U NITED S TATES E NVIRONMENTAL P ROTECTION A GENCY

W ASHINGTON

, DC 20460

P ESTICIDE D ISCHARGE E VALUATION W ORKSHEET FOR THE

P ESTICIDE G ENERAL P ERMIT (PGP) FOR D ISCHARGES FROM THE

A PPLICATION OF P ESTICIDES Form Approved

OMB No.

XXXX

- XXXX

This w orksheet is for any d ecision

- maker required to submit a Notice of Intent (NOI) and a small entity, as defined in Appendix A of the Pesticide

General Permit (PGP)

. Th e information on th is 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 p esticide use pattern for the pest management area:

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

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 descri ption:

________________________

________________________________ ________________________________ ________________________________ _______________

________________________________ ________________________________ ________________________________ ________________

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 th e 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 a pplication s tart d ate: / / Pesticide a pplication end d ate: / /

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)

Applica tion 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 acco rdance with a system

designed to assure that qualified personnel properly gather and evaluate the information submitted. On the bas is 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:

Sig nature/Responsible Official: Date: / /

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

Pre parer Name :

Organization:

Phone:

– – E xt Date: / /

E

- Mail: