EQP 2790 (Rev. 02/06) AQ Page 1 of 3 MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY
WATER BUREAU



### APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE FOR CHEMICAL TREATMENT TO CONTROL NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH

Pursuant to Part 31, Water Resources Protection, of the Natura l Resources and Environmental Protection Act, 1994 PA 451, as ame nded (NREPA), and Part 33, Aquatic Nuisance Control, of the NREPA, applicati on is made by the undersigned for a permit to chemically treat the waters described below for the control of nu isance aquatic plant and/or algae growth.



### SECTION I. GENERAL INFORMATION

APPLICANT INFORMATION WATERBODY INFORMATION

APPLICANT NAME WATERBODY NAME (IF CANAL/MARINA, ALSO LIST NAME OF CANAL/MARINA)

MAILING ADDRESS COUNTY(IES)

CITY, STATE, ZIP CODE TOWNSHIP NAME(S) TOWN(S) RANGE(S) SECTION(S)

TELEPHONE (DAYTIME) FACSIMILE OTHER INFORMATION FOR PRECISE LO CATION (E.G., NEARBY CROSSROADS)

LAKE ADDRESS (IF DIFFERENT FROM MAILING ADDRESS) SURFACE AREA OF ENTIRE WATERBODY (ACRES)



### SECTION II. TREATMENT AREA

1. DIMENSION OF TOTAL TREATMENT AREA Length feet Width feet Average depth of treatment area feet

2. TOTAL SURFACE ACRES PROPOSED FOR TREATMENT ACRES (1 acre = 43,560 square feet) Multiply length in feet by wi dth in feet and divide by 43,560.



### SECTION III. REQUIRED FEES Fees are based on the size of the proposed treatment area. ALL FEES ARE NON-REFUNDABLE. Check appropriate box:

For treatment of areas less than 1⁄2 acre, the required fee is $75.00.
For treatment of areas of 1⁄2 acre or more but less than 5 acres, t he required fee is $200.00.
For treatment of areas of 5 acres or more but less than 20 acres, t he required fee is $400.00.
For treatment of areas of 20 acres or more but less than 100 acres, t he required fee is $800.00.
For treatment of areas of 100 acres or more, the required fee is $1,500.00.

Certificate of Coverage under General Permit No. ___________________ – $75.00 (all current G eneral Permits and the list of pre-approved waterbodies may be obtained by visiting http://www.michigan.gov/deq or by calling 517-241-7734).

Payment must be made in full or your applicati on will be returned. Checks should be payable to: STATE OF MICHIGAN

. Submit your check, completed application form, and if nece ssary, a treatment map and authoriz ation letter or contract to:

MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALITY CASHIER’S OFFICE – WB – AQ
P.O. BOX 30657 LANSING, MICHIGAN 48909-8157 FOR CASHIER'S USE ONLY: 37000-40509-9037-481003-00MICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALIITY, WATER BUREAU
APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE FOR CHEMICAL TREATMENT TO CONTROL NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH

EQP 2790 (Rev. 02/06) AQ Page 2 of 3 

### SECTION IV. TREATMENT INFORMATION (Use product labels to determine amount of chemical to be used on each species.)

Applicants seeking a Certificate of Co verage may skip the table (see below).

NAME OF EACH COMMERCIAL PRODUCT
OR CHEMICAL REQUESTED LIQUID OR

GRANULAR TARGET PLANT(S) AND/OR ALGAE (Be Specific) DIMENSION IN FEET OR

AREA IN ACRES OF

TREATMENT AMOUNT OF EACH

CHEMICAL
REQUESTED APPROXIMATE DATE(S) OF

APPLICATION

L G

L G

L G

L G

L G

L G

L G

L G

L G

Certificate of Coverage applicants – request the option to use any of the chemicals approved under a General Permit. The waterbody must qualify under an existing General Permit for aquatic nuisance control activiti es. Each General Permit lists the approved chemicals, application rates, and permit conditions. Check box if appropriate.



### SECTION V. TREATMENT MAP

Provide a proposed treatment map for the waterbody to be tr eated on 8 1⁄2” x 11” paper. The map must show an accurate representation of the waterbody shape, and should include: (1) depth contours 1 ; (2) treatment area by chemical type; (3) known wetlands within or adjacent to the treatment area; (4) water level contro l structures; (5) inlets and outlets; and (6 ) private and public access sites and parks. The legend should include the lake name, county, waterbody size, proposed treatment area size, a scale in feet, a "North" directional arrow, and a key to the chemic al products used in the treated areas. The map must include all information and be of suffici ent quality to allow the Michigan Department of Environmental Quality (MDEQ) to evaluate the proposed treatm ent or the application may be returned.

1 Certain depth contour maps may be downloaded from http://www.michigan.gov/dnr . If a map is not available, the applicant should estimate the depth contours within the treatment area at 5-foot intervals.

Certificate of Coverage applicants – treatment map has previously been submitted in this applicant’s name, and no change from the previous treatment is pr oposed. Therefore, a new treatment map is not required for a Certificate of Coverage. Check box if appropriate.



### SECTION VI. SAFETY AND P UBLIC HEALTH INFORMATION 1. The residential drinking water supply with in the proposed treatment area is: Municipal Private Both

NOTE: Granular endothall and granular 2,4-D produc ts may not be applied within 75 feet of ANY well OR within 250 feet of wells less than 30 feet deep. Isolation distanc es are measured from the well location.

2. Does the lake or pond being treated have an outlet that flows any time during the year? Yes No If the answer is yes, please pr ovide the following information:

a. Is there a water level control structure? Yes No

If yes, indicate type of water level control structure (e.g., dam, high-water overfl ow):

b. What is the outlet flow? Intermittent ContinuousMICHIGAN DEPARTMENT OF ENVIRONMENTAL QUALIITY, WATER BUREAU
APPLICATION FOR PERMIT OR CERTIFICATE OF COVERAGE FOR CHEMICAL TREATMENT TO CONTROL NUISANCE AQUATIC PLANT AND/OR ALGAE GROWTH

EQP 2790 (Rev. 02/06) AQ Page 3 of 3 

### SECTION VII. RESPONSIBILITY FOR UNDERTAKING TREATMENT 1. Treatment by: Individual Property Owner Statutory Lake Board (PA 451 of 1994, as amended) Group of Individual Property Owners Township (PA 188 of 1954, as amended) Lake Association, Condo Association, Other:
Homeowners Associat ion, Other Association

If the primary contact person is not the applicant, please provide the followi ng contact information:

NAME OF PERSON RESPONSIBLE FOR ORGANIZING THE TREATMENT NAME OF ASSOCIATION, LAKE BOARD, TOWNSHIP BOARD, ORGANIZATION, ETC.

MAILING ADDRESS CITY STATE ZIP CODE TELEPHONE (DAYTIME) FACSIMILE

2. If applicant is not the property ow ner, attach a letter or contract dem onstrating authorization for treatment.

3. If more than one property is involved, pr ovide contact information for all property owners. For five or more properties, provide information for five property owner s with knowledge of the treatment. Note : Applicants who are commercial applicators with a current Emergency Notification Procedure (ENP ) on file with the MDEQ, or riparian property owners who have hired a commercial applicator with an ENP (pro vide copy of contract), may skip this item.

Name Address City State Zip Code Telephone
Number



### SECTION VIII. CERTIFICATION I certify that the information provided is, to the best of my knowledge, correct. It is understood that a permit, if granted, can be revoked by the MDEQ, as specified in R 323.3109 promulgated pursuant to Part 33 of Act 451 of 1994, as amended. If a permit is granted, I agree to use materials strictly in accordance with label and permit requirements, take full responsibility for plann ing and carrying out the permitted treatment, and agree to indemnify and save harmless the State of Michigan against any and all action s, claims, briefs, demands, damages, costs, loss, and expenses in any manner resulting from or arising out of the permitted treatm ent. I agree to submit the post-treatment data required. I HEREBY CERTIFY THAT THE PR OPERTIES TO BE TREATED ARE
EITHER UNDER MY LEGAL CONTROL AND/OR UNDER THE LEGAL CONTROL OF PARTIES WHO HAVE GRANTED ME PERMISSION TO APPLY PESTICIDES, OR I REPRESENT A UNIT OF GOVERNMENT WITH AUTHORITY TO APPLY
PESTICIDES. I ACCEPT RESPONSIBILITY FOR THE PERMIT THAT MAY BE ISSUED PURSUANT TO THIS APPLICATION
AND UNDERSTAND THAT VIOLATIONS ARE SUBJECT TO PENALTIES UNDER PART 33 OF ACT 451 OF 1994, AS AMENDED INCLUDING IMPRISONMENT AND FINES UP TO $25,000.

Prior to carrying out the permitted chemical treatment, I will have obtained written permission from all of the property owners within the treatment area, for the chemic al treatment of their bottomland property:

Yes (including property owner treating own property) No - check basis for authority: Statutory Lake Board Township/Special Assessment District

Applicant Signature: Date:

Name (print):