UNITED STATES ENVIRONMENTAL PROTECTION AGENCY

WASHINGTON, DC 20460

PESTICIDE DISCHARGE EVALUATION WORKSHEET FOR THE 

PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE 

APPLICATION OF PESTICIDES

Form Approved

OMB No.

XXXX-XXXX

This worksheet is for any decision-maker required to submit a Notice of Intent (NOI) and a small entity, as defined in Appendix A of the Pesticide 

General Permit (PGP). The information on this worksheet must be retained for each pesticide application activity.

A. General Information

1. Operator Name:

2. Worksheet Preparer Name:

3. Pest Management Area: #__ of ## ____

4. Pest Management Area Name: ___________________________________________________________________________________________

5. Indicate the pesticide use pattern for the pest management area: 

a. Mosquito and Other Flying Insect Pests b. Weed and Algae Pests c. Animal Pests d. Forest Canopy Pests

6. 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: ____________________________________________

 ________________________________________________________________________________________________________________

B. Pest Evaluation

1. Identify the target pest(s) and explain why control is needed: ____________________________________________________________________

_________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________

2. Describe pest management measure(s) implemented before the first pesticide application: _____________________________________________

_________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

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

______________________________________________________________________________________________________________________

C. Pesticide Application 

1. Operator name(s) and contact information for pesticide applicator(s):

Operator Name:

Street:

City: State: Zip Code: -

Contact Name:

Phone: Ext

E-mail:
2. Pesticide application start date: / / Pesticide application end date: / /

3. Name of each pesticide product used, EPA registration number, and quantity of pesticide applied (as packaged or as formulated): Circle lbs or gallons.

Product Name Product Name Product Name

EPA Reg. No. EPA Reg. No. EPA Reg. No.

Quantity

(lbs or gallons)

Quantity

(lbs or gallons)

Quantity

(lbs or gallons)

 

Application method: _______________________ Application method: _______________________ Application method: _______________________

4. Visual monitoring was conducted during pesticide application and/or post-application? Yes. No. If no, describe why not? ________________

__________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

5. Any adverse effects identified during visual monitoring? Yes. No. If yes, describe. _______________________________________________

__________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

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 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 contained is, to the best of my knowledge 

and belief, true, accurate, and complete. I am aware that there are significant penalties for recording 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: / /

Pesticide Discharge Evaluation Worksheet Preparer (Complete if worksheet was prepared by someone other than the certifier)

Preparer Name: 

Organization:

Phone: – – Ext Date: / /

E-Mail: