UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, DC 20460 

NOTICE OF INTENT (NOI) OF COVERAGE UNDER THE PESTICIDE 

GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE APPLICATION 

OF PESTICIDES 

Form Approved 

OMB No. 

2040-0284

Submission of this completed Notice of Intent (NOI) constitutes notice that the Operator identified in Section B intends to be authorized to discharge pollutants 

to Waters of the United States within the pest 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. To be granted coverage, all information required on this form must be completed. Please read and make sure you comply with all permit 

requirements, 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. Mark whether this is the first time you are requesting coverage under the Pesticide General Permit or if this is a change of information for a discharge 

already covered under the 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 selecting 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 government 

b. State government 

c. Local government 

d. Mosquito control district (or similar) 

e. Irrigation control district (or similar) 

f. Weed control district (or similar) 

g. Other: If other, provide brief description of 

type of operator: 

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

Yes No 

Please note: If you answer “Yes” to question 4 you are required to develop a Pesticide Discharge Management Plan (PDMP) and submit an Annual 

Report reflecting all pesticide uses for which you are requesting permit coverage under this NOI. 

5. In which state are your pest management areas located? Please specify only one state per NOI: 

6. Mailing Address: 

a. Street: 

b. City: c. State: d. ZIP Code: – 

e. Telephone: – – Ext f. Fax: – – 

g. Contact Name: 

h. E-mail: 

EPA FORM 6100-22 Page 1 of 8 
 

C. 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: ________________________________________________________________________________________________ 

Provide 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 occurring 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: – – Ext 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. AnimalPest Control 

b. Weed and Algae Pest Control d. ForestCanopy Pest Control 

6. Receiving Waters (check one): 

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

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

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

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

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

7. Tier 3 Waters 

Is coverage 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 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. 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 waters are

identified as impaired by a substance which is either an active ingredient ofthe pesticide designated for use or is a degradate of such an active 

ingredient. See Part 1.1.2.1 of the permit. Check one: 

a. Waters 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. Waters 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 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

____________________________________________________________________________________________________________________ 

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 Service (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 the 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 and discharge-related 

activities on federally-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 federally-designated 

critical habitat; or 

ii. Written 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 has been authorized through NMFS’ issuance of a permit under section 10 of the ESA, and such authorization addresses the 

effects of the pesticide discharges and discharge-related activities on federally-listed species and federally-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 Declared Pest Emergency Situation. 

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 

containing 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 the 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 occurred 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 product(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 which 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 (attach additional 

pages as necessary): 

EPA FORM 6100-22	 Page 3 of 8 
 

E. 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: – – Ext 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 Table 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-Makers Required to Submit NOIs 

PGP Part/ 

Pesticide Use 

Which Decision-Makers Must 

Submit NOIs? 

For Which Pesticide 

Application Activities? 

All four use Any Decision-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, 

as 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 responsible 

for pest control 

Mosquito control districts, or 

similar pest control districts 

All activities resulting in a 

discharge for which the 

Decision-maker is responsible 

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 calendar 

year 

1.1.1(b) -

Weed and 

Algae 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 responsible 

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 responsible 

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 responsible 

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 responsible 

for pest control 

Local governments or other 

entities that exceed the annual 

treatment area threshold 

identified here 

Treatment 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. 

When 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, prepare your Pesticide Discharge 

Management 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 identified in the Part 1.1of 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. For 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 

Date2 

Any Decision-maker with any 

discharge to Waters of the 

United States containing NMFS 

Listed Resources of Concern, 

except for those discharges in 

response to a Declared Pest 

Emergency Situation, as 

defined in Appendix A. 

At least 30 days 

before any discharge 

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 

Pest Emergency 

Situation. 

Any Decision-maker with any 

discharge to Waters of the 

United States containing NMFS 

Listed Resources of Concern, 

in response to a Declared Pest 

Emergency Situation, as 

defined in Appendix A. 

Within 15 days after 

beginning to 

discharge in response 

to a Declared Pest 

Emergency Situation. 

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-maker 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 or contact the NOI Center toll 

free at 866-352-7755. 

EPA FORM 6100-22 Page 5 of 8 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 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 those 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 these 

discharges will continue. If 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 

States containing NMFS 

Listed Resources of 

Concern. Except for such 

waters, changes 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 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. 

Any Decision-maker 

discharging 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 

Decision-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 

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

this form that use of eNOI will incur undue burden or expense over the use of the 

paper NOI form and then provide a basis for that determination. 

EPA will immediately post on the pesticides eNOI Website all NOIs received. Late 

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

If you file a waiver from using eNOI; you 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 

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 NOI, submit the original with a signature in ink. Do not send 

copies. 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 

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 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 if 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 submittal deadlines and discharge authorization dates. Note: All 

eligible discharges are authorized for permit coverage through January 12, 2012 

without submission of an NOI. 

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b.	 Check this box if this is a change of information for a discharge already covered 

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

tracking 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 eNOI System 

(www.epa.gov/npdes/pesticides/enoi). For additional details regarding a change of 

information, see Table 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 Decision-maker for the pesticides applications described in this 

notice. A Decision-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. Indicate the type of Operator: 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 Operator 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 Management Plan (PDMP) and submit future Annual Reports 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 coverage under EPA’s Pesticide General Permit is desired. 

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

pest management area 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 permit (e.g., if 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. Attach a map of the pest management area or describe 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 management area. If 

this address is the same as the Decision-maker’s mailing address, indicate that by 

checking the box. If it is 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 the NOI 

is required. For 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 Waters of the United States 

within the pest management area or if permit coverage is being requested to 

specific Waters of the United States within the pest management area. If specific 

waters are being requested, write the names of the waterbodies. If permit coverage 

is being requested for all waters of the United States within the pest management 

area 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 facility (http://cfpub.epa.gov/npdes/stormwater/tmdltool.cfm). 

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

National Resource Water) Water of the United States. If yes, write the name(s) of 

the Tier 3 water(s) in the space provided. Describe and demonstrate why it is 

necessary to apply the pesticide discharge to protect the water quality, 

environment, 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. See Part 1.1.2.1 of the permit for more 

information on discharges 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 discharge-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 federallydesignated as critical under the ESA (“critical habitat”) except as provided in 

criterion b, c, and for at least 60 days, d, below. For a subset of listed species and 

critical 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 term of 

coverage under the permit. 

2. If you checked criterion d or criterion 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, number of 

planned discharges, approximate date(s) of planned discharge(s), and the rational 

supporting your determination that you meet the criterion for which the Decisionmaker 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 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. If you are certifying under criterion d (which allows 

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 criterion b, c, or e (for which NMFS has already evaluated the 

effects of these discharges). If you certify under one of these criteria and do 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 

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-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 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, state, federal, or other public facility: by either a principal executive or 

ranking elected official. 

If the 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 8 
 

 

 

 

Paperwork Reduction Act Notice 

The public reporting and recordkeeping burden for this collection of information is 

estimated to average 2.5 hours or 150 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 that address. 

EPA FORM 6100-22 Page 8 of 8 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, DC 20460 

NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT 

(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES 

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 termination (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 discharge 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 over decision-making responsibility 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: ZIP 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 3 
 

C. 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 Termination, 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 Operator from liability for any violations of the Clean Water Act. 

Printed Name: 

Title: 

E-Mail: 

Signature/Responsible Official: Date: / / 

NOT Preparer (Complete if NOT was prepared by someone other than the certifier) 

Preparer Name: 

Organization: 

Phone: – – Ext Date: / / 

E-Mail: 

EPA FORM 6100-23 Page 2 of 3 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS FOR COMPLETING THE NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT (PGP) FOR
 

DISCHARGES FROM THE APPLICATION OF PESTICIDES
 

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 

notifies the Operator to apply for an NPDES individual permit or alternative general 

permit, coverage under this permit terminates 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 permit. 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 or contact the NOI Center 

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, the Operator must submit the NOT 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 files a waiver from the requirement to use eNOI for submission of the 

NOT. The Electronic Submission Waiver is at the top of this NOT form. An Operator 

waived from the requirement to use eNOI for any NOT submission must certify to 

EPA on this form that use of eNOI will incur undue burden or expense over the use 

of the paper NOT form and then provide a basis for that determination. 

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 with a signature in ink. Do not 

send copies. 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. 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 

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 eNOI 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 options: 

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 NPDES individual 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. Provide the date of transfer and 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 general permit requirement will be met. 

Provide the printed full legal name, 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 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, state, federal, 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 

NOT 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 

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 

(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB 

control number in any correspondence. Do not send the completed NOT form to that 

address. 

EPA FORM 6100-23	 Page 3 of 3 

 

 

 

 

 

 

 

 

 

 

 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, DC 20460 

PESTICIDE DISCHARGE EVALUATION WORKSHEET FOR THE 

PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE 

APPLICATION OF PESTICIDES 

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). The information on this worksheet must be retained for each pesticide application activity. 

A. General Information 

1. Operator Name: 

2. Worksheet 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 the first pesticide application: 

__________________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________________ 

__________________________________________________________________________________________________________________ 

C. Pesticide Application 

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

Company Name: 

Street: 

City: State: Zip Code: -

Contact Name: 

Phone: – – Ext 

E-mail: 

EPA FORM 6100-26 Page 1 of 3 
 

 

 

 

 

 

 

 

 

 

 

 

2. Pesticide application start date: / / Pesticide application end date: / / 

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: 

Signature/Responsible Official: Date: / / 

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

Preparer 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 PESTICIDE GENERAL PERMIT 

(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES 

Who Must Complete a PDEW? 

Any Operator, who is a Decision-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 Worksheet (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 Operator 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 Operators 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 Pest Management Area. 

5. Identify the pesticide use pattern(s) for the Pest Management Area. 

6.	 For each treatment area, provide a brief description and location 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 Waters 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 Pest Management Measure(s) implemented 

before pesticide application. For example, identify if you have performed 

physical control techniques such as pulling weeds, removing breeding habitat, 

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 monitoring was conducted during the pesticide application 

and/or post-application. If visual monitoring was not performed, provide a brief 

description of why visual monitoring was not conducted. 

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

Provide a brief decription of any adverse effects 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-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 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, 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 certifier (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 information 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, 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 Pesticide 

Discharge Evaluation Worksheet to this address. 

EPA FORM 6100-26	 Page 3 of 3 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, DC 20460 

ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR 

DISCHARGES FROM THE APPLICATION OF PESTICIDES 

Form Approved 

OMB No. 

2040-0284

This form is for any Operator that is a Decision-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 Reporting 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: – – Ext f. Fax: – – 

4. Contact Information: 

a. Contact Name: 

b. Title: 

c. E-mail: 

B. Adverse Incidents and Corrective 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, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-6 for each Pest Management Area in which adverse 

incidents were observed or corrective actions were taken. 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. Date: / / 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 action(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 5 
C. Pest Management Area(s) (use additional pages for each Pest Management Area) 

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 Pest Management Area: 

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 Waters 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 discharges: ___________________________________________________________________________ 

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

Company Name: 

Street: 

City: State: Zip Code: - 

Contact Name: Title: 

Phone: – – Ext 

E-mail: 

5. Was this pest control activity addressed in your Pesticide Discharge Monitoring Plan (PDMP) beforepesticide application: Yes No Not Applicable 

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 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 sprayer ______ 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 5 
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 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: / / 

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

Preparer Name: 

Organization: 

Phone: – – Ext Date: / / 

E-Mail: 

EPA FORM 6100-25 NOTE: Copy this page and attach additional pages as necessary Page 3 of 5 
 

 

 

 

 

 

 

 

 

 

 

 

 

Instructions for Completing the Annual Report Form for the Pesticide General Permit (PGP) for
 

Discharges from the Application of Pesticides
 

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

Any Operator that is a Decision-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 discharge 

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

submit an annual report 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 Section 7.6 of the permit. 

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 year. 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 

exceeds an annual treatment area threshold after December 1 in a calendar year, 

an annual report is not required for that first partial year but annual reports are 

required thereafter, with the first annual report submitted also including information 

from the first partial year. 

When Operator terminates 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 Annual 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 submitting 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 of 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 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 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 not send copies. Also, faxed copies will not be accepted. 

Completing 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. Enter 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 eNOI 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 Decision-maker for the pesticides applications described 

in this report. A Decision-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 was 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 Pest Management 

Area for which an adverse incident was observed or corrective action was taken. 

2. Enter the name of the Pest Management Area. 

3.	 If applicable, enter the date of any adverse incidents resulting 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 permit. 

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 permit. 

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 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). 

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 Pest Management 

Area. 

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. Indicate whether any pesticide application activities resulted in a discharge to 

Waters of the United States containing NMFS Listed Resources of Concern, 

as defined in Appendix A of the permit. If yes, provide approximate date(s) of 

the discharge. Additional information on NMFS Listed Resources of Concern 

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

NOTE: Copy this page and attach additional pages as necessary	 Page 4 of 5 
 

 

 

 

 

4. 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 question. 

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 method. 

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.) 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 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 decisions which 

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, state, 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 Notice 

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 

Reporting Form to this address. 

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

 

 

 

 

 

 

 

 

 

 

 

 

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY 

WASHINGTON, DC 20460 

THIRTY (30)-DAY ADVERSE INCIDENT WRITTEN REPORT FOR 

THE PESTICIDE GENERAL PERMIT (PGP) 

FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES 

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 Operators 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 the 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-Hour 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). Attach additional information if necessary. 

1. Caller’s Contact Information: 

a. Name: 

b. Telephone Number: – – Ext 

2. Operator Information: 

a. Operator Name: 

b. Mailing 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 6 
 

 

 

 

7. 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 Time the Operator Notified EPA of the Adverse Incident 

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 6 
D. 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. 

Pesticide Pesticide 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 6 
E. 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: – – Ext 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 Operators 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 adverse 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 which the 

Operator otherwise became aware, in which: (1) there is evidence that a person or 

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

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 constitutes 

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 incidents 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 species. 

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 this Adverse Incident Report if the adverse 

incident is reportable. Check yes if the adverse incident is reportable. If 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 the 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 called 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, enter the NPDES Permit 

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 eNOI 

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 than 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 Operator 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 incident. Include the EPA pesticide registration number for each 

product applied in the area of the adverse incident. Attach 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 under this permit, provide details of 

your notification of those other Operator(s). 

Section C. Date and Time the Operator Notified EPA of the Adverse Incident 

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 possible. 

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. Indicate 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, if 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 6 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 

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 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, 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 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 Adverse 

Incident Report to this address. 

EPA FORM 6100-24 Page 6 of 6