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LEED Materials Submittal Form

Project: Date Submitted:

Sub-Contractor:

Contact: Email: Phone:

Material / Product Name: Mat. / Prod. Cost:

Spec Section:

EPD Program Operator:

EPD Type:

ENVIRONMENTAL PRODUCT DECLARATION (EPD)

Supporting documentation attached

Actual

Industry-wide generic Type III Product-specific Type III Product-specific, self-reported with cradle-to-gate scope

No Yes (if yes, continue filling out section)EPD is available for this material/product:

Estimated

SOURCING OF RAW MATERIALS No Yes

Supporting documentation attachedMATERIALS INGREDIENTS No Yes

EPD attached No Yes

CII Report Type:GreenScreen (GS)Globally Harmonized System (GHS)

Declare Health Product Declaration (HPD)Facts — NSF/ANSI 336

ANSI/BIFMA e3 Furniture Sustainability StandardCradle-to-Cradle

Product Lens

Yes (if yes, continue filling out section)NoProduct has a Chemical Ingredients Inventory (CII) list:

MIO System:

REACH OptimizationGreenScreen v1.2Cradle-to-Cradle v2 Gold or v3 Silver

Cradle-to-Cradle v2 Platinum or v3 Gold/Platinum

Yes (if yes, continue filling out section)NoProduct uses a Material Ingredient Optimization (MIO) system:

EPR Program: EPR Program % Responsibility:

Yes (if yes, continue filling out section)

Leadership Extraction Practices (check all that apply)

Extended Producer Responsibility Program (EPR) participant

Bio-based product meets Sustainable Agriculture Network (SAN) Standard. Bio-based %:

FSC certified wood product. Certified %: FSC Chain of Custody Certificate #:

Recycled content within product. Pre-consumer % (by weight):

Salvaged, refurbished, or reused product. % (by weight):

Entire product is sourced regionally within 100 miles of project site (list City/State as location)

Extraction location:

Post-consumer % (by weight):

No

CSR Report Type: Manufacturer Declared Third Party Verified

Manufacturer has a Corporate Social Responsibility (CSR) Report:

Manufacture location:

Purchase location:

Total miles:

Total miles:

Total miles:

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LEED Materials Submittal Form

Date: 03.22.2021Rev: REL

No Yes (if yes, continue filling out section)Material is applied on-site, within building weather barrier:

No (if no, continue filling out section) YesProduct is an inherently non-emitting source:

VOC Emission Requirements (check all that apply)

Yes NoDoes submitted material contain lead?

Yes NoDoes submitted material contain PVC?

Yes NoDoes submitted material containtropical or virgin hardwood?

Product Type:

Total Volume Purchased (L):

Allowable VOC Content (g/L): VOC Content (g/L):

Yes (if yes, continue filling out section)

Source Category: FlooringCeilings, Wall, or InsulationComposite Wood Furniture Interior Paint or Coating

Interior Adhesive & Sealants

YesNoProduct meets California Department of Public Health (CDPH) Std Method v1.1-2010:

YesNoThis Low-Emitting Materials product contains lead:YesNoThis Low-Emitting Materials product contains intentionally added Cadmium:

Emission Certifications:

SCS Indoor Advantage GOLD

RFCI FloorScore

CRI Green Label PlusIntertek ETL Evnironmental VOC/VOC+

MAS Certified Green

Self-reported

UL Greenguard GOLD

Berkeley Anaytical ClearChem

Range of TVOCs after 14 days: 5.0mg/m3 or more0.5 mg/m3 or less between 0.5 and 5.0 mg/m3

CDPH High Performance Product

VOC Content Requirements (check all that apply)

SCAQMD Rule 1168 (Interior Adhesive & Sealants)

SCAQMD Rule 1113 (Interior Paint or Coating)ANSI / BIFMA Std Method M7.1-2010 (Furniture)CARB ULEF or NAUF (Composite Wood)

LOW-EMITTING MATERIALS Supporting documentation attached No Yes4