U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY
W ASHINGTON

, DC 20460

N OTICE OF I NTENT (NOI) OF C OVERAGE U NDER THE P ESTICIDE
G EN ERAL P ERMIT (PGP) FOR D ISCHARGES FROM THE A PPLICATION

OF P ESTICIDES Form Approved

OMB No.

2040- 0284

Submission of this completed N otice of Intent (NOI) constitutes notice that the O perator identified in Section B intends to be authorized to discharge pollutants

to W aters of the United States within the pe s t management area identified in Section C under EPA’s Pesticide General Permit

. Submission of this NOI constitutes notice that the party identified in Section B of this form has read, understands, and meets the eligibility conditions of Part 1 of the permit ; agrees to comply with all applicable terms and conditions of the permit ; and understands that continued authorization under the permit is contingent on maintaining eligibility for coverage. T o be granted coverage, all information required on this form must be completed. Please read and make sure you comply with all permit requireme nts, including the requirement for large entities to prepare a Pesticide Discharge Management Plan (PDMP) prior to NOI submittal . Refer to the instructions at the end of this form to complete your NOI.

Electronic Submission Waiver (skip if submitting through EPA’s eNOI system)

I hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNOI will incur undue burden or expense over my use of this paper NOI form.

Briefly describe the reason why use of the electronic system causes undue burden or expense.

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

A. Notice of Intent Status

1. M ark whether this is the first time you are requesting coverage under th e Pesticide General Permit or if this is a change of information for a discharge

already covered under th e Pesticide General Permit

. If this is a change of information, supply the NPDES permit tracking number for the discharge.

a. Original NOI Submission

b

. NOI Change of Information: (NPDES Permit Tracking Number )

Please note: When s elect i ng A.1. b please fill out Section B (Operator Name and Mailing Address) and the fields of the NOI that need to be modified.

B. Operator Information

1. Operator Name:

2. IRS Employer Identification Number (EIN):

–

3. Operator Type (check one):

a. Federal g overnment

b. State g overnment

c. Local g overnment

d. M osquito control distr ict (or similar)

e. I rrigation control district (or similar)

f. W eed control district (or similar)

g

. Other: If other, provide brief description of
type o f operator :

4. Are you a large entity as defined in Appendix A of the permit ? (check one):

Yes No

Please no te: If you answer “Yes” to question 4 you are required to develop a P esticide D ischarge Management P lan (PDMP) and s ubmit an Annual Report reflecting all pesticide uses for which you are requesting permit coverage under this NOI

.

5. In wh ich state are yo ur pest management areas located? Please specify only one state per NOI:

6. Mailing Address:

a. Street:

b. City: c. S tate: d. ZIP Code:

–

e. Telephone:

– – E xt f. Fax:

– –

g. Contact Name :

h. E- mail :

EPA FORM 6100-22 Page 1 of 8C. Pest Management Areas: Complete Section C for each Pest Management Area for which coverage under EPA’s Pesticide

General Permit is desired. Copy this section for non -electronic submissions.

Pest Management Area #___ of ##___

1. Pest Management Area Name:

________________________________ ________________________________ ________________________________

P rovide a map of the location of the Pest Management Area (attach map) or describe the location of the Pest Management Area in detail

.

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

2. Are any of your activities for which you are requesting coverage under this NOI occur ring on Indian Country Lands? Yes No

If yes, identify the reservation or otherwise describe those areas :

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

3. Are any of your activities (in this pest management area) for which you are requesting coverage under this NOI occurring on areas considered “federal

facilities” as defined by the permit? Yes No

4 . Mailing address and contact information of the pesticide applicator ( or check here if same as provided in Section B):

a. Street:

b. City: c. State: d. ZIP Code:

–

e

. Telephone: – – E xt f. Fax : – –

g. Contact Name :

h. E- mail :

5 . Pesticide Use Patterns to be included in this Pest Management Area (check all that apply):

a. Mosquito and Other Flying Insect Pest Control c. Animal Pest Control

b. Weed and Algae Pest Control d. Forest Canopy Pest Control

6

. Receiving Waters (check one):

a. Coverage requested for all W aters of the United States within the Pest Management Area identified above.

b. Coverage requested specifically for the following W aters of the United States within the Pest Management Area identified above.

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

c. Coverage requested for all W aters of the United States within the Pest Management Area identified above except for :

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

7

. Tier 3 Waters

Is c overage requested for discharge to a Tier 3 water (Outstanding National Resource Water) of the United States ? Yes No If yes, answer a and b:

a. Name of Tier 3 water(s): _______________________________________________________________________________________________

b. Provide rationale for determination that pesticide discharge is necessary to protect water quality, the environment, and/or public h ealth and that

any such discharge will not degrade water quality or will degrade water quality only on a short

- term or temporary basis :

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

8

. WaterQuality Impaired Waters

Operators are not eligible for coverage under this permit for any discharges from a pesticide application to Waters of the Un ited States if the water s are identified as impaired by a substance which is either an active ingredient of the pesticide designated for use or is a degradate of such an active ingredient. See Part 1.1.2.1 of the permit . C heck one:

a. Water s are NOT impaired by any substance which is either an active ingredient of a pesticide to be discharged or a degradate of such an active ingredient

b. Water s are on a current state list as being impaired by a substance which is either an active ingredient of a pesticide to be discharged or a degradate of such an active ingredient; however, evidence is attached documenting that the waters are no longer impaired

.

EPA FORM 6100-22 Page 2 of 8____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________ D. Endangered Species Protection: Complete Section D for each Pest Management Area for which coverage under EPA’s Pesticide General Permit is desired. Copy this section for non-electronic submissions.

Pest Management Area #___ of ##___

1. Identify the criterion for which you are eligible for permit coverage as it applies to Federally Listed Threatened or Endangered Species (i.e., Species)

and/or Federally Designated Critical Habitat (i.e., Habitat) (check one):

a

. Pesticide application activities will not result in a point source discharge to one or more Waters of the United States containing National Marine

Fisheries Ser vice (NMFS) Listed Resources of Concern, as defined in Appendix A, of the PGP

.

b

. Pesticide application activities for which permit coverage is being requested will discharge to one or more Waters of the United States containing

NMFS Listed Resources of Concern

, as defined in Appendix A of the PGP

, but consultation with NMFS under Section 7 of the Endangered Species Act ( ESA ) has been concluded for pesticide application activities covered under th e PGP . Consultations can be either formal or informal, and would have occurred only as a result of a separate federal action. The consultation addressed the effects of pesticide discharges a nd discharge

- related

activities on f ederally

- listed threatened or endangered species and federally

- designated critical habitat, and must have resulted in either:

i. A biological opinion from NMFS finding no jeopardy to federally

- listed species and no destruction/adverse modification of fede rally- designated

critical habitat; or

ii. W ritten concurrence from NMFS with a finding that the pesticide discharges and discharge

- related activities are not likely to adversely affect

federally

- listed species or federally

- designated critical habitat.

c

. Pesticide application activities for which permit coverage is being requested will discharge to one or more Waters of the United States containing

NMFS Listed Resources of Concern , as defined in Appendix A of the PGP, but all “take” of these resources associated with such pesticide application activities ha s been authorized through NMFS’ issuance of a permit under section 10 of the ESA, and such authorization addresses the

effects of th e pesticide discharges and discharge

- related activities on federally

- listed species and federa lly- designated critical habitat. (The term “take” means to harass, pursue, hunt, shoot, wound, kill, trap, capture, or collect, or to attempt to engage in any such conduct. See Section 3 of the Endangered Species Act, 16 U.S.C. § 1532 (19).)

d

. Pesticide application activities were, or will be, discharged to one or more Waters of the United States containing NMFS Listed Resources of

Concern , as defined in Appendix A of the PGP

, but only in response to a D eclared P est E mergency S ituation

.

e

. Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more Waters of the United States containing NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those where the Decision

- maker includes in the NOI written correspondence from NMFS that pesticide application activities performed consistent with appropriate measures will

avoid or eliminate the likelihood of adverse effects to NMFS Listed Resources of Concern

.

f

. Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more Waters of the United States

c ontaining NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those from pesticide application activities that are demonstrated by the Decision

- maker as not likely to adversely affect NMFA Listed Resources of Concern or that the pest poses a greater threat to th e NMFS Listed Resources of Concern than does the discharge of the pesticide

.

2

. If you checked criterion d or criterion f above, provide the following information for all discharges to Waters of the United States containing NMFS Listed

Resources of Concern identified within the pest management area for which permit coverage is being requested. For discharges pursuant to criterion d

, Declared Pest Emergency Situations, information for items a through g should also include any discharges that have already oc curred prior to NOI

submission as well as the activities you performed in the 15 day period before submission of this NOI was required

. In some cases, implementation of pest management measures as specified in the permit involves a degree of “adaptive management” such that exact timing and quantities of applications cannot be determined in advance for the duration of the permit. In such cases, the permittee must provide the required information to the extent feasible and consistent with the implementation of the selected pest management measures.

a. Describe the location of the pest management area in detail or provide a map of the location:

b. Pest(s) to be controlled:

____________________________________________________________________________________________________________________

c. ___________________________________________________

Pesticide p roduct (s) to be discharged and method of application : _________________________________________________________________

________________________________________________________________

d

. Planned quantity and rate of discharge (s) for each method of application:

_________________________________________________________

e. Number of planned discharges: ____________

f. Approximate date(s) of planned discharge(s) :

_______________________________________________________________________________

g. Your rationale supporting your determination that you meet the criterion for whi ch you are submitting this NOI, including appropriate measures to be undertaken to avoid or eliminate the likelihood of adverse effects. For certifications pursuant to Criterion D, indicate whether the discharge is likely to adversely affect NMFS Listed Resources of Concern and, if so, any feasible measures to avoid or eliminate such adverse effects (a ttach additional pages as necessary) :

EPA FORM 6100-22 Page 3 of 8E. Certification

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. On the basis of my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Printed Name:

Title:

E- Mail:

Signature/Responsible Official: Date: / /

NOI Preparer (Complete if NOI was prepared by someone other than the certifier)

Preparer Name :

Organization:

Phone: – – E xt Date: / /

E- Mail:

EPA FORM 6100-22 Page 4 of 8

### Instructions for Completing the Notice of Intent (NOI) for Coverage Under the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides

Who Must File a NOI with EPA ?

Any Operator , as described in the Part 1.2. 2 of the permit and meeting the eligibility requirements identified in Part 1.1 of the permit and T able 1 below must submit a complete and accurate NOI

. As required in the permit, only certain Operators that are

also Decision

- makers must submit NOIs.

Table 1

. Decision -M akers Required to Submit NOIs

PGP Part/

Pesticide Use Which Decision

- M akers Must

Submit NOIs? For Which Pesticide Application Activities?

All four use Any D ecision

- maker with an Activities resulting in a patterns eligible discharge to a Tier 3 discharge to a Tier 3 water

identified in water (Outstanding National

Part 1.1.1 Resource Water) consistent with

Part 1.1.2.2

All four use Any Decision

- maker with an Activities resulting in a patterns eligible discharge to Waters of discharge to Waters of the

identified in the United States containing United States containing NMFS

Part 1.1.1 NMFS Listed Resources of Concern, as defined in Appendix A Listed Resources of Concern,

a s defined in Appendix A

1.1.1(a)

- Mosquito and Other Flying

Insect Pest

Control Any Agency for which pest management for land resource stewardship is an integral part of the organization’s operations. All activities resulting in a discharge for which the Federal or State agency is resp onsible for pest control

Mosquito control districts, or similar pest control districts All activities resulting in a discharge for which the

Decision

- maker is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

identified here Adulticide treatment if more than 6,400 acres during a c alendar

year

1.1.1(b)

- Weed and Algae Pest

Control Any Agency for which pest management for land r esource stewardship is an integral part of the organization’s operations. All activities resulting in a discharge for which the Federal or State agency is resp onsible for pest control

Irrigation and weed control districts, or similar pest control

districts All activities resulting in a discharge for which the

Decision

- maker is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

identified here Treatment during a calendar

year if more than either:

20 linear miles

OR
80 acres of water (i.e., surface area)

1.1.1(c)

- Animal Pest

Control Any Agency for which pest management for land resource stewardship is an integral part of the organization’s operations. All activities resulting in a discharge for which the Federal or State agency is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

identified here Treatment during a calendar

year if more than either:

20 linear miles

OR

80 acres of water (i.e., surface area)

1.1.1.(d)

- Forest Canopy

Pest Control Any Agency for which pest management for land resource stewardship is an integral part of the organization’s operations. All activities resulting in a discharge for which the Federal or State agency is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

identified here T reat ment if more than 6 ,400

acres during a calendar year One NOI can be submitted for multiple pest management areas in a state for which you are seeking permit coverage; however, no more than one state can be included on any single NOI form

.

W hen to File the NOI Form ?

Do not file your NOI until you have obtained and thoroughly read a copy of the permit

. A copy of the permit is on EPA ’s website ( www.epa.gov/npdes/pesticides ). The permit describes procedures to ensure your eligibility, prepar e your Pesticide Discharge

M anagement Plan (PDMP), and complete the NOI form questions

— all of which must be done before you sign the NOI certification statement attesting to the accuracy and completeness of your NOI. You will also need a copy of the permit once you have

obtained coverage so that you can comply with the implementation requirements of the permit. Note: PDMP is not required for 1) any application made in response to a Declared Pest Emergency Situation, as defined in Appendix A of the permit; and 2) any Decision

- maker that is required to submit an NOI solely because their application results in a point source discharge to Waters of the United States containing NMFS Listed Resources of Concern, as defined in Appendix A of the permit.

All eligible discharges are authorized for permit coverage through January 12, 2012 without submission of an NOI. For any discharges after January 12, 2012,

Decision

- makers meeting the eligibility requirements iden tified in the Part 1.1 of the permit and Table 1 must submit a complete and accurate NOI according to Tables 2

, and 3 and consistent with the requirements of the Part 1.2 of the permit

. F or example, for discharges occurring on or before January 12, 2012 but continuing after January 12, 2012, NOIs are due no later than January 3 , 2012 to ensure uninterrupted

coverage.

Table 2

. NOI Submittal Deadlines and Discharge Authorization Dates for Discharges from the Application of Pesticides 1

After January 12, 2012, any eligible discharge for which an NOI is required must

submit an NOI consistent with the earliest due date identified below. If EPA receives an NOI on or before January 2, 2012 (or on or before December 12, 2011, for discharges to Waters of the United States containing NMFS Listed Resources of Concern), uninterrupted coverage continues.2 NOI due dates for any discharges occurring on or after January 12, 2012 are as follows:

Operator Type NOI Submission

Deadline Discharge Authorization

Date 2

Any Decision

- maker with any discharge to Waters of the

United States c ontaining NMFS

Listed Resources of Concern, except for those discharges in response to a Declared Pest Emergency S ituation, as defined in Appendix A

. At least 30 days before any di scharge

to Waters of the

United States containing NMFS

Listed Resources of Concern, as defined

in Appendix A

. 5 No earlier than 30 days

after EPA posts on the Internet a receipt of a complete and accurate

NOI. 3 , 5

Any Decision

- maker with a discharge in response to a Declared Pest Emergency for which that activity triggers the NOI requirement identified in Part 1.2.2, except for any discharges to Waters of the United States containing NMFS

Listed Resources of Concern. At least 30 days after beginning discharge. Immediately upon beginning to discharge for

activities conducted in response to a Declared

Pes t Emergency

Situation.

Any Decision

- maker with any discharge to Waters of the

United States c ontaining NMFS Listed Resources of Concern, in response to a Declared Pest Emergency S ituation, as defined in Appendix A

. Within 15 days after beginning to discharge in response

to a Declared Pest Emergency S ituation. Immediately upon beginning to discharge for

activities conducted in response to a Declared

Pest Emergency Situation

for a period of at least 60 days. 4

Any Decision

- m aker that exceeds any annual treatment

area threshold. At least 10 days before exceeding an

annual treatment area

threshold. No earlier than 10 days after EPA posts on the Internet receipt of a complete and accurate

NOI.

Any Decision

- maker otherwise required to submit an NOI as

identified in Table 1 At least 10 days before any discharge

for which an NOI is required No earlier than 10 days after EPA posts on the Internet receipt of a complete and accurate

NOI. If you have questions about whether you need to file an NOI or questions about completing the form, see www.epa.gov/npdes/pesticides o r contact the NOI C enter toll

free at 866

- 352

- 7755.

EPA FORM 6100-22 Page 5 of 81 State, territory and tribal specific requirements in addition to the requirements in this table are provided in Part 9.0.

2 On the basis of a review of an NOI or other information, EPA may delay

authorization to discharge beyond any timeframe identified in Table 2, determine that additional technology

- based and/or water quality

- based effluent limitations or other conditions are necessary, or deny coverage under this permit and require submission of an application for an individual NPDES permit, as detailed in Part 1.3 of the permit.

3 Within 30 days after EPA posts on the Internet receipt of a complete and accurate

NOI, for thos e areas with NMFS Listed Resources of Concern, as defined in Appendix A of the permit, NMFS will provide EPA with a determination as to whether it believes the eligibility criterion of “not likely to adversely affect listed species or designated critical habitat” has been met, could be met with conditions that NMFS identifies, or has not been met. EPA expects to rely on NMFS’ determination in deciding whether to withhold authorization. If NMFS does not provide EPA with this information within 30 days of EPA posting on the Internet receipt of a complete and accurate NOI, the discharges will be authorized 30 days after EPA posts on the Internet receipt of a complete NOI.

4 In any Declared Pest Emergency Situation in areas with Waters of the United

States containing NMFS Listed Resources of Concern, NMFS will have 30 days after submission of an NOI to provide EPA with a determination as to whether the eligibility criteria of “not likely to adversely affect listed species or designated critical habitat” has been met, could be met with conditions that NMFS identifies, or has not been met. EPA expects to rely on NMFS’ determination in deciding whether to allow continued permit coverage and if additional conditions are necessary. If NMFS does not provide EPA with a recommendation within 30 days of EPA posting on the Internet receipt of a complete and accurate NOI, authorization for t hese discharges will continue. I f EPA identifies additional permit conditions, or includes additional permit conditions recommended by NMFS, as necessary to qualify discharges as eligible for coverage beyond 60 days under the PGP, those conditions remain in effect for the life of the permit.

5 EPA may authorize certain discharges in less than 30 days, but no fewer than 10

days, for any discharges authorized under Criterion B, C, or E of Part 1.1.2.4 (for which NMFS has already evaluated the effects of these discharges).

Table 3

. NOI Change of Information Submittal Deadlines and Discharge

Authorization Dates

Operator Type NOI Submission

Deadline Discharge Authorization

Date

Any Decision

- maker requiring permit coverage for a pest management

area not identified on a previously submitted NOI for this permit, except for discharges to any; (1) Tier

3 water , or (2) Waters of the United

State s containing NMFS

Listed Resources of

Concern

. Except for such
waters, c hanges other

than identification of a new pest management area or a new pesticide use pattern do not require a

revised NOI submittal. At least 10 days before beginning to discharge in that newly identified area unless discharges are in response to a Declared Pest Emergency Situation

in which case not later than 30 days after beginning discharge. No earlier than 10 days after EPA posts on the Internet the receipt of a complete and accur ate NOI unless discharges are in response to a Declared Pest Emergency Situation in which case coverage is available immediately upon beginning to discharge from activities conducted in response to Declared Pest Emergency

Situation.

Any Decision

- maker

dis charging to a Tier3 water not identified by name on a previously

submitted NOI for this permit, except for Tier 3 waters containing NMFS

Listed Resources of

Concern At least 10 days before beginning to discharge in that newly identified area unless discharges are in response to a Declared Pest Emergency Situation

in which case not later than 30 days after beginning discharge. No earlier than 10 days after EPA posts on the Internet the receipt of a complete and accurate NOI unless discharges are in response to a Declared Pest Emergency Situation in which case coverage is available immediately upon beginning to discharge from activities conducted in response to Declared Pest Emergency

Situation. NOI Submission Discharge Authorization Operator Type Deadline Date

Any Decision

- maker with At least 30 days before No earlier than 30 days any discharge to Waters of beginning to discharge in after EPA posts on the

the United States that newly identified Internet receipt of a containing NMFS Listed treatment area unless complete and accurate Resources of Concern, as discharges are in NOI unless discharges are defined in Appendix A, not response to a Declared in response to a Declared identified on a previously Pest Emergency Situation Pest Emergency Situation

submitted NOI for this in which case not later in which case coverage is permit. This includes than 15 days after available immediately changes in any treatment beginning discharge. upon beginning to area, pesticide product, discharge from activities

method or rate of conducted in response to application, or Declared Pest Emergency approximate dates of Situation. applications.

Where to File the NOI Form

The Decision

- maker must prepare and submit the NOI using EPA’s electronic Notice of Intent system (eNOI) available on EPA’s website ( www.epa.gov/npdes/pesticides/enoi ) unless eNOI is otherwise unavailable or the

D ecision

- maker has filed a waiver from the requirement to use eNOI for submission of

the NOI. The Electronic Submission Waiver is at the top of this form

. Decision

- makers

w aived from the requirement to use eNOI for NOI submission must certify to EPA on

this form t hat use of eNOI will incur undue burden or expense over the use of the paper N OI form and then provide a basis for th at determ ination.

EPA will immediately post on th e pesticides eNOI W ebsite all NOIs received

. Late NOIs will be accepted, but authorization to discharge will not be retroactive.

If you file a waiver from using eNOI ; yo u must send the NOI to one of the addresses

listed below.

Via United States Mail: United States Environmental Protection Agency Office of Water, Water Permits Division Mail Code 4203M, ATTN: NPDES Pesticides 1200 Pennsylvania Avenue, NW Washington, DC 20460

Via overnight/express delivery: United States Environmental Protection Agency

Of

fice of Water, Water Permits Division EPA East Building

- Room 7420, ATTN: NPDES Pesticides 1201 Constitution Avenue, NW Washington, DC 20004

Phone: 202

- 564

- 9545

If you have questions, contact EPA’s Pesticides Notice Processing Center toll free at

866

- 352

- 7755

.

• If you file a paper NOI, submit the original with a signature in ink

. Do n ot s end

c opies. Also, faxed copies will not be accepted.

• If you are required to develop a PDMP , that document does not need to be

submitted for review unless specifically requested by EPA. You must keep a copy of your PDMP on

- site or otherwise make it available to facility personnel responsible for implementing provisions of the permit.

Completing the NOI Form

T o complete this form, type or print in uppercase letters in the appropriate areas only. Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. You may also use this paper form as a checklist for the information you will need when filing an NOI electronically via EPA’s Pesticides eNOI System

.

Section A. NOI Status

1. Indicate if this is the first time you are requesting coverage under the permit or if

this is a change of information.

a. Check this box i f this is the first time you are requesting coverage under the permit

for these discharges

. If this is the first time you are requesting coverage, refer to

Table 2 for NOI s ubmitta l d eadlines and d ischarge a uthorization d ates

. Note: A ll eligible discharges are authorized for permit coverage through January 12, 2012

without submission of an NOI.

EPA FORM 6100-22 Page 6 of 8b. Check this box if this is a change of information for a discharge already covered

under th e permit. If this is a change of information, supply the NPDES permit

t racking number that you received in your confirmation letter or e

- mail from EPA’s Pesticide Notice Processing Center. You can find the tracking number assigned to your previous NOI using EPA’s e NOI System ( www.epa.gov/npdes/pesticides/eno i )

. For additional details regarding a change of information, see Tabl e 3. Also fill out Section B of this form (Operator Name and Mailing Address) and the associated fields of information that need to be modified

on the NOI.

Section B. Operator Information

1. Provide the legal name of the person, firm, public organization or any other public

entity that is the D ecision

- maker for the pesticides applications described in t his

notice . A D ecision

- maker is an Operator who has control over the decision to perform pesticide applications including the ability to modify those decisions that result in a discharge to Waters of the United States.

2. Provide the Employer Identification Number (EIN from the Internal Revenue Service

( IRS)), commonly referred to as your tax payer ID number

. If the operator does not have an EIN, enter “N/A” in the space provided

. 3. I ndicate the type of O perator: federal government, state government, local

government, mosquito control district (or similar), irrigation control district (or similar) , weed control district (or similar), or other

. If other, provide brief description of type of O perator in the space provided

. 4. Indicate whether or not you are a “large entity” as defined in Appendix A of the

permit

. Note that if you are a large entity, you are required to develop a Pesticide Discharge M anagement Plan (PDMP) and submit future Annual Report s reflecting all pesticide uses for which you are requesting permit coverage under this NOI.

5. Indicate which state your pest management areas are located. Specify only one

state per NOI. If there is more than one state, additional NOIs must be submitted.

6. Provide the Decision

- maker ’s mailing address, telephone number, fax number

(optional), name, and e- mail address. Correspondence will be sent to this address.

Section C. Pest Management Area: Information for each Pest Management Area

for which c overage under EPA’s Pesticide General Permit is d esired

. 1. Indicate whether you are submitting an NOI for multiple pest management areas

. A

p est management a rea is the area of land, including any water, for which you have responsibility and are authorized to conduct pest management activities as covered by this pe rmit (e.g., i f you are a mosquito control district, your pest management area is the total area of the district). You must complete a Section C for each pest management area

. If you are submitting an NOI for only one area, enter “1” of “1.” If you are submitting NOIs for multiple pest management areas, enter the number for

the NOI for which you are requesting coverage followed by the total number of pest management areas for which you are requesting coverage. Enter the name of the pest management area. Atta ch a map of the pest management area or d escr i be the

location of the pest management area in the space provided.

2. Indicate whether pesticide application will occur on Indian County Lands, and if so,

provide the name of the reservation, if applicable

. 3. Indicate whether pesticide application will occur on a Federal Facility, as defined in

Appendix A of the permit

. 4. Enter the mailing address of the contact person for the pest m anagement a rea. If

this address is the same as the Decision

- maker’s mailing address, indicate that by checking the box

. If it i s a different address, enter the mailing address, telephone number, fax number (optional), contact name, and e- mail address.

5. Indicate the pesticide use patterns for the pest management area for which th e NOI

is required

. F or additional information regarding pesticide use patterns, see Part

1.1.1 of the permit. Check all the use patterns that apply to the pest management

area.

6. Indicate if permit coverage is being requested for all W aters of the United States

within the p est m anagement a rea or if permit coverage is being requested to specific W aters of the United States within the p est m anagement a rea. If specific waters are being requested, write the names of the waterbodies. If permit c overage is being requested for all waters of the United States within the p est m anagement

a rea except for specific waterbodies, name those specific waterbodies in the space provided. EPA’s Water Locator Tool can help you identify the closest receiving water to your f acility ( http://cfpub.epa.gov/npdes/stormwater/tmdltool.cfm ).

7. I ndicate if permit coverage is being requested to discharge to a Tier 3 ( Outstanding

National Resource Water) W ater of the Un i ted States

. If yes, write the name (s) of

the Tier 3 water(s) in the space provided. D escribe and demonstrate why it is necessary to apply the pesticide discharge to protect the water quality,

en vironment, and/or public health and that any such discharge will not degrade water quality or will degrade water quality only on a short

- term or temporary basis. 8. Verify that waters within the pest management area are either not impaired by substances which are either active ingredients in the pesticide planned for use or degradates of such active ingredients, OR that evidence shows that the target waters in question are no longer impaired . S ee Part 1.1.2.1 of the permit for more

information on d ischarges to Water Quality Impaired Waters

.

Section D. Endangered Species Protection

. Complete Section D for each Pest Management Area for which coverage under EPA’s PGP is desired.

Identify the Pest Management Areas, corresponding to those in Part C.

1. Coverage under the permit is available only for discharges and di scharge

- related

activities, as defined in Appendix A of the permit , that are not likely to jeopardize the continued existence of any species that are federally

- listed as endangered or threatened (“listed”) under the Endangered Species Act (ESA) and not likely to result in the adverse modification or destruction of habitat that is federally

designated as critical under the ESA (“critical habitat”) except as provided in

c riterion b, c, and for at least 60 days, d , below

. For a subset of listed species and

c ritical habitat, identified as NMFS Listed Resources of Concern and defined in Appendix A, there are specific criteria for determining eligibility. To demonstrate eligibility, you must meet one or more of the six criteria ( a-f ) for the entire te rm of

cover age under the perm it.

2. If you checked c riterion d or c riterion f

, you are required to provide a description of

the location of the pest management area or a map of the location, the pest(s) to be controlled, pesticide product(s) to be discharged and method of application

, planned quantity and rate of discharge(s) for each application method , n umber of planned discharges , a pproximate date(s) of planned discharge(s), and the rational

s upporting your determination that you meet the c riterion for wh i ch the Decision

maker is submitting this NOI and documentation demonstrating the finding of “not likely to adversely affect.” If you certify under criteria f and do not hear from EPA within 30 days, you may assume your discharge is authorized. For certif ications pursuant to Criterion d , indicate whether the discharge is likely to adversely affect NMFS Listed Resources of Concern and, if so, any feasible measures to avoid or

eliminate such adverse effects . I f you are certifying under criterion d (which al lows you to discharge 15 days before you even submit your NOI), your NOI should describe both the pest emergency activities you plan to do after you submit your NOI as well as the activities you performed in that 15 day period before you had to

submit the NOI. See Part 1.1.2.4 of the permit for more information regarding Endangered and Threatened Species and Critical Habitat Protection . If you certify under criterion d and do not hear from EPA, you may assume that permit authorization continues unless notified otherwise.EPA may authorize certain discharges in less than 30 days, but no fewer than 10 days, for any discharges

authorized under c riterion b

, c , or e (for which NMFS has already evaluated the effects of these discharges). If you certify under one of these criteria and d o not hear from EPA within 30 days, you may assume your discharge is authorized.

Section E. Certification

Enter the certifier’s printed name and title. Sign and date the form. For more information about the certification statement and signature, see Appendix B of the permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal statutes provide for severe penalties for submitting false information. Federal regulat ions require this application to be signed as follows:

For a corporation : by a responsible corporate officer, means:

(i) president, secretary, treasurer, or vice

- president of the corporation in charge of a

principal business function, or any other person who performs similar policy or

decision

- mak ing functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities,

provided the manager is authorized to make management decisions that govern the operation of the regulated activity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long

- term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole proprietorship : by a general partner or the proprietor; or

For a municipal, s tate, f ederal, or other public facility : by either a principal executive or ranking elected official.

If th e NOI was prepared by someone other than the certifier (for example, if the NOI was prepared by the PDMP contact or a consultant for the certifier’s signature), include the name, organization, phone number and e

- mail address of the NOI preparer.

EPA FORM 6100-22 Page 7 of 8Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of information is estimated to average 2 .5 hours or 1 5 0 minutes per response.

Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed NOI form to th at address.

EPA FORM 6100-22 Page 8 of 8U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY
W ASHINGTON

, DC 20460

N OTICE OF T ERMINATION (NOT) OF C OVERAGE UNDER THE P ESTICIDE G ENERAL P ERMIT (PGP) FOR D ISCHARGES FROM THE A PPLICATION OF P ESTICIDES Form Approved

OMB No.

2040

- 0284

Electronic Submission Waiver (skip if using eNOI)



### I hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNOI will incur undue burden or expense over my use of this paper Notice of Termination form.

Briefly describe the reason why use of the electronic system causes undue burden or expense.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

A. Permit Information



### 1. NPDES Permit Tracking Number :

2. Reason for t ermination (check one only):

a. You have ceased all discharges from the application of pesticides for which you obtained permit coverage and you do not expect

to dis c harge during the remainder of the permit term.

b. You have obtained permit coverage under an NPDES individual permit or alternative NPDES general permit for all pesticide

discharges requiring NPDES permit coverage.

c

. A new Operator has taken ov er decision

- maki ng r esponsibility for the pest

control activities covered under an existing NOI

. Provide the transfer date and the new Operator information. Date of transfer: / /



### New Operator Name:

Street :

City: State : Z IP Code:
–



### Telephone:
– – ext



### E- mail:

B. Operator Information



### 1. Operator Name:

2

. IRS Employer Identification Number (EIN): –



### 3. Mailing Address:

Street:

City: State : ZIP Code:
–



### Telephone:
– – ext



### 4

. Contact Name :

E- mail:

EPA FORM 6100

- 23 Page 1 of 3C

. Certification

I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A above. I understand that by submitting this Notice of T ermination, I am no longer authorized to discharge pesticides to waters of the United States. This document and all attachments were prepared under my direction and supervision in accordance with a system designed to ensure that qualified personnel properly gather and evaluate the information submitted. On the basis of my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine or imprisonment. Additionally, I understand that the submittal of this Notice of Termination does not release a pesticide Operat or from liability for any violations of the Clea n Water Act.



### Printed Name:

Title:

E- Mail:

Signature/Responsible Official: Date: / /

NO T Preparer (Complete if NO T was prepared by someone other than the certifier)



### Preparer Name :

Organization:

Phone:
– – 

### E xt Date: / /



### E- Mail:

EPA FORM 6100

- 23 Page 2 of 3I NSTRUCTIONS FOR C OMPLETING THE N OTICE OF T ERMINATION (NOT) OF C OVERAGE UNDER THE P ESTICIDE G ENERAL P ERMIT (PGP) FOR
D ISCHARGES FROM THE A PPLICATION OF P ESTICIDES

Who Must File an NOT Form with EPA ?

Any Operator required to submit a Notice of Intent (NOI) is required to submit a

Notice of Termination ( NOT ) to end coverage under this permit. However, if EPA

notif ies the Operator to apply for an NPDES individual permit or alternative general permit, coverage under this permit terminate s automatically. Dischargers automatically covered under this permit as identified in Part 1.2.3 of the permit are likewise automatically terminated upon permanent cessation of discharge consistent with any of the criteria identified in Part 1.2.5. 3 of the perm it

. As required in the permit, only certain Operators that are also Decision

- makers must submit NOIs.

If you have questions about whether you need to file an NOT or questions about completing the form, see www.epa.gov/npdes/pesticides o r contact the NOI C enter

toll free at 866

- 352

- 7755.

When to File the NOT Form ?

Operators must file the NOT form within 30 days after one or more of the conditions

in Part 1.2.5.2 of the permit have been met.

Where to File the NOT Form ?

Consistent with Part 1.2.5.1 of the permit , t he Operator must submit the NOT using EPA’s electronic Notice of Intent (eNOI) S ystem available on EPA’s website ( www.epa.gov/npdes/pesticides/enoi ) unless eNOI is otherwise unavailable or the Operator file s a waiver from the requirement to use eNOI for submission of the

NO T. The Electronic Submission Waiver is at the top of this NOT form. A n Operator waived from the requirement to use eNOI for any NOT submission must certify to

EPA on this form t hat use of eNOI will incur undue burden or expense over the use of the paper NOT form and then provide a basis for th at determ ination.

Filing electronically is the fastest way to terminate permit coverage and help ensure that your NOT is complete

.
If you do file a waiver from using eNOI; you must send the NOT to one of the

addresses listed below.

Via United States Mail: United States Environmental Protection Agency Office of Water, Water Permits Division Mail Code 4203M, ATTN: NPDES Pesticides 1200 Pennsylvania Avenue, NW Washington, DC 20460

Via overnight/express delivery:

United States Environmental Protection Agency Office of Water, Water Permits Division EPA East Building

- Room 7420, ATTN: NPDES Pesticides 1201 Constitution Avenue, NW Washington, DC 20004

Phone: 202

- 564

- 9545

If you file a paper NOT, submit the original form wi th a signature in ink

. Do n ot

s end c opies. Also, faxed copies will not be accepted.

Completing the NOI Form

To complete this form, type or print in uppercase letters in the appropriate areas only. M ake sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above . You can also use this paper form as a checklist for the information you will need when filing an NOT electronically via EPA’s Pesticides eNOI system.

Section A. Permit Information

1. Enter the existing NPDES Permit Tracking Number assigned by eNOI or the EPA ’s

Pesticides Processing Center. You can find the tracking number assigned to your previous NOI using EPA’s e NOI System ( www.epa.gov/npdes/pesticides/enoi ).

2. Select the appropriate box to indicate why you are submitting an NOT to end

permit coverage. Select one of the three termination opt ions:

a

. Select this box if you have ceased all discharges from the application of

pesticides for which you obtained permit coverage and you do not expect to discharge during the remainder of the permit term

.

b

. Select this box if you have obtained NPDE S individua l permit coverage or

alternative NPDES permit coverage. c

. Select this box if a new Operator has taken over decision

- making responsibility of pest control activities covered under an existing NOI and you are no longer the Operator

. P rovide the date of transfer a nd the name and

contact information of the new Operator

.

Section B. Operator Information

1. Provide the full legal name of the person, firm, public organization, or other entity

that is the Operator who is the Decision

- maker for the pesticide application described in this application.

2. Provide the Operator ’s IRS Employer Identification Number.

3. Provide the Operator ’s mailing address and telephone number

. Correspondence

will be sent to this address.

4. Provide a contact person’s full legal name and e

- mail address. This person will

be contacted regarding any NOT communication.

Section C. Certification

Carefully read the certification statement. By completing and submitting the NOT, the Operator certifies that every applicable g eneral permit requirement will be met. Provide the printed full legal nam e , title and email address of the certifier

. Sign and date the form. (CAUTION: An unsigned or undated NOT form will prevent the termination of permit coverage.) Federal statutes provide for severe penalties for submitting false information on this application form. Federal regulations require this application to be signed as follows:

For a corporation: by a responsible corporate officer, which means:

(i) president, secretary, treasurer, or vice president of the corporation in charge of a principal business function, or any other person who performs similar policy

or decision

- making functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decis ions that govern the operation of the regulated act ivity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long

- term environmental complian ce with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole proprietorship: by a general partner or the proprietor; or

For a municipal, s tate, f ederal, or other public facility: by either a principal executive or ranking elected official.

If the NOT was prepared by someone other than the certifier (for example, if the

NO T was prepared by the PDMP contact or a consultant for the certifier’s signature), include the name, organization, phone number and e

- mail addre ss of the

NOT preparer.

Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of information is estimated to average 0 .5 hours or 30 minutes per response.

Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (28 22T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed NOT form to th at

address.

EPA FORM 6100

- 23 Page 3 of 3U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY
W ASHINGTON

, DC 20460

P ESTICIDE D ISCHARGE E VALUATION W ORKSHEET FOR THE
P ESTICIDE G ENERAL P ERMIT (PGP) FOR D ISCHARGES FROM THE
A PPLICATION OF P ESTICIDES Form Approved

OMB No.

2040- 0284

This worksheet is for any Operator who is also a Decision-maker required to submit a Notice of Intent (NOI) and is a small entity, as defined in Appendix A of the Pesticide General Permit (PGP). Th e information on this worksheet must be retained for each pesticide application activity.

A. General Information

1. Operator Name:

2. Work s heet Preparer Name:

3. Pest Management Area: # __ of ## ____

4. Pest Management Area Name: ________________________________________________________________________________________

5. Indicate the pesticide use pattern for the Pest Management Area:

a. Mosquito and Other Flying Insect Pests b. Weed and Algae Pests c. Animal Pests d. Forest Canopy Pests

6. For each treatment area (use additional pages for each treatment area):

a. Provide a description of the treatment area within this Pest Management Area, including location description:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

b. Size of treatment area (in acres or linear feet): _____ acres or ______ linear feet.

c. Name or location of any Waters of the United States to which discharges occurred:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

B. Pest Evaluation

1. Identify the target pest(s) and explain why pest control is needed:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

2. Describe Pest Management Measure(s) implemented before th e first pesticide application:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

C. Pesticide Application

1. Name and contact information for pesticide applicator(s):

Company Name:

Street:

C i ty: State: Zip Code:

-

Contact Name:

Phone: – – E xt

E- mail:

EPA FORM 6100-26 P age 1 of 32. Pesticide a pplication s tart d ate: / / Pesticide a pplication end d ate: / /

3. Name of each pesticide product used, EPA registration number, and quantity of pesticide applied (as packaged or as formulated): Circle lbs or gallons.

Product Name Product Name Product Name

EPA Reg. No. EPA Reg. No. EPA Reg. No.

Quantity (lbs or gallons) Quantity (lbs or gallons) Quantity (lbs or gallons)

Application

method:

____________________________ Application

method:

___________________________ Application

method:

___________________________

4. Visual monitoring was conducted during pesticide application and/or post-application? Yes. No. If no, describe why not?

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

5. Any adverse effects identified during visual monitoring? Yes. No. If yes, describe.

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

D. Certification

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. On the basis of my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information contained is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for recording false information, including the possibility of fine and imprisonment for knowing violations.

Printed Name:

Title:

E- Mail:

Sig nature/Responsible Official: Date: / /

Pesticide Discharge Evaluation Worksheet Preparer (Complete if worksheet was prepared by someone other than the certifier)

Pre parer Name :

Organization:

Phone: – – Ext Date: / /

E- Mail:

EPA FORM 6100-26 Page 2 of 3

### Instructions for Completing the Pesticide Discharge Evaluation Worksheet (PDEW) for the P ESTICIDE 

### G ENERAL 

### P ERMIT 

### (PGP) FOR 

### D ISCHARGES FROM THE 

### A PPLICATION OF 

### P ESTICIDES

Who Must Complete a PDEW?

Any Operator, who is a D ecision

- maker required to submit a Notice of Intent (NOI) and is a small entity as defined in Appendix A of the permit may complete this Pesticide Discharge Evaluation Works heet (PDEW) to meet the requirements of

Part 7.4 of the PGP

. Pest management area, as defined in Appendix A of the permit, can be a large area (e.g., an entire town) or a very specific well

- defined management area ( e.g., a lake). Thus, a pest management area can have one or more treatment areas. Operators required to retain the information contained on this worksheet must do

so for each treatment area. For treatment areas with the same or similar pests, the Operator can use one worksheet to document pest management activities for those multiple treatment areas.

When to Complete a PDEW ?

Before any pesticide application, any Operator using this form to meet its obligations under the PGP must complete Part B of this worksheet. Part C, except for the pesticide application end date and total quantity of pesticide applied, must be completed as soon as possible but no later than 14 days after the first pesticide application. The total quantity of pesticide applied and the pesticide application end date must be completed as soon as possible but no later than 14 days after completion of pesticide application for this project.

Any Operato r using this form to meet its obligations under the PGP must retain this worksheet for at least 3 years from the date that coverage is granted under the PGP or when the permit expires or is terminated. These O perators must make this worksheet available to EPA, including an authorized representative of EPA, upon request.

Completing the PDEW

To complete this form, type or print in uppercase letters in the approriate areas only. Make sure you complete all questions.

Section A. General Information

1. Enter the Operator ’s full legal name.

2. Enter the full legal name of the person completing the form.

3. Section A should be completed for each Pest Management Area. Indicate which

Pest Management Area out of the total number of Pest Management Areas for which the section is being completed (i.e., Pest Management Area 1 of 10 total Pest Management Areas).

4. Enter the name of the P est M anagement A rea.

5. Identify the pest icide use pattern(s) for the Pest Management A rea.

6. For each treatment area, provide a brief description and loc a tion description of

the treatment area within the Pest Management Area; size of the treatment area in acres or linear feet, and name or location of any Water s of the United States to which discharges occur.

Section B. Pest Evaluation

1. Identify the target pest(s) and provide a brief description of why pest control is

needed.

2. Provide a brief description of any P est M anagement M easure(s) implemented

before pesticide application. For example, identify if you have performed physical control techniques such as pulling weeds, removing breeding h abitat, or trapping animals.

Section C. Pesticide Application

1. Provide the company name and contact information of the pesticide applicator.

2. Enter the date that the pesticide application began and ended.

3. Enter the name of each pesticide product used including the EPA Registraion

Number

, the quanity of pesticide applied, and the method used to apply the pesticide (e.g., fixed wing aircraft, backpack sprayer)

. 4. Indicate if visual monito r ing was conducted during the pesticide application

and/or post

- application. If visual monitoring was not performed, provide a brief

descri p tion of why visual monitoring was not condu cted.

5. Indicate if there were any adverse effects identifed during visual monitoring.

Provide a brief decription of any adverse ef fects that were identified. Section D . Certification

Enter the certifier’s printed name and title. Sign and date the form. For more information about the certification statement and signature, see Appendix B of the permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal statutes provide for severe penalties for submitting false information. Federal regulations require this application to be signed as follows:

For a corporation : by a responsible corporate officer, means:

(i) president, secretary, treasurer, or vice

- president of the corporation in charge of

a principal business function, or any other person who performs similar policy or

decision

- mak ing functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities,

provided the manager is authorized to make management decisions that govern the operation of the regulated activity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long

- term env ironmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole proprietorship : by a general partner or the proprietor; or

For a municipal, state, federal, or other public facility : by either a principal executive or ranking elected official.

If the PDEW was prepared by someone other than the ce rtifier (for example, if the

PDEW was prepared by a consultant for the certifier’s signature), include the name, organization, phone number and e

- mail address of the PDEW preparer.

Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of infor mation is estimated to average 1 hour or 60 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Coll ection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Pesticide Discharge Evaluation Worksheet to this a ddress.

EPA FORM 6100-26 Page 3 of 3U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY
W ASHINGTON

, DC 20460

A NNUAL R EPORTING F ORM FOR THE P ESTICIDE G ENERAL P ERMIT (PGP) FOR
D ISCHARGES FROM THE A PPLICATION OF P ESTICIDES Form Approved

OMB No.

2040

- 0284

This form is for any Operator that is a De ci sion- maker required to submit an NOI. The annual report must be submitted no later than February 15 of the following year for all pesticide activities covered under the permit occurring during the previous calendar year as detailed in Part 7 of the permit

.

Electronic Submission Waiver (skip if using eNOI)

I hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNOI will incur undue burden or expense over my use of this paper Annual Reportin g form.

Briefly describe the reason why use of the electronic system causes undue burden or expense :

________________________________________________________________________________________________ _______________________________________

________________________________________________________________________________________________ _______________________________________

A. General Information

1

. NPDES Permit Tracking Number :

2. Operator Name:

3. Operator Contact Information :

a. Street :

b. City : c . State : d. ZIP Code: –

e. Telephone:

– – E xt f. Fax: – –

4. Contact Information :

a. Contact Name :

b. Tit le :

c . E

- mail :

B . Adverse Incidents and Correc tive Actions

1. Was an adverse incident observed and/or corrective actions taken for any Pest Management Area for which you have coverage under the permit ?

a. No adverse incidents were observed or corrective action was taken. (Proceed to Section C )

b. Yes, a n a dverse incident was observed and/or a corrective action was taken. (Com plete questions 2 -6 for each Pest Management Area in which adverse

incidents we re observed or corrective actions were take n. Copy this section for non

- electronic submissions ).

Pest Management Area #____ of ##____

2 . Pest Management Area Name:

___________________________________________________________________________________________________

3 . If applicable, provide the date for any adverse incidents as a result of those treatment(s), as described in Part 6.4 of the permit (use additional pages, if needed):

Date of adverse incident observation :

4 . Date and time the Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, and any instructions received from EPA

. / /

a. Dat e: / / c. Who the Operator spoke with at EPA :

________________________________________

b. Time: ___________________________________________ d. Instructions received from EPA :

________________________________________________________________________

________________________________________________________________________

5 . Date of submission of Thirty (30)

- Day Adverse Incident Written Report:

6 . Describe any corrective act i on(s), including spill responses, resulting from pesticide application activities and the rationale for such action(s), subsequent to those steps

described in the Thirty (30)

- Day Adverse Incident Written Report :

________________________________________________________________________________________________ ____________________________________

________________________________________________________________________________________________ ____________________________________

________________________________________________________________________________________________ ____________________________________

________________________________________________________________________________________________ ____________________________________

________________________________________________________________________________________________ ____________________________________ / /

EPA FORM 6100

- 25 NOTE: Copy this page and attach additional pages as necessary Page 1 of 5C

. Pest Management Area(s) (use addition al pages for each Pest Management A rea)

Pest Management Area # of ##

1. Have any discharges from pest control activities occurred in this calendar year?

a. No discharge from pest control activities this calendar year. Note: Checking this box completes Section C if you had no discharge from pest control activities this

year. Proceed to section D.

b. Yes. Proceed to question 2.

2 . Indicate the pesticide use pattern for the P est M anagement A rea:

a. Mosquito and Other Flying Insect Pest Control b. Weed and Algae Pest Control c. Animal Pest Control d. Forest Canopy Pest Control

3

. For each treatment area (use additional pages for each treatment area) :

a. Provide a description of the treatment area within this Pest Management Area , including location description :

________________________________________________________________________________________________ ________________________________

________________________________________________________________________________________________ ________________________________

b

. Size of treatment area (in acres or linear feet): __

__

_ acres or ___

__

_ linear feet

.

c. Name or location of any Waters of the United States to which discharges occurred:

________________________________________________________________________________________________ ________________________________

________________________________________________________________________________________________ ________________________________

d. Target Pest(s) :

____________________________________________________________________________________________________________________

e. Did any pesticide application activities result in a discharge to W aters of the United States containing NMFS Listed Resources of Concern as defined in Appendix A of the permit ?

Yes No If yes, approximate date(s) of any discharge s:

___________________________________________________________________________

4

. Name and contact information for pesticide applicat or (s) (or check here if same as provided in Section A):

Company Name:

Street:

City: State: Zip Code:

-

Contact Name : Title:

Phone: – – E xt

E- mail:

5. Was this pest control activity addressed in your P esticide D ischarge M onitoring P lan (PDMP) before pesticide application : Yes No Not Applicable

6 . Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Reg istration N umber(s) and by application method

.

Circle if quantity indicated is in lbs or gallons : Add additional pages if necessary.

Product Name

__________________________ Product Name

___________________________ Quantity Applied (lbs or gallons Quantity Applied (lbs or gallons

– – of product ): of product ):

Application method: Application method:

a. Aerially by fixed

- wing

______ lbs or gallons a. Aerially by fixed

- wing ______ lbs or gallons

b. Aerially by rotary aircraft ______ lbs or gallons b. Aerially by rotary aircraft ______ lbs or gallons

c. Land

- based sprayer (includes backpack, land ______ lbs or gallons c. Land

- based sprayer (includes backpack, ______ lbs or gallons
vehicle mounted sprayers, high pressure land vehicle mounted sprayers, high canopy sprayer) pressure canopy sprayer)

d

. Aquatic vehicle mounted spra yer ______ lbs or gallons d

. Aquatic vehicle mounted sprayer ______ lbs or gallons

e

. Direct mixture (includes metering, subsurface ______ lbs or gallons e

. Direct mixture (includes metering,

______ lbs or gallons

applications) subsurface applications)

f

. Chemigation ______ lbs or gallons f

. Chemigation ______ lbs or gallons

g

. Other (specify):

_____________________ ______ lbs or gallons g

. Other ( specify) :

____________________ ______ lbs or gallons

EPA FORM 6100

- 25 NOTE: Copy this page and attach additional pages as necessary Page 2 of 5D. Certification

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in acco rdance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. O n the basis of my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Printed Name:

Title:

E- Mail:

Signature/Responsible Official: Date: / /

Annual Report Preparer (Complete if the Annual Report was prepared by someone other than the certifier)

Preparer Name:

Organization:

Phone: – – E xt Date: / /

E- Mail:

EPA FORM 6100

- 25 NOTE: Copy this page and attach additional pages as necessary Page 3 of 5Instructions for Completing the Annual Report Form for the Pesticide General Permit (PGP) for

Discharge s from the Application of Pesticides

Who Must File an Annual Report with EPA ? Section A. General Information

Any Operator that is a D ecision

- maker required to submit a Notice of Intent ( NOI )

and is a large entity as defined in Appendix A of the permit and any Decision

- maker required to submit an NOI solely because of their application results in a d ischarge

to W aters of the United States containing NMFS Listed Resources of Concern , must

submit an annual r eport to EPA each calendar year. Once required to submit an annual report for one year, an annual report must be filed each subsequent year of this permit whether or not you have discharges from the application of pesticides in

accordance with S ection 7.6 of the perm it

.

When to File an Annual Report ?

Any Operator required to file an annual report must submit the annual report no later than February 15 of the following year for all pesticide activities covered under this permit occurring during the previous calendar ye ar. If the Operator is required to submit an NOI based on an annual treatment area threshold, the annual report must include information for the calendar year, with the first annual report required to include activities for the portion of the calendar year after the point at which the Operator exceeded the annual treatment area threshold. If the Operator first

exceed s an annual treatment area threshold after December 1 in a calendar year

, an annual report is not required for that first partial year but annu al reports are required thereafter, with the first annual report submitted also including information from the first partial year.

When Operator terminate s permit coverage, as specified in Part 1.2.5 of the permit

, an annual report must be submitted for the portion of the year up through the date of termination. The annual report is due no later than February 15 of the following year.

Where to File the Annual Report ?

The Operator must prepare and submit the A nnual Report using EPA’s electronic Notice of Intent (eNOI) system available on EPA’s website ( www.epa.gov/npdes/pesticides/enoi ) unless eNOI is otherwise unavailable or the Operator has filed a waiver from the requirement to use eNOI for subm i tting the Annual Report. The Electronic Submission Waiver is at the top of this form. Any Operator waived from the requirement to use eNOI for Annual Report submission must certify to EPA on this form that use o f eNOI will incur undue burden or expense over the use of the paper Annual Report form and then provide a basis for

that determination.

If you do file a waiver from using eNOI; you must send the Annual Report to one of

the addresses listed below.

Via Unite d States Mail: United States Environmental Protection Agency Office of Water, Water Permits Division Mail Code 4203M, ATTN: NPDES Pesticides 1200 Pennsylvania Avenue, NW Washington, DC 20460

Via overnight/express delivery: United States Environmental Protection Agency Office of Water, Water Permits Division EPA East Building

- Room 7420, ATTN: NPDES Pesticides 1201 Constitution Avenue, NW Washington, DC 20004

Phone: 202

- 564

- 9545

If you have questions, contact EPA’s Pesticides Notice Processing Center toll free

at (866) 352

- 7755.

If you file a paper Annual Report, please submit the original with a signature in ink

. Do n ot send copies. Also, faxed copies will not be accepted.

Comple ting the Annual Report Form

To complete this form, type or print in uppercase letters in the appropriate areas only. Make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the address above. You may also use this paper form as a checklist for the information you will need when filing an Annual Report electronically via EPA’s Pesticides eNOI system. 1. En ter your permit tracking number that you received in your NOI confirmation

letter or e

- mail from EPA’s Pesticide Notice Processing Center. You can find the tracking number assigned to your NOI by using EPA’s e NOI System ( www.epa. gov/npdes/pesticides/enoi ).

2. Provide the legal name of the person, firm, public organization or any other

public entity who is the D ecision

- maker for the pesticides applications described

in t his report . A D ecision

- maker is an Operator who has control over the decision to perform pesticide applications including the ability to modify those decisions that result in a discharge to Waters of the United States.

3. Enter the address, telephone number, and fax number of the Operator.

4. Provide the full legal name, title and e

- mail address of a contact person for the

Annual Report.

Section B. Adverse Incidents and Corrective Actions

1. Identify if an adverse incident w as observed and corrective actions were taken

for any Pest Management Area for which you have coverage under the permit

. If

no, proceed to Section C

. If yes, complete Section B for each P est M anagement

A rea for which an adverse incident was observed or corrective action was taken

.
2. Enter the name of the P est M anagement A rea.

3. If a pplicable, e nter the date of any adverse incidents result ing from the

treatments , as described in Part 6.4 of the permit

. Use additional pages if there are multiple dates to be described.

4. Enter the date and time the Operator contacted EPA to notify the Agency of the

adverse incident, pursuant to Part 6.4.1.1 of the perm it

.

a. Indicate the date of the contact

.
b. Indicate the time of the contact

.

c. Indicate who the Operator spoke with at EPA

.
d. Indicate any instructions received from EPA

.
5

. Enter the date that the Thirty (30)

- Day Adverse Incident Written Report was

submitted, pursuant to Part 6.4.2 of the perm it

.
6. Provide a description of any corrective action(s) resulting from pesticide

application activities and the rationale for the action(s), performed subsequently to or in addition to any actions described in the Thirty (30)

- Day Adverse Incident Written Report.

Section C. Pest Management Area(s)

Section C should be completed for each P est M anagement A rea. Indicate which

P est M anagem ent A rea out of the total number of P est M anagement A reas for which the section is being completed (i.e.

, P est M anagement A rea 1 of 10 total P est

M anagement A reas).

1. Identify if you had a discharge from pest control activities this calendar year.

Check yes if you had discharge from pest control activities this calendar year.

Check no if you had no discharge from pest control activities this calendar year. Note: Checking the no box completes Section C

2. Select the box for the type of pesticide use pattern for the P est M anagement

A rea.

3. Provide a description of the treatment area (use additional pages for each

treatment area).

a. Provide a description of the treatment area, including a description of the

location.

b. Provide the size of the treatment area in acres or linear feet.

c. Provide the name or location of any Waters of the United States to which

discharges occur.

d. Provide a description of the target pest(s).

e. I ndicate whether any pesticide application activities resulted in a discharge to

W aters of the United States containing NMFS Listed Resources of Concern

, as defined in Appendix A of the perm it

. If yes, provide approximate date(s) of the discharge. Additional information on NMFS Listed Resources of Concern

is availab le on EPA’s website at www.epa.gov/npdes/pesticides

.

NOTE: Copy this page and attach additional pages as necessary Page 4 of 54. Provide the company name(s), mailing address, a contact person, contact person’s title, telephone number and e

- mail address for the pesticide applicator(s). If the information is the same as Section A, check the appropriate box and proceed to the next ques tion.

5. Indicate if the pest control activity was addressed in your PDMP before pesticide

application.

6. Enter the total amount of each pesticide product applied for the reporting year by

the product name, EPA Registration Number(s) and by application m ethod. Circle whether the quantity applied is in pounds or gallons. Copy and attach additional pages, as necessary.

Section D. Certification

Enter the certifier’s printed name and title. Sign and date the form. For more information about the certification statement and signature, see Appendix B of the permit

. (CAUTION: An unsigned or undated form will not be accepted .) Federa l statutes provide for severe penalties for submitting false information. Federal regulations require this application to be signed a s fo llows:

For a corporation : by a responsible corporate officer, means:

(i) president, secretary, treasurer, or vice

- president of the corporation in charge of a

principal business function, or any other person who performs similar policy or

decision makin g functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities,

provided the manager is authorized to make management decisions which govern the operation of the regulated act ivity including having th e explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long term environmental compliance with environmental laws and regulations; the manager can ensure

that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole proprietorship : by a general partner or the proprietor; or

For a municipal, s tate, Federal, or other public facility : by either a principal executive or ranking elected official.

If the Annual Report was prepared by someone other than the certifier (for example,

if the Annual Report was prepared by the PDMP contact or a consultant for the certifier’s signature), include the name, organization, phone number and e

- mail address of the Annual Report preparer.

Paperwork Reduction Act N otice

The public reporting and recordkeeping burden for this collection of information is estimated to average 8 hours or 480 minutes per response.

Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Annual Report ing Form to this address.

NOTE: Copy this page and attach additional pages as necessary Page 5 of 5

### U NITED 

### S TATES 

### E NVIRONMENTAL 

### P ROTECTION 

### A GENCY


### W ASHINGTON



### , DC 20460

T HIRTY 

### (30) -D AY 

### A DVERSE 

### I NCIDENT 

### W RITTEN 

### R EPORT FOR


### T HE 

### P ESTICIDE 

### G ENERAL 

### P ERMIT 

### (PGP)

F OR 

### D ISCHARGES FROM THE 

### A PPLICATION OF 

### P ESTICIDES 

### Form Approved

OMB No.

2040

- 0284

This form is for Operators required to submit a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state lead agency for pesticide regulation. Where multiple Operators are authorized for a discharge that results in an adverse incident, reporting by any one of the Oper ato rs constitutes compliance for all of the Operators, provided a copy of this report is also provided to all of the other authorized Operators within 30 days of the reportable adverse incident.

A. Reportable Adverse Incident.

Is the adverse incident reportable? Reporting of adverse incidents is not required under th e PGP in the following situations: (a) An Operator is aware of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application; (b) An Operator has been notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents; (c) An Operator receives information of an adverse incident, but that information is clearly erroneous; or (d) An adverse incident occurs to pests that are similar in kind to potential target pests identified on the FIFRA label.

Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation.

No. STOP. You are not required to complete this report. However, you may consider using this form to document the incident and your rationale for why reporting of the adverse incident is not required. This information may be useful to support your rationale should you be questioned on

such.

B. Information from the 24-H our Adverse Incident Notification

When an Operator observes or is otherwise made aware of an adverse incident, which may have resulted from a discharge from a pesticide application, the Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at www.epa.gov/npdes/pesticides . This notification must be made by telephone within 24 hours of the Operator becoming aware of the adverse incident. Operators must include in the written report the information provided to EPA in the 24-hour adverse incident notification (PGP Part 6.4.1.1). At tach additional information if necessary.

1. Caller’s Contact Information:

a. Name:

b. T elephone Number: – – E xt

2. Operator Information:

a. Operator Name:

b. M ailing Address:

Street:

City: State: ZIP Code:
–

3. NOI NPDES Permit Tracking Number: (Enter “NA” if not applicable)

4. Contact person, if different than the person providing the 24-hour notice under item 1 above:

a. Name:

b. Telephone Number: – – Ext

5. Describe how and when the Operator became aware of the adverse incident:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

6. Describe the location of the adverse incident:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

EPA FORM 6100-24 Page 1 of 67. Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7a below, for each product applied in the area of the adverse incident:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

a. Pesticide Registration Number: Pesticide Registration Number:

8. Describe any steps the Operator has taken or will take to correct, repair, remedy, clean up, or otherwise address any adverse effects:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

9. Identify any other Operators authorized for coverage under this permit for discharges from the pesticide application activities that resulted in the adverse incident and if so, provide details of your notification of those other Operator(s) :

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

C. Date and T ime the Operator N otified EPA of the Adverse I ncident

1. Date EPA was contacted: / / 2. Time EPA was contacted: _____________________________

3. Name and/or title of the person the Operator spoke with at EPA:

a. Name: 

### b. Title:

4. Instructions received from EPA:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

EPA FORM 6100-24 Page 2 of 6D. Other Information Required in the Thirty (30) Day Adverse Incident Report

Please attach additional information if necessary.

1. Location of incident, including the names of any waters affected and appearance of those waters (sheen, color, clarity, etc):

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

2. Describe the circumstances of the adverse incident including species affected, estimated number of affected individuals, and approximate size of dead or distressed organisms:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

3. Describe the magnitude and scope of the affected area (e.g. aquatic square area or total stream distance affected):

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

4. Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name of pesticide product and EPA registration number.

P esticide P esticide application rate: application rate:

Intended use site: Intended use site:

Method of application: Method of application:

Product: Product:

EPA Reg. No.: EPA Reg. No.:

5. Describe the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for pesticides applied):

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

6. Provide an indication of which laboratory test(s), if any, were performed, and when . (Note: A summary of the test results must be provided within 5 days after they become available, if not available at the time of submission of this report.):

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

7. Describe the actions to be taken to prevent recurrence of adverse incidents:

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

EPA FORM 6100-24 Page 3 of 6E. Certification

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. On the basis of my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Printed Name:

Title:

E- Mail:

Signature/Responsible Official: Date: / /

Adverse Incident Report Preparer (Complete if Adverse Incident Report was prepared by someone other than the certifier)

Preparer Name:

Organization:

Phone: – – E xt Date: / /

E- Mail:

EPA FORM 6100-24 Page 4 of 6

### Instructions for Completing and Submitting the Thirty (30) Day Adverse Incident Written Report for the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides

Who Must Submit a 30

- day Adverse Incident Report?

All Operator s who observe or are otherwise made aware of a reportable adverse

incident pursuant to Part 6.4 of the permit must submit on adverse incident report

. However, even for those identified adverse incidents for which the Operator is not required to report, EPA recommends that Operators consider using this form to document the incident and the rationale for why reporting of the adverse incident is not required. This information may be useful to support a rationale should this determination be questioned.

An a dverse incident, as defined in the Appendix A of the permit, is an unusual or unexpected incident that an Operator has observed upon inspection or of whi ch the Operator otherwise bec a me aware, in which: (1) t here is evidence that a person or

non

- target organism has likely been exposed to a pesticide residue, and (2) t he

person or non

- target organism suffered a toxic or adverse effect. See Appendix A of the permit , for the complete definition of adverse incident.

Where multiple Operators are authorized for a discharge that results in an adverse incident, notification and reporting by any one of the Operators constitute s compliance for all of the Operators, provided a copy of the written report required in

Part 6.4.2 of the permit is also provided to all of the other authorized Operators within 30 days of the reportable adverse incident.

When to File the Adverse Incident Report

Operators must a provide a written report of any reportable adverse incident s to the appropriate EPA Regional office and to the state lead agency for pesticide regulation within 30 days of the adverse incident pursuant to Part 6.4.1.1 of the permit

.
Where to File the 30

- day Adverse Incident Report

The Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at www.epa.gov/npdes/pesticides of the adverse incident within 24 hours. The Operator(s) must provide a written report of the adverse incident to the appropriate EPA Regional office at the address listed in Part 8 of the permit and to the state lead agency for pesticide regulation (see http://npic.orst.edu/state1.htm ).

If an Operator becomes aware of an adverse incident affecting a federally listed threatened or endangered species or its federally designated critical habitat which may have resulted from a discharge from the Operator’s pesticide application, the Operator must immediately notify the National Marine Fisheries Service (NMFS) in the case of an anadromous or marine species, or the United States Fish and Wildlife Service (FWS) in the case of a terrestrial or freshwater spe cies.

Completing the 30

- day Adverse Incident Report

To complete this form, type or print in uppercase letters in the appropriate areas only. Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the appropriate EPA Regional office.

Section A. Reportable Adverse Incident

The Operator is required to submit th is Adverse Incident Report if the adverse incident is reportable. Check yes if the adverse incident is reportable. I f an Adverse Incident Report is not required, check no. No further action is needed on this form. Reporting of adverse incidents is not required under th e PGP in the following

situations:

a. An Operator is aware of facts that indicate that the adverse incident was not

related to toxic effects or exposure from the pesticide application;

b. An Operator has been notified by EPA, and retains such notification, that the

reporting requirement has been waived for this incident or category of incidents;

c. An Operator receives information notifying the Operator of an adverse incident,

but that information is clearly erroneous; or

d. An adverse incident occurs to pests that are similar in kind to potential target

pests identified on the FIFRA label. Section B. Information from the 24

- hour Adverse Incident Notification

1. Provide contact information for the person that c alled EPA to report the adverse

incident

.

a. Enter the legal name of the caller.

b. Enter the phone number of the caller.

2. Provide the Operator’s contact information.

a. Enter the legal name of the Operator.

b. Enter the mailing address of the Operator.

3. If an NOI was filed as required in Part 1.2 of the permit, e nter the NPDES Perm it

Tracking Number assigned by eNOI or the EPA’s Pesticides Processing Center. You can find the tracking number assigned to your NOI using EPA’s e NOI System ( www.epa.gov/npdes/pesticides/enoi )

. If no NOI submitted, enter “ NA ” for not applicable

. 4. Provide information for a contact person

, if different th a n the person that called

EPA to report the adverse incident.

a. Enter the legal name of the contact person.

b. Enter the phone number of the contact person.

5. Provide a description of how and when the O perator became aware of the

adverse incident.

6. Provide a description of the location of the adverse incident.

7. Provide a description of the adverse incident and the pesticide product used in

the adverse incide nt. Include the EPA pesticide registration number for each product applied in the area of the adverse incident. A ttach additional pages if

necessary

8. Provide a description of any steps the Operator has taken to correct, repair,

remedy, clean up or otherwise address the adverse effects of the incident.

9. Identify any other Operators authorized for coverage under the permit for

discharges from the pesticide application activities that resulted in the adverse

incident. If other Operators are authorized unde r this permit , provide details of your notification of those other Operator(s)

.

Section C. Date and T ime the Operator N otified EPA of the A dverse I ncident

1. Enter the date that EPA was contacted to report the adverse incident.

2. Enter the time EPA was contacted to report the adverse incident.

3

. Provide the legal name and title of the person contacted at EPA.

4

. Provide a description of the instructions received by EPA.

Section D. Other Information Required in the Thirty (30) Day Adverse Incident Report

1. Enter the location of the adverse incident and include the names of any waters

affected. Please include the appearance of those waters (sheen, color, clarity, etc.).

2. Provide a description of the circumstances of the adverse incident including

species affected, estimated number of affected individuals and approximate size

of dead or distressed organisms.

3. Provide a description of the magnitude and scope of the affected area. Include

aquatic square area or total stream distance affected

, if pos sible.

4. Provide the pesticide application rate, intended use site (e.g., on the bank, above

waters, or directly to water)

, method of application

, and the name of pesticide product and EPA registration number

. 5. Provide a description of the habitat and the circumstances under which the

adverse incident occurred (including any available ambient water data for pesticides applied ).

6. I ndicate which laboratory test(s) were performed and when, if laboratory tests

were performed. The summary of the test results must be provided within 5 days after they become available , i f not available at the time of submission of this report

. 7. Provide a description of the actions to be taken to prevent recurrence of adverse

incidents

.

EPA FORM 6100-24 Page 5 of 6Section E. Certification

Enter th e certifier’s printed name and title. Sign and date the form. For more information about the certification statement and signature, see Appendix B of the permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal statutes provide for severe penalties for submitting false information. Federal regulations require this application to be signed as follows:

For a corporation : by a responsible corporate officer, which means:

(i) president, secretary, treasurer, or vice

- president of the corporation in charge of a

principal business function, or any other person who performs similar policy or

decision

- mak ing functions for the corporation, or

(ii) the manager of one or more manufacturing, production, or operating facilities,

provided the manager is authorized to make management decisions that govern the operation of the regulated activity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long

- term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where au thority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;

For a partnership or sole proprietorship : by a general partner or the proprietor; or

For a municipal, state, federal, or other public facility : by either a principal executive or ranking elected official.

If the report was prepared by someone other than the certifier (for example, if the report was prepared by a consultant for the certifier’s signature), include the name, organization, phone number and e

- mail address of the report preparer and the date that the report was prepared

.

Paperwork Reduction Act Notice

The public reporting and recordkeeping burden for this collection of information is estimated to average 4 hours or 240 minutes per respo nse. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Str ategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Adverse Incident Report to this address.

EPA FORM 6100-24 Page 6 of 6