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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