTER INCLUDED:              YES         NO
         INTEGRAL FLOW CONTROL WITH WATER
         DISPENSER AND ICE MAKER                         NUMBER OF FILTER ELEMENTS:




MODEL NUMBER(S) OF REPLACEMENT FILTERS OR MEDIA TYPE AND AMOUNT:

                               NAME                                              MODEL NUMBER




THE MATERIALS USED TO CONSTRUCT THIS PRODUCT HAVE BEEN EVALUATED BY A QUALIFIED LABORATORY AND
FOUND TO MEET REQUIREMENTS OF THE FOLLOWING STANDARD:
                            NSF/ANSI STANDARD 42 OR 53                  NSF/ANSI STANDARD 61

                            NSF/ANSI STANDARD 44                        US FDA TILE 21 (21 CFR)

                            OTHER:

NAME OF TESTING LABORATORY:



IF THIS PRODUCT CONTAINS ELECTRICAL COMPONENTS, IS IT LISTED BY AN ACREDITED AGENCY?

                            YES (IF “YES”, PLEASE SUBMIT PROOF OF COMPLIANCE TO THE ELECTRICAL CODE.)

                            NO (IF “NO”, WOULD YOU LIKE UL ELECTRICAL TO CONTACT YOU?          YES     NO)



PLEASE INDICATE IF THE TEST REPORT DATA WILL BE USED IN A SUBMITTAL FOR PRODUCT APPROVAL TO ANY OF THE
FOLLOWING REGULATORY AGENCIES: (Indicating an agency below is considered consent to send applicable test data to those agencies)
                            CALIFORNIA                MASSACHUSETTS                      IAPMO

                            WISCONSIN                 IOWA                               OTHER

                            NO REGULATORY AGENCY APPROVAL REQUESTED




           Applicant                                      Page 3 of 6                                «VariationNumber»
                                                                                                  Issued: January 5, 2005
                                GENERAL PRODUCT INFORMATION – PART 2

                                           METHOD OF MANUFACTURE

Give a brief description of the process involved in each stage of manufacture of this product. Please specify the
designation (trade name, model number, etc) and supplier (name and address) of each manufacturing aid, such as a
mold release agent, a lubricant, or an adhesive that is used, if it is not specified in the formulation provided on page 5.
For molded parts, please specify molding parameters (time, temp, pressure). If more than one manufacturing location is
involved, indicate the location(s) where each manufacturing step occurs.




                                                APPLICATION INFORMATION

         Please enclose product literature and any relevant publication for each submitted system. Indicate below
         the type of literature enclosed.

         Literature enclosed:


                  INSTALLATION, OPERATION, AND MAINTENANCE INSTRUCTIONS

                  DATA PLATE SUCH AS PERMANENT PLATE OR LABEL

                  PACKAGING/LABELING OF REPLACEMENT COMPONENTS (IF APPLICABLE)

                  PERFORMANCE DATA SHEETS

                  OTHER




             Applicant                                    Page 4 of 6                            «VariationNumber»
                                                                                                Issued: January 5, 2005
                                                SUPPLIER INFORMATION

                         Please provide contact information for each supplier listed on the Wetted Parts List
                                                                        CONTACT INFORMATION
NAME OF SUPPLIER                         ADDRESS                                                                          CONTACT NAME
                                                                     (PHONE NUMBER, FAX, EMAIL)




             Applicant                                       Page 5 of 6                                «VariationNumber»
                                                                                                       Issued: January 5, 2005
                                                                   WETTED PARTS LIST


PRODUCT NAME:                                                                VOLUME:                                 PAGE                of

List every part that comes in contact with drinking water and provide the requested information. If there is more than one supplier of a part, indicate each supplier.
                         This page can be replaced by a document that contains the required information, even if it is in a different format.
                                                                                                                                                QTY        WETTED
                                                              SUPPLIER’S MODEL NUMBER/
     PART DESCRIPTION                  PART NUMBER                                                              SUPPLIER                         IN     SURFACE AREA
                                                                  PART DESIGNATION
                                                                                                                                              PRODUCT       (CM²)




I hereby certify that all information in this document is accurate and complete to the best of my knowledge.
                                                                                                                 RETURN THIS FORM To:
                                                                                                                 Mary Risper, Customer Service
                                                                                                                 333 Pfingsten Road, Northbrook, IL 60062
Supplier Name                                     Supplier Signature/Date                                        Phone: (847) 664-4911
                                                                                                                 Fax: (847) 575-4005
                                                                                                                 Email: water@us.ul.com

Company Name                                      Title




                           Applicant                                         Page 6 of 6                                 «VariationNumber»
                                                                                                                       Issued: January 5, 2005