### U 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 ISCHARGE S FROM THE 

### A PPLICATION

OF 

### P ESTICIDES 

### Form Approved

OMB No.

XXXX

- XXXX

Submission of this completed N otice 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 Par t 1 of t he PGP; agrees to comply with all

applicable terms and conditions of the PGP; and understands that continued authorization under the PGP is contingent on maint aining eligibility for coverage.

T o be granted coverage, all information required on this form mu st 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.

________________________________ ________________________________ ________________________________ ______________

________________________________ ________________________________ ________________________________ ______________

A. Notice of Intent Status

M ark whether this is the first time you are requesting coverage under this General Permit or if this is a change of informatio n 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 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

. 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 P esticide D ischarge M onito ring P lan (PDMP) and submit 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. City: c. State: d. ZIP Code :



### –

e. Telephone:



### – – ext f. Fax:



### – –

g. Contact Name :

h. E

- mail :

### C. Operator Information: C omplete 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 for this use (attach map), or describe the location of the Pest Management Area in detail

.

________________________________ ________________________________ ________________________________ __________________________

________________________________ ________________________________ ________________________________ __________________________

________________________________ ________________________________ ________________________________ __________________________

________________________________ ________________________________ ________________________________ __________________________

2 . Are any of your activities for which you are requesting covera ge 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.

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

c. Coverage requested for all waters 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 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 h ealth a nd that

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

- term or temporary basis :

____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

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 water s 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.

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, evidenc e is attached documenting that the water s 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 cove rage 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 acti vities 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 fed erally

- 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 feder ally

- 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 , 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 the 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 containin g 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 Appendi x 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 c ontaining

NMFS Listed Resources of Concern , as defined in Appendi x 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 p roduct ( 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) ( i n MM/DD/YYYY f ormat) :

________________________________________________________ _______________

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.)

________________________________ ___________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

________________________________ ________________________________ ________________________________ _____________________

### 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 sub mitting false

information, including the possibility of fine and imprison ment 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)

Prepare r Name :

Organization:

Phone:

– – E xt Date: / /



### E

- Mail: