UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460

ADVERSE INCIDENT REPORT 

FOR THE PESTICIDE GENERAL PERMIT (PGP)

FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES

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 

hours of the Operator becoming aware of the adverse incident. Please 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:

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 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 (if known): ______________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________
B. Date and time the Operator Notified EPA of the Adverse Incident

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, if applicable :

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

Consistent with permit requirements, Operator must also complete Part D below if 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 provided 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 waters (sheen, color, clarity, etc):

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

2. Describe the circumstances of the adverse incident including species affected, estimated number of 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 

application rate:

Pesticide 

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: _______________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________
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 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: