NOTE: Copy this page and attach additional pages as necessary 

### U NITED 

### S TATES 

### E NVIRONMENTAL 

### P ROTECTION 

### A GENCY



### W ASHINGTON



### , DC 20460

A NNUAL 

### R EPORTING 

### F ORM FOR THE 

### P ESTICIDE 

### G ENERAL 

### P ERMIT 

### (PGP) FOR



### D ISCHARGES FROM THE 

### A PPLICATION OF 

### P ESTICIDES Form Approved

OMB No.

XXXX

- XXXX

Decision

- makers who are required to submit an NOI and are defined as a large entity in Appendix A, or Decision

- makers who are required to submit an NOI for discharges

to Waters of the United States containing NMFS Listed Resources of Concern, as defined in Appendix A, must s ubmit an annual report to EPA each calendar year for the

duration of coverage under the PGP, whether or not the Decision

- maker has discharges from the application of pesticides in any subsequent calendar year. The annual

report must be submitted no later than February 15 of the following year for all pesticide activities covered under the PGP occurring during the previous calendar year.

Decision

- makers who are required to submit an NOI based on an annual treatment area threshold must i nclude information for the calendar year, with the first annual report

required to include activities for the portion of the calendar year after the point at which Decision

- makers exceeded the annual treatment area threshold. If the Decision

maker first e xceeds an annual treatment area threshold after December 1, an annual report is not required for that first partial year but an annual report is required

thereafter, with the first annual report submitted also including information from the first partial y ear. When Decision

- makers terminate permit coverage, as specified in Part

1.2.5, an annual report must be submitted for the portion of the year up through the date of termination. The annual report is due no later than February 15 of the next year.



### Electronic Submission Waiver

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 Notice of Termi nation form.

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

________________________________ ________________________________ ________________________________ ________________________________ _________



### A. General Information

1

. NPDES Permit Tracking Number :

2. Operator Name:

3

. Operator Contact Information :

a. Street :

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



### –

e. Telephone:



### – – ext f. Fax:



### – –

4. Contact Information :

a

. Contact Name :

b. Title:

c . E

- mail :



### B . Adverse Incidents and Correc tive Actions

1. Was an adverse incident observed and/or corrective actions taken for any Pest Management Area for which you have coverage under the PGP?

a. No adverse incidents were observed or corrective action was taken. (Proceed to question 6)

b. Yes, a n a dverse incident was observe d and/or a corrective action was taken. (Com plete questions 2

- 5 for each Pest Management Area in which adverse

inc idents we re observed or corrective actions were taken. Copy this section for non

- electronic submissions )

.

Pest Management Area #____ of ##____

2 . Pest Management Area Name:

________________________________ ________________________________ ________________________________ ___

3 . If applicable, enter any adverse incidents as a result of those treatment(s), as described in the PGP Part 6.4 (use additio nal pages, if needed):

a. Date of adverse incident observation :

4

. Date and time the Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, an d any instructions received from EPA

.

a. Date:

b. Time:

________________________________ ___________

c. Who the Operator spoke with at EPA

________________________________ _______________________

d. Instructions received from EPA

________________________________ ________________________________ ________________________________ _______

________________________________ ________________________________ ________________________________ ________________________________ __

5 . Date of submission of Thirty (30)

- Day Adverse Incident Written Report:

6 . Describe any corrective action(s), including spill responses, resulting from pesticide application activities and the ratio nale for such action(s) , subsequent to those steps

described in the Thirty (30)

- Day Adverse Incident Written Report

________________________________ ________________________________ _________________

________________________________ ________________________________ ________________________________ ________________________________ ____

________________________________ ________________________________ ________________________________ ________________________________ ____

________________________________ ________________________________ ________________________________ ________________________________ ____

________________________________ ________________________________ ________________________________ ________________________________ ____

________________________________ ________________________________ ________________________________ ________________________________ ____ / /

/ /

/ /NOTE: Copy this page and attach additional pages as necessary



### C

. Pest Management Area(s) (use addition al pages for each Pest Management A rea)

Pest Management Area # of ##

1. Have any discharges from pest control activities occurred in this calendar year?

a. No discharge from pest control activities this calendar year . Note: Checking this box completes Section C if you had no di scharge from pest control activities this

year. Proceed to section D.

b. Yes. Proceed to question 2.

2 . Indicate the p esticide use pattern for the P est M anagement A rea:

a. Mosquito and Other Flying Inse ct Pest Control b. Weed and Algae Pest Control c. Animal Pest Control d. Forest Canopy Pest

Control

3

. For each treatment area (use additional pages for each treatment area) :

a

. Provide a description of the treatment area within this Pest Management Area , including location description :

________________________________ _________

________________________________ ________________________________ ________________________________ ________________________________

________________________________ ________________________________ ________________________________ ________________________________

b

. Size of treatment area (in acres or linear feet): __

__ _ acres or ___

__ _ linear feet

.

c

. Name or location of any Waters of the United States to which discharges occurred:

________________________________ _____________________________

________________________________ ________________________________ ________________________________ ________________________________

d. Target Pest(s)

________________________________ ________________________________ ________________________________ _____________________

e. Identify pesticide application activities that resulted in a point source discharge to Waters of the United States containing NMFS Listed Resources of Concern:

Yes No

4

. Operator name(s) and contact information for pesticide applicat ion (s) (or check here if same as provided in Section A):

Operator Name:

Street:

City: State: Zip Code:

-

Contact Name : Title:

Phone: Ext

E

- mail:

5. Was this pest control activity addressed in your P esticide D ischarge M onitoring P lan (PDMP) before pesticide application : Yes No Not Applicable

6 . Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Registration N umber(s) and by application method

. Circle if quantity indicated is in lbs or gallons :

Product Name

__________________________

– Quantity Applied (lbs or gallons

of product ): Product Name

___________________________

– Quantity Applied (lbs or gallons

of product ):

Application method:

a. Aerially by fixed

- wing

b. Aerially by rotary aircraft

c. Land

- based sprayer (includes backpack, land

vehicle mounted sprayers, high pressure

canopy sprayer)

d

. Aquatic vehicle mounted sprayer

e

. Direct mixture (includes metering, subsurface

applications)

f

. Chemigation

g

. Other ( specify ) :

_________________ ______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons Application method:

a. Aerially by fixed

- wing

b. Aerially by rotary aircraft

c. Land

- based sprayer (includes backpack,

land vehicle mounted sprayers, high

pressure canopy sprayer)

d

. Aquatic vehicle mounted sprayer

e

. Direct mixture (includes metering,

subsurface applications)

f

. Chemigation

g

. Other ( specify ) :

_________________ ______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallonsNOTE: Copy this page and attach additional pages as necessary

Product Name

__________________________

– Quantity Applied (lbs or gallons

of product ): Product Name

___________________________

– Quantity Applied (lbs or gallons

of product ):

Application method:

a. Aerially by fixed

- wing

b. Aerially by rotary aircraft

c. Land based sprayer (includes backpack, land

vehicle mounted sprayers, high pressure

canopy sprayer)

d

. Aquatic vehicle mounted spra yer

e

. Direct mixture (includes metering, subsurface

applications)

f

. Chemigation

g

. Other ( specify ) :

_________________ ______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons Application method:

a. Aerially by fixed

- wing

b. Aerially by rotary aircraft

c. La nd based sprayer (includes backpack,

land vehicle mounted sprayers, high

pressure canopy sprayer)

d

. Aquatic vehicle mounted sprayer

e

. Direct mixture (includes metering,

subsurface applications)

f

. Chemigation

g

. Other ( specify ) :

_________________ ______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons

______ lbs or gallons



### D. Certification

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

that qualified personnel properly gathered and evaluated the information submitted. O n 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 a nd belief, true, accurate, and complete. I am

aware that t here are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowi ng violations.



### Printed Name:

Title:

E

- Mail:

Signature/Responsible Official: Date: / /



### Annual Report Preparer (Complete if the Annual Report was prepared by someone other than the certifier)

Preparer Name:

Organization:

Phone:

– – E xt Date: / /



### E

- Mail: