<p> NSF International Unit 30 Fern Close | Pen-y-Fan Industrial Estate Oakdale | Gwent | NP11 3EH | UK Tel: +44 (0) 1495 236 260 Fax: +44 (0) 1495 242 499 Email: [email protected] Website: www.nsf.org</p><p>BS 6920 TESTING OF NON-METALLIC COMPONENTS WITH REGARD TO THEIR EFFECT ON THE QUALITY OF WATER</p><p>APPLICATION FORM FOR FACTORY APPLIED PRODUCTS A product which is applied and cured (if appropriate) under carefully controlled conditions as part of a manufacturing process in a factory or workshop.</p><p>Organisation</p><p>Contact Name</p><p>Product</p><p>For NSF use only Enquiry Number MAT/ENQ: Date Application Received: Laboratory Reference MAT/LAB: Regulations testing sample number:</p><p>NSF International is a trading title of NSF Wales Ltd, a company registered in England and Wales, Registration number: 3754780</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 1 of 8 1. APPLICATION FOR TESTING</p><p>To enable NSF International (hereafter referred to as NSF) to perform the test to the required standard, please ensure that the relevant Sections of the Application Form are completed IN FULL prior to submission of any test samples. Completed application forms should be submitted to the Account Management Team via email to [email protected] or posted to the address on Page 1.</p><p>IMPORTANT Please use a separate Application Form for each product/material – photocopies of this form are acceptable.</p><p>When we have received a completed Application Form we will contact you with a quotation for the work requested and the product requirements for testing.</p><p>All work undertaken is subject to NSF Conditions of Service together with the NSF Wales term Sheet.</p><p>An application for testing comprises:</p><p> a completed Application Form;  chemical composition*;  appropriate Product Safety Data Sheets;  Instructions for Use.</p><p>* Information on the chemical composition of the product is required for Health and Safety risk assessment. All information provided will be treated in the strictest confidence – if preferred confidential information may be submitted in a separate envelope marked ‘Confidential’, for the personal attention of Mrs Ruth Manning to the address on the first page.</p><p>If extra space for any section of this form is required, please attach an extra sheet clearly indicating the name of the applicant, product name, section and page number to which it refers.</p><p>On completion of the testing, NSF can provide assistance in liaising with the Water Regulations Advisory Scheme (WRAS) for listing in the Water Fittings and Materials Directory.</p><p>If you require assistance completing your Application Form or have any queries, please contact the Account Management Team via the following:</p><p>Tel: +44 (0) 1495 236 260 Email: [email protected]</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 2 of 8 2. TESTS REQUIRED</p><p>Please complete one of the following two boxes on this page if FULL or AUDIT tests are required. Please complete the box on page 6 if LIMITED tests are required.</p><p>FULL TESTS Tick if Required For new products/materials</p><p>Full Tests of Effect on Water Quality Cold Water Use Only</p><p>Full Tests of Effect on Water Quality Hot & Cold Water Use</p><p>For Hot & Cold Water Use, please specify 65 °C the maximum water temperature at which the product is to be used 85 °C</p><p>Other Please specify 30 °C to 85 °C (£100 surcharge)</p><p>If this testing is for WRAS approval of a fitting and you have a Regulations Testing Sample Number please give this number:</p><p>OR</p><p>AUDIT TESTS for WRAS re-approval</p><p>As specified in a letter from the Water Regulations Advisory Scheme Tick if Required</p><p>A copy of this letter must be enclosed with the application form; please contact WRAS if you have not received this letter.</p><p>Cold Water Use Only</p><p>Hot & Cold Water Use</p><p>For Hot & Cold Water Use, please specify the maximum water temperature at which the product is to be used (30 °C to 85 °C)</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 3 of 8 This box should be completed only if LIMITED tests are required.</p><p>LIMITED TESTS Tick if Required For product development, reformulation, etc. or as specified by WRAS for reasons other than an audit test</p><p>Odour and Flavour Test BS 6920-2.2</p><p>Appearance of water BS 6920-2.3</p><p>Growth of Aquatic Micro-organisms Test (MDOD) BS 6920-2.4</p><p>Extraction of substances that may be of concern to public health (cytotoxicity) BS 6920-2.5</p><p>Extraction of metals BS 6920-2.6</p><p>Cold Water Use Only</p><p>Hot & Cold Water Use</p><p>For Hot & Cold Water Use, please specify the maximum water temperature at which the product is to be used (30 °C to 85 °C)</p><p>Please state the reason limited testing is required:</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 4 of 8 3. PRODUCT INFORMATION</p><p>It is important to give as much information as possible about the product for testing; this will assist in interpretation of the test results and preparation of the final report. Incomplete information could delay testing, report preparation and subsequent approval.</p><p>Information on the chemical composition of the product is also required for interpretation of results and to comply with Health and Safety requirements. All information provided will be treated in the strictest confidence. Please also include the Material Safety Data Sheets (MSDS) for chemicals, materials and components (where appropriate).</p><p>General Information</p><p>Submitting organisation</p><p>Product</p><p>Product manufacturer</p><p>Location of the product manufacturing site</p><p>Trade name, grade and reference of the product</p><p>Date product manufactured</p><p>Date samples prepared</p><p>Batch number</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 5 of 8 Material manufacturer</p><p>Location of the material manufacturing site</p><p>Trade name, grade and reference of the material</p><p>Manufacturing process</p><p>General composition of product</p><p> e.g. Epoxy Powder Coating, Enamel, etc.</p><p>Does the product contain a Biocide? Yes No</p><p>WRAS will require further information before deciding whether approval can be granted for products containing a biocide and will request additional testing, please contact NSF for more information.</p><p>Please provide a detailed description of the samples sent for testing:</p><p>Include (if appropriate) name, size, colour, opacity, markings, etc.</p><p>Typical use of the product</p><p>If the product is manufactured from a WRAS Approved Material please give the approval number</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 6 of 8 Chemical Composition, please provide information on the chemical composition of the product (this information must be provided unless the product is being used as part of a WRAS FITTING APPROVAL only):</p><p>Other Testing Has the product or any of the ingredients been subject to any Toxicological evaluation? Yes No Not known</p><p>Has the product or any of the ingredients been subject to any Migration tests? Yes No Not known</p><p>Has the product or any of the ingredients been subject to any Biodeterioration or Biodegradation evaluation? Yes No Not known</p><p>If you have answered yes to any of the above questions please provide/attach any relevant information.</p><p>Has the product been previously tested by a WRAS accredited Test Laboratory? Yes No Not known If yes please provide details here:</p><p>Is the product a modification of any product previously tested by a WRAS accredited Test Laboratory? Yes No Not known If yes please provide details here:</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 7 of 8 4. SPECIFIC INFORMATION FOR WRAS MATERIAL APPROVALS (the information on this page must be provided unless the product is being used as part of a WRAS FITTING APPROVAL only)</p><p>Please provide the following details of the test sample preparation. Date of preparation: </p><p>Method of preparation:</p><p>Number, nature and thickness of coats applied (including primers):</p><p>Method of application and mix ratio(s), if applicable:</p><p>Was the product prepared in accordance with the application instructions? (Y/N):</p><p>Substrate onto which the product was applied e.g. glass, stainless steel:</p><p>Ambient temperature at time of application (°C):</p><p>Cure Period:</p><p>Cure temperature (°C ±):</p><p>Application form completed by:</p><p>Name:</p><p>Signature:</p><p>Date:</p><p>WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 8 of 8 WORK/MAT 001(f) Issue No. 23 Issue date 18/01/17 Page 9 of 8</p>