### U NITED 

### S TATES 

### E NVIRONMENTAL 

### P ROTECTION 

### A GENCY



### W ASHINGTON



### , DC 20460

A DVERSE 

### I NCIDENT 

### R EPORT

FOR 

### T HE 

### P ESTICIDE 

### G ENERAL 

### P ERMIT 

### (PGP)

F OR 

### D ISCHARGES FROM THE 

### A PPLICATION OF 

### P ESTICIDES 

### Form Approved

OMB No.

XXXX

- XXXX

A

. 24

- hour Adverse Incident Notification

Information to be submitted for the 24

- hour adverse incident notification (PGP Part 6.4.1 .1 ) . This notification must be made by telephone within 24

hour s of the Operator becoming aware of the adverse incident. Please attach a dditional information if necessary.

1. Caller’s Contact Information :

a. Name :

b

. Telephone Number :

– – ext

2. Operator Information :

a. Operator

Name :

b

. M ailing A ddress :

Street:

City: State : ZIP Code:

–

3. NOI NPDES Permit T racking Number:

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 :

________________________________ ________________________________ _______________

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________

7. Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7 a below , for each product

applied in the area of the adverse incident :

________________________________ ________________________________ _________________

________________________________ ________________________________ ________________________________ ____________________

a. Pesticide Registration Number: Pesticide Registration Number:

8

. Descri be 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 resul ted in the adverse incident (i f known ) :

________________________________ ________________________________ ______________

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________B

. Date and time the Operator Notified EPA of the A dverse I ncident

1. Date EPA was contacted: / /

2. Time EPA was contacted:

___________________________ EST

3

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

a. Name : 

### b. Title:

4

. Instructions received from EPA :

________________________________ ________________________________ __________________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

C. Rationale Why Adverse Incident Notification Not Required

Provide an explanation of why the Operator believes the adverse incident could not have been caused by exposure to the pesticide , i f applicable :

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________ Consistent with permit requirements

, Operator must also complete Part D below i f unable to justify why adverse incident notification is not required.

D

. Thirty (30) Day Adverse Incident Report

Information to be submitted within 30 days of a reportable adverse incident (PGP Part 6.4.2 ). This information must be provide d to the appropriate EPA

Regional office and includes sections A and B above. Please attach additional information if necessary.

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

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

2. Describe the circumstances of the adverse incident including species affected, estimated number of individual s and approximate size of dead or

distressed organisms :

________________________________ ________________________________ ________________________________ __

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

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

________________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

4

. Provide the p esticide application rate, intended use site (e.g., on the bank, above waters, or directly to water)

, method of application

, and the name

of pesticide product and EPA registration number

.

P esticide

application rate: P esticide

application rate:

I ntended use site : I ntended use site :

M ethod of application : M ethod 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 , i f not available at the time of submission of this report.):

________________________________ ____________

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________

7

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

________________________________ _______________________

________________________________ ________________________________ ________________________________ ____________________

________________________________ ________________________________ ________________________________ ____________________D

. Certification ( Appendix B, Subsection B.11 )

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in acco rdance with a system

designed to assure that qualified personnel properly gathered and evaluated the information submitted. 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 th e

possibility of fine and imprisonment for knowing violations

.

Printed Name:

Title:

E

- Mail:

Signature/Responsible Official: Date: / /

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

Preparer Name:

Organization:

Phone:

– – E xt Date: / /

E

- Mail: