Application No:_________ Date Received:__________ Special Permit Application- MOSQUITO/BLACK FLY NH Division of Pesticide Control PO Box 2042, Concord, NH 03302-2042 (603) 271-3550 3/08 OFFICE USE ONLY Referred to: Approve Disapprove Signature Date Dept. Environ. Services ______ ______ _______________ ______ Dept. Res. & Eco. Dev. ______ ______ _______________ ______ Fish & Game Department ______ ______ _______________ ______ Dept. of Agriculture ______ ______ _______________ ______ Div. of Public Health ______ ______ _______________ ______ Div. of Pesticide Cont. ______ ______ _______________ ______ Type of Application Type of Material Aerial _____ Insecticide _______________ Ground _____ Herbicide _________________ Other______________________ Total Acreage __________________ ______________________ COMPLETED BY APPLICANT 1. Name of applicant (individual, firm or agency):______________
_____________________________________________________________ Address: ____________________________________________________ City: __________________________ State: ____ Zip: ___________ Tel:_______________FAX:_______________License #:_____________ 2. Name and address of party requesting application of pesticides (private, public, cooperative, or other):
_____________________________________________________________ Address: ____________________________________________________ City: _________________________ State: ____ Zip: ____________ Tel:__________________________FAX:___________________________ 3. Have there been any previous pesticide applications made to this site under special permit? Yes ____ No _____. If yes, specify special permit number, and year of issue and site(s) treated:______________________________________________________
______________________________________________________________ 4. Reason or need for the proposed pesticide application: a. Establish why pesticides application or treatment is necessary (submit survey results and other factors pertaining to basis for treatment proposal):
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_____________________________________________________________ _____________________________________________________________ Permit App.: Mosquito - Page 1 of 5b. Who determined the need for pesticide treatment?

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_____________________________________________________________ _____________________________________________________________ 5. Description of Application: a. Target organism(s):____________________________________

______________________________________________________ ______________________________________________________ b. Application Method(s) (type of equipment, nozzles, etc.): (1) For Adulticide:____________________________________
______________________________________________________ ______________________________________________________ (2) For Larvicide:_____________________________________
______________________________________________________ ______________________________________________________ (3) Other:_____________________________________________
______________________________________________________ ______________________________________________________ c. Method of calibration and frequency for each type of application equipment (consult manufacturer and label of product as to specifications):______________________

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________________________________________________________ ________________________________________________________ d. On the lines provided below list the pesticide(s) to be used, the active ingredient of each one and each product’s EPA registration number [ATTACH COPY OF LABEL(s)] : Product Name Active Ingredient EPA Registration #
_________________ ________________ __________________ _________________ ________________ __________________ _________________ ________________ __________________ _________________ ________________ __________________ _________________ ________________ __________________ _________________ ________________ __________________ e. On the lines provided below list the pesticide(s) to be used, the rate of application and the total formulation amount to be applied: Product Name Rate of Application Formulation Amount
___________________ ___________________ ______________________ ___________________ ___________________ ______________________ ___________________ ___________________ ______________________ ___________________ ___________________ ______________________ ___________________ ___________________ ______________________ Permit App.: Mosquito - Page 2 of 5f. Number of applications with approximate date(s) of pesticide application(s):

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______________________________________________________________ ______________________________________________________________ g. Sequence of applications(s): (1) Number of application areas or blocks_______________ (2) Acreage of each_____________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________ (3) Total acreage_______________________________________ (4) Urban or rural applications_________________________ h. Environmental Consideration: (1) Explain any pesticide management techniques that will be incorporated into the pesticide management program specifically for environmental protection, such as mixing and filling sites, water resource protection, selection of pesticides that are considered low in persistence, etc:_______________________________________________________

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(2) If proposal entails the use of a pesticide with labeling that contains precautions related to environmental hazard, such as groundwater protection precautions, provide explanation justifying the use of these materials over those that are less hazardous to the environment:_______________________________________________

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___________________________________________________________ _____________________________________________________ 6. Map and description of treatment area: a. Submit detailed map(s) showing the treatment area and any public water supplies within 1000 feet of the treatment area. The map should be at a scale of at least 1 inch equals 2000 feet (1:24000) or at least 1 centimeter equals 240 meters (1:25000). United States Geological Survey Topographic Maps are preferred at scales of 1:24000 or 1:25000 and must show: Permit App.: Mosquito - Page 3 of 5(1) Proposed treatment area(s); (a) Adulticiding route(s); (b) Larviciding surface waters to be treated (2) Adjacent area(s); (3) Land type/vegetative cover; (4) Surface waters within and adjacent to subject area(s); (5) location of nearby public water wells; and (6) Topographic Features. b. Description of treatment area: (1) Location and description of area_________________________

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______________________________________________________________ ______________________________________________________________ (2) Specify all activities in the treatment area which might be affected by the pesticide application(s) including apiaries, cropping, ornamental nurseries, recreational areas, schools, etc._____________________________________

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______________________________________________________________ ______________________________________________________________ c. Location of survey site(s)_________________________________

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______________________________________________________________ ______________________________________________________________ 7. Name and location of any public water supply wells relative to the treatment area(s) [append if necessary]____________________
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_______________________________________________________________ _______________________________________________________________ 8. Are the owners of all areas to be treated in agreement to the proposed treatment? Yes____ or No_____ a. If not, explain:__________________________________________
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_____________________________________________________________ _____________________________________________________________ b. What mechanism will be employed to comply with those who do not want property treated?________________________________
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_____________________________________________________________ _____________________________________________________________ Permit App.: Mosquito - Page 4 of 5Permit App.: Mosquito - Page 5 of 5 9. I certify that all information presented is accurate and true; cancellation of this application and withdrawal of license (Registration, Permit) may result from any falsification of the information presented. Applicant Signature_________________________________________ Print Name:_________________________________________________ Title:______________________________________________________ Representing:_______________________________________________ Date:_______________________________________________________ 10. Town Official Signature_____________________________________ Print Name: ________________________________________________ Title:______________________________________________________ Date:_______________________________________________________ Because of possible adverse effects from repeated chemical pesticide applications, year after year, within public water supply watersheds, this agency recommends that you and your client pursue every means to include pesticide management practices that focus on water contamination prevention. It is highly recommended to incorporate and use methods to control future pesticide problems by methods other than chemical control into your pesticide management program. In general, we would not look favorably on annual or repeated chemical treatment in public water supply watersheds that do not consider pesticide management programs that demonstrate water contamination prevention methods. Enclosures: DETAILED MAPS - US Geological Survey - Current Map SUPPORT DATA - Further description as required LABEL(S) - Product(s) to be utilized NOTE: Application must be submitted with an original plus four (4) copies (5 sets total) of application, maps, labels and support information. (ALLOW 120 DAYS FOR PROCESSING)