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

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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: 

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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. 

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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: 

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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 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 

Pest 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 or contact the NOI Center toll 

free at 866-352-7755. 

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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