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.

XXXX-XXXX

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 PGP; agrees to comply with all 

applicable terms and conditions of the PGP; and understands that continued authorization under the PGP 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. Refer to the instructions at the end of this form to complete your NOI.

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 NOI form.

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

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A. Notice of Intent Status

Mark whether this is the first time you are requesting coverage under this General Permit or if this is a change of information for a 

discharge already covered under this General Permit. If this is a change of information, supply the NPDES permit tracking number for the 

discharge.

1. Original NOI Submission

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

Please note: When Selecting # 2 please fill out Section B (Operator Name and Mailing Address) and the fields of the NOI that needs 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 PGP? (check one):

Yes No

Please note: If you answer “Yes” to question 4 you are required to develop a Pesticide Discharge Monitoring 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:
C. Operator Information: 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 for this use (attach map), or describe the location of the Pest Management Area in detail. 

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2. Are any of your activities for which you are requesting coverage under this NOI occur 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 occur on areas considered “federal facilities” 

as defined by the PGP? Yes No

4. Mailing address and contact information (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

b. Weed and Algae Pest Control

c. Animal Pest Control

d. Forest Canopy 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.

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

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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 1) and 2):

1) Name of Tier 3 water(s): ________________________________________________________________________________________________

2) 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: ____________________

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8. Water Quality Impaired Waters

Operators are not eligible for coverage under this permit for any discharges from a pesticide application to Waters of the United States if the waters are

identified as impaired by a substance which is either an active ingredient the pesticide designated for use or is a degradate of such an active ingredient. 

See Part 1.1.2.1 of the PGP.

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.
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 ##___

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 NMFS Listed 

Resources of Concern, as defined in Appendix A, for this permit.

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, but consultation with NMFS under section 7 of the ESA has been concluded for 

pesticide application activities covered under this permit. 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, 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, but only in response to a declared pest emergency situation.

E. 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. Eligible discharges include those from pesticide application activities performed 

consistent with appropriate measures to avoid or eliminate the likelihood of adverse effects as provided in writing from NMFS, and the Operator must 

provide EPA with the required relevant supporting information from NMFS.

F. 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. Eligible discharges include those from pesticide application activities that are 

demonstrated not likely to adversely affect federally-listed species or their designated critical habitat.

If you checked item F. above, list all NMFS Listed Resources of Concern identified within the area for which permit coverage is being requested:

1. Pest(s) to be controlled: ________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

2. Pesticide product(s) to be discharged: _____________________________________________________________________________

3. Planned quantity and rate of discharge(s) __________________________________________________________________________

4. Number of planned discharges: ____________

5. Approximate date(s) of planned discharge(s) (in MM/DD/YYYY format): 

_______________________________________________________________________

6. Your rationale supporting your determination that you meet Criterion F, including appropriate measures to be undertaken to avoid or eliminate 

the likelihood of adverse effects. (Attach additional pages as necessary.) ___________________________________________________

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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. I further certify that the applicant has sufficient title, 

right, or interest in the property where the proposed activity occurs.

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: