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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460

ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR 

DISCHARGES FROM THE APPLICATION OF PESTICIDES

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 submit 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 include 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 Decisionmaker first exceeds 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 year. 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 Termination 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 Corrective 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, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-5 for each Pest Management Area in which adverse 

incidents were 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 additional 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, and 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 rationale for such action(s), subsequent to those steps 

described in the Thirty (30)-Day Adverse Incident Written Report _________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________

/ /

/ /

/ /
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C. Pest Management Area(s) (use additional pages for each Pest Management Area)

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 discharge from pest control activities this 

year. Proceed to section D.

b. Yes. Proceed to question 2. 

2. Indicate the pesticide use pattern for the Pest Management Area: 

a. Mosquito and Other Flying Insect 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 application(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 Pesticide Discharge Monitoring Plan (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 Number(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 gallons
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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 gallons

D. 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 gathered and evaluated the information submitted. On the basis of my inquiry of the person or persons who manage the system, or 

those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am 

aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

Printed Name:

Title:

E-Mail:

Signature/Responsible Official: Date: / /

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

Preparer Name:

Organization:

Phone: – – Ext Date: / /

E-Mail: