### United States Environmental Protection Agency 2011 NPDES Pesticides General Permit



# D-1 

# Appendix D

. Notice of Intent Form

### United States Environmental Protection Agency 2011 NPDES Pesticides General Permit



# D-2U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY
W ASHINGTON

, DC 20460

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

OF P ESTICIDES Form Approved

OMB No.

2040- 0284

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

to W a ters of the United States within t he 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. T o be granted coverage, all information required on this form must be completed. Please read and make sure you comply with all permit requireme nts, including the requirement for large entities to prepare a Pesticide Discharge Management Plan (PDMP) prior to NOI submittal . Refer to the instructions at the end of this form to complete your NOI.

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

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

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

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

A. Notice of Intent Status

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

already covered under th e Pesticide General Permit

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

a. Original NOI Submission

b

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

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

B. Operator Information

1. Operator Name:

2. IRS Employer Identification Number (EIN):

–

3. Operator Type (check one):

a. Federal g overnment

b. State g overnment

c. Local g overnment

d. M osquito control distr ict (or similar)

e. I rrigation control district (or similar)

f. W eed control district (or similar)

g

. O ther: If other, provide brief description of

t ype of operator :

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

Yes No

P l ease note: If you answer “Yes” to question 4 you are required to develop a P esticide D ischarge Management P lan (PDMP) and s ubmit an Annual Report reflecting all pesticide uses for which you are requesting permit coverage under this NOI

.

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

6. Mailing Address:

a. Street:

b . C ity: c. State: d. ZIP Code:

–

e. Telephone:

– – E xt f. Fax:

– –

g. Contact Name :

h. E- mail :

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

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

Pest Management Area #___ of ##___

1. Pest Management Area Name:

________________________________ ________________________________ ________________________________

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

.

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

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

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

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

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

facilities” as defined by the permit? Yes No

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

a. Street:

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

–

e

. Telephone: – – E xt f. Fax : – –

g. Contact Name :

h. E- mail :

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

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

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

6

. Receiving Waters (check one):

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

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

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

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

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

7

. Tier 3 Waters

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

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

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

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

- term or temporary basis :

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

8

. WaterQuality Impaired Waters

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

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

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

.

EPA FORM 6100-22 Page 2 of 8____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________

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

Pest Management Area #___ of ##___

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

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

a

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

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

.

b

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

NMFS Listed Resources of Concern

, as defined in Appendix A of the PGP

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

- related

activities on f ederally

- listed threatened or endangered species and federally

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

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

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

critical habitat; or

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

- related activities are not likely to adversely affect

federally

- listed species or federally

- designated critical habitat.

c

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

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

effects of th e pesticide discharges and discharge

- related activities on federally

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

d

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

Concern , as defined in Appendix A of the PGP

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

.

e

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

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

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

.

f

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

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

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

.

2

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

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

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

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

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

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

b. Pest(s) to be controlled:

____________________________________________________________________________________________________________________

c. ___________________________________________________

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

________________________________________________________________

d

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

_________________________________________________________

e. Number of planned discharges: ____________

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

_______________________________________________________________________________

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

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

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

Printed Name:

Title:

E- Mail:

Signature/Responsible Official: Date: / /

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

Preparer Name :

Organization:

Phone: – – E xt Date: / /

E- Mail:

EPA FORM 6100-22 Page 4 of 8

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

Who Must File a NOI with EPA ?

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

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

also Decision

- makers must submit NOIs.

Table 1

. Decision -M akers Required to Submit NOIs

PGP Part/

Pesticide Use Which Decision

- M akers Must

Submit NOIs? For Which Pesticide Application Activities?

All four use Any D ecision

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

identified in water (Outstanding National

Part 1.1.1 Resource Water) consistent with

Part 1.1.2.2

All four use Any Decision

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

identified in the United States containing United States containing NMFS

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

a s defined in Appendix A

1.1.1(a)

- Mosquito and Other Flying

Insect Pest

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

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

Decision

- maker is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

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

year

1.1.1(b)

- Weed and Algae Pest

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

Irrigation and weed control districts, or similar pest control

districts All activities resulting in a discharge for which the

Decision

- maker is resp onsible for pest control

Local governments or other

entities that exceed the annual

treatment area threshold

identified here Treatment during a calendar

year if more than either:

20 linear miles

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

1.1.1(c)

- Animal Pest

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

Local governments or other

entities that exceed the annual

treatment area threshold

identified here Treatment during a calendar

year if more than either:

20 linear miles

OR

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

1.1.1.(d)

- Forest Canopy

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

Local governments or other

entities that exceed the annual

treatment area threshold

identified here T reat ment if more than 6 ,400

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

.

W hen to File the NOI Form ?

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

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

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

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

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

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

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

Decision

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

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

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

coverage.

Table 2

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

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

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

Operator Type NOI Submission

Deadline Discharge Authorization

Date 2

Any Decision

- maker with any At least 30 days No earlier than 30 days discharge to Waters of the before any discharge after EPA posts on the United States containing NMFS to Waters of the Internet a receipt of a

Listed Resources of Concern, United States complete and accurate except for those discharges in containing NMFS NOI. 3 , 5 response to a Declared Pest Listed Resources of Emergency Situation, as Concern, as defined defined in Appendix A. in Appendix A

. 5

Any Decision

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

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

activities conducted in response to a Declared

Pes t Emergency

Situation.

Any Decision

- maker with any Within 15 days after Immediately upon discharge to Waters of the beginning to beginning to discharge for United States containing NMFS discharge in response activities conducted in Listed Resources of Concern, to a Declared Pest response to a Declared in response to a Declared Pest Emergency Situation. Pest Emergency Situation Emergency Situation, as for a period of at least 60 defined in Appendix A. 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 o r contact the NOI C enter toll

free at 866

- 352

- 7755.

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

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

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

- based and/or water quality

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

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

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

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

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

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

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

Table 3

. NOI Change of Information Submittal Deadlines and Discharge

Authorization Dates

Operator Type NOI Submission

Deadline Discharge Authorization

Date

Any Decision

- maker requiring permit coverage for a pest management

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

3 water , or (2) Waters of the United

State s containing NMFS

Listed Resources of

Concern

. Except for such
waters, c hanges other

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

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

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

Situation.

Any Decision

- maker

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

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

Listed Resources of

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

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

Situation. NOI Submission Discharge Authorization Operator Type Deadline Date

Any Decision

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

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

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

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

Where to File the NOI Form

The Decision

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

D ecision

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

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

. Decision

- makers

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

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

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

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

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

listed below.

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

Via overnight/express delivery: United States Environmental Protection Agency

Of

fice of Water, Water Permits Division EPA East Building

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

Phone: 202

- 564

- 9545

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

866

- 352

- 7755

.

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

. Do n ot s end

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

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

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

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

Completing the NOI Form

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

.

Section A. NOI Status

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

this is a change of information.

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

for these discharges

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

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

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

without submission of an NOI.

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

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

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

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

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

on the NOI.

Section B. Operator Information

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

entity that is the D ecision

- maker for the pesticides applications described in t his

notice . A D ecision

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

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

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

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

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

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

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

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

permit

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

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

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

6. Provide the Decision

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

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

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

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

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

. A

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

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

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

location of the pest management area in the space provided.

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

provide the name of the reservation, if applicable

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

Appendix A of the permit

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

this address is the same as the Decision

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

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

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

is required

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

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

area.

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

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

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

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

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

. If yes, write the name (s) of

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

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

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

information on d ischarges to Water Quality Impaired Waters

.

Section D. Endangered Species Protection

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

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

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

- related

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

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

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

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

. For a subset of listed species and

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

cover age under the perm it.

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

, you are required to provide a description of

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

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

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

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

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

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

authorized under c riterion b

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

Section E. Certification

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

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

(i) president, secretary, treasurer, or vice

- president of the corporation in charge of a

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

decision

- mak ing functions for the corporation, or

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

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

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

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

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

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

- mail address of the NOI preparer.

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

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

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

EPA FORM 6100-22 Page 8 of 8