Appendix D - Forms

2397ss02_APP D (03122014).pdf

NPDES Pesticide General Permit for Point Source Discharges from the Application of Pesticides (New)

Appendix D - Forms

OMB: 2040-0284

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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.
2040-0284

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 permit; agrees to
comply with all applicable terms and conditions of the permit; and understands that continued authorization under the permit 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 (PDMP) prior to NOI submittal. Refer to the
instructions at the end of this form to complete your NOI.

Electronic Submission Waiver (skip if submitting through EPA’s eNOI system)
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
1. Mark whether this is the first time you are requesting coverage under the Pesticide General Permit or if this is a change of information for a discharge
already covered under the Pesticide General Permit. If this is a change of information, supply the NPDES permit tracking number for the discharge.
a.

Original NOI Submission

NOI Change of Information:

(NPDES Permit Tracking Number)

Please note: When selecting A.1.b please fill out Section B (Operator Name and Mailing Address) and the fields of the NOI that need to be modified.

B. Operator Information
1. Operator Name:
2. IRS Employer Identification Number (EIN):

–

3. Operator Type (check one):
a.

Federal government

State government

Local government

Mosquito control district (or similar)

Irrigation control district (or similar)

Weed control district (or similar)

Other: If other, provide brief description of
type of operator:

4. Are you a large entity as defined in Appendix A of the permit? (check one):
Yes

Please note: If you answer “Yes” to question 4 you are required to develop a Pesticide Discharge Management 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:
e. Telephone:

c. State:

–

Ext

f. Fax:

d. ZIP Code:

–

–
–

g. Contact Name:
h. E-mail:

EPA FORM 6100-22

Page 1 of 8

C. Pest Management Areas: 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 (attach map) or describe the location of the Pest Management Area in detail.
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Yes

2. Are any of your activities for which you are requesting coverage under this NOI occurring on Indian Country Lands?

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 occurring on areas considered “federal
facilities” as defined by the permit?
Yes
No
4. Mailing address and contact information of the pesticide applicator (or check here

if same as provided in Section B):

a. Street:
b. City:

c. State:

e. Telephone:

–

Ext

d. ZIP Code:
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

Animal Pest Control

Weed and Algae Pest Control

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.

Coverage requested specifically for the following Waters of the United States within the Pest Management Area identified above.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

Coverage requested for all Waters of the United States within the Pest Management Area identified above except for:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

7. Tier 3 Waters
Is coverage requested for discharge to a Tier 3 water (Outstanding National Resource Water) of the United States?
If yes, answer a and b:

Yes

a. Name of Tier 3 water(s): _______________________________________________________________________________________________
b. 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:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
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 of the pesticide designated for use or is a degradate of such an active
ingredient. See Part 1.1.2.1 of the permit. 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

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.

EPA FORM 6100-22

Page 2 of 8

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 ##___
1. Identify the criterion for which you are eligible for permit coverage as it applies to 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 National Marine
Fisheries Service (NMFS) Listed Resources of Concern, as defined in Appendix A, of the PGP.

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 of the PGP, but consultation with NMFS under Section 7 of the Endangered Species
Act (ESA) has been concluded for pesticide application activities covered under the PGP. 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.

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 of the PGP, 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).)

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 of the PGP, but only in response to a Declared Pest Emergency Situation.

Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more Waters of the United States
containing NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those where the Decision-maker
includes in the NOI written correspondence from NMFS that pesticide application activities performed consistent with appropriate measures will
avoid or eliminate the likelihood of adverse effects to NMFS Listed Resources of Concern.

Pesticide application activities for which permit coverage is being requested in the NOI will discharge to one or more Waters of the United States
containing NMFS Listed Resources of Concern, as defined in Appendix A of the PGP. Eligible discharges include those from pesticide application
activities that are demonstrated by the Decision-maker as not likely to adversely affect NMFA Listed Resources of Concern or that the pest poses a
greater threat to the NMFS Listed Resources of Concern than does the discharge of the pesticide.

2. If you checked criterion d or criterion f above, provide the following information for all discharges to Waters of the United States containing NMFS Listed
Resources of Concern identified within the pest management area for which permit coverage is being requested. For discharges pursuant to criterion d,
Declared Pest Emergency Situations, information for items a through g should also include any discharges that have already occurred prior to NOI
submission as well as the activities you performed in the 15 day period before submission of this NOI was required. In some cases, implementation of
pest management measures as specified in the permit involves a degree of “adaptive management” such that exact timing and quantities of applications
cannot be determined in advance for the duration of the permit. In such cases, the permittee must provide the required information to the extent feasible
and consistent with the implementation of the selected pest management measures.
a.

Describe the location of the pest management area in detail or provide a map of the location:

Pest(s) to be controlled:

____________________________________________________________________________________________________________________

Pesticide product(s) to be discharged and method of application: ________________________________________________________________

Planned quantity and rate of discharge(s) for each method of application: _________________________________________________________

Number of planned discharges: ____________

Approximate date(s) of planned discharge(s): _______________________________________________________________________________

Your rationale supporting your determination that you meet the criterion for which you are submitting this NOI, including appropriate measures to be
undertaken to avoid or eliminate the likelihood of adverse effects. For certifications pursuant to Criterion D, indicate whether the discharge is likely to
adversely affect NMFS Listed Resources of Concern and, if so, any feasible measures to avoid or eliminate such adverse effects (attach additional
pages as necessary):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-22

Page 3 of 8

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.
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

E-Mail:

EPA FORM 6100-22

Page 4 of 8

Instructions for Completing the Notice of Intent (NOI) for Coverage Under the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides
Who Must File a NOI with EPA?
Any Operator, as described in the Part 1.2.2 of the permit and meeting the eligibility
requirements identified in Part 1.1 of the permit and Table 1 below must submit a
complete and accurate NOI. As required in the permit, only certain Operators that are
also Decision-makers must submit NOIs.
Table 1. Decision-Makers Required to Submit NOIs
PGP Part/
Pesticide Use

Which Decision-Makers Must
Submit NOIs?

All four use
patterns
identified in
Part 1.1.1

Any Decision-maker with an
Activities resulting in a
eligible discharge to a Tier 3
discharge to a Tier 3 water
water (Outstanding National
Resource Water) consistent with
Part 1.1.2.2

All four use
patterns
identified in
Part 1.1.1

Any Decision-maker with an
eligible discharge to Waters of
the United States containing
NMFS Listed Resources of
Concern, as defined in
Appendix A

Activities resulting in a
discharge to Waters of the
United States containing NMFS
Listed Resources of Concern,
as defined in Appendix A

1.1.1(a) Mosquito and
Other Flying
Insect Pest
Control

Any Agency for which pest
management for land resource
stewardship is an integral part of
the organization’s operations.

All activities resulting in a
discharge for which the Federal
or State agency is responsible
for pest control

Mosquito control districts, or
similar pest control districts

All activities resulting in a
discharge for which the
Decision-maker is responsible
for pest control

Local governments or other
entities that exceed the annual
treatment area threshold
identified here

Adulticide treatment if more than
6,400 acres during a calendar
year

Any Agency for which pest
management for land resource
stewardship is an integral part of
the organization’s operations.

All activities resulting in a
discharge for which the Federal
or State agency is responsible
for pest control

Irrigation and weed control
districts, or similar pest control
districts

All activities resulting in a
discharge for which the
Decision-maker is responsible
for pest control

Local governments or other
entities that exceed the annual
treatment area threshold
identified here

Treatment during a calendar
year if more than either:
20 linear miles
OR
80 acres of water (i.e., surface
area)

Any Agency for which pest
management for land resource
stewardship is an integral part of
the organization’s operations.

All activities resulting in a
discharge for which the Federal
or State agency is responsible
for pest control

Local governments or other
entities that exceed the annual
treatment area threshold
identified here

Treatment during a calendar
year if more than either:
20 linear miles
OR
80 acres of water (i.e., surface
area)

1.1.1(b) Weed and
Algae Pest
Control

1.1.1(c) Animal Pest
Control

Any Agency for which pest
1.1.1.(d) Forest Canopy management for land resource
stewardship is an integral part of
Pest Control
the organization’s operations.
Local governments or other
entities that exceed the annual
treatment area threshold
identified here

For Which Pesticide
Application Activities?

All activities resulting in a
discharge for which the Federal
or State agency is responsible
for pest control
Treatment if more than 6,400
acres during a calendar year

If you have questions about whether you need to file an NOI or questions about
completing the form, see www.epa.gov/npdes/pesticides or contact the NOI Center toll
free at 866-352-7755.
EPA FORM 6100-22

One NOI can be submitted for multiple pest management areas in a state for which
you are seeking permit coverage; however, no more than one state can be included on
any single NOI form.
When to File the NOI Form?
Do not file your NOI until you have obtained and thoroughly read a copy of the permit.
A copy of the permit is on EPA’s website (www.epa.gov/npdes/pesticides).The permit
describes procedures to ensure your eligibility, prepare your Pesticide Discharge
Management Plan (PDMP), and complete the NOI form questions—all of which must
be done before you sign the NOI certification statement attesting to the accuracy and
completeness of your NOI. You will also need a copy of the permit once you have
obtained coverage so that you can comply with the implementation requirements of
the permit. Note: PDMP is not required for 1) any application made in response to a
Declared Pest Emergency Situation, as defined in Appendix A of the permit; and 2)
any Decision-maker that is required to submit an NOI solely because their application
results in a point source discharge to Waters of the United States containing NMFS
Listed Resources of Concern, as defined in Appendix A of the permit.
All eligible discharges are authorized for permit coverage through January 12,
2012 without submission of an NOI. For any discharges after January 12, 2012,
Decision-makers meeting the eligibility requirements identified in the Part 1.1of the
permit and Table 1 must submit a complete and accurate NOI according to Tables 2,
and 3 and consistent with the requirements of the Part 1.2 of the permit. For example,
for discharges occurring on or before January 12, 2012 but continuing after January
12, 2012, NOIs are due no later than January 3, 2012 to ensure uninterrupted
coverage.
Table 2. NOI Submittal Deadlines and Discharge Authorization Dates for
Discharges from the Application of Pesticides 1
After January 12, 2012, any eligible discharge for which an NOI is required must
submit an NOI consistent with the earliest due date identified below. If EPA receives
an NOI on or before January 2, 2012 (or on or before December 12, 2011, for
discharges to Waters of the United States containing NMFS Listed Resources of
Concern), uninterrupted coverage continues.2 NOI due dates for any discharges
occurring on or after January 12, 2012 are as follows:
Operator Type
NOI Submission
Discharge Authorization
Deadline
Date2
Any Decision-maker with any
discharge to Waters of the
United States containing NMFS
Listed Resources of Concern,
except for those discharges in
response to a Declared Pest
Emergency Situation, as
defined in Appendix A.

At least 30 days
before any discharge
to Waters of the
United States
containing NMFS
Listed Resources of
Concern, as defined
in Appendix A.5

No earlier than 30 days
after EPA posts on the
Internet a receipt of a
complete and accurate
NOI.3, 5

Any Decision-maker with a
At least 30 days after
discharge in response to a
beginning discharge.
Declared Pest Emergency for
which that activity triggers the
NOI requirement identified in
Part 1.2.2, except for any
discharges to Waters of the
United States containing NMFS
Listed Resources of Concern.

Immediately upon
beginning to discharge for
activities conducted in
response to a Declared
Pest Emergency
Situation.

Any Decision-maker with any
discharge to Waters of the
United States containing NMFS
Listed Resources of Concern,
in response to a Declared Pest
Emergency Situation, as
defined in Appendix A.

Within 15 days after
beginning to
discharge in response
to a Declared Pest
Emergency Situation.

Immediately upon
beginning to discharge for
activities conducted in
response to a Declared
Pest Emergency Situation
for a period of at least 60
days.4

Any Decision-maker that
exceeds any annual treatment
area threshold.

At least 10 days
before exceeding an
annual treatment area
threshold.

No earlier than 10 days
after EPA posts on the
Internet receipt of a
complete and accurate
NOI.

Any Decision-maker otherwise
required to submit an NOI as
identified in Table 1

At least 10 days
before any discharge
for which an NOI is
required

No earlier than 10 days
after EPA posts on the
Internet receipt of a
complete and accurate
NOI.
Page 5 of 8

1
2

State, territory and tribal specific requirements in addition to the requirements in this
table are provided in Part 9.0.
On the basis of a review of an NOI or other information, EPA may delay
authorization to discharge beyond any timeframe identified in Table 2, determine
that additional technology-based and/or water quality-based effluent limitations or
other conditions are necessary, or deny coverage under this permit and require
submission of an application for an individual NPDES permit, as detailed in Part 1.3
of the permit.
Within 30 days after EPA posts on the Internet receipt of a complete and accurate
NOI, for those areas with NMFS Listed Resources of Concern, as defined in
Appendix A of the permit, NMFS will provide EPA with a determination as to
whether it believes the eligibility criterion of “not likely to adversely affect listed
species or designated critical habitat” has been met, could be met with conditions
that NMFS identifies, or has not been met. EPA expects to rely on NMFS’
determination in deciding whether to withhold authorization. If NMFS does not
provide EPA with this information within 30 days of EPA posting on the Internet
receipt of a complete and accurate NOI, the discharges will be authorized 30 days
after EPA posts on the Internet receipt of a complete NOI.
In any Declared Pest Emergency Situation in areas with Waters of the United
States containing NMFS Listed Resources of Concern, NMFS will have 30 days
after submission of an NOI to provide EPA with a determination as to whether the
eligibility criteria of “not likely to adversely affect listed species or designated critical
habitat” has been met, could be met with conditions that NMFS identifies, or has
not been met. EPA expects to rely on NMFS’ determination in deciding whether to
allow continued permit coverage and if additional conditions are necessary. If
NMFS does not provide EPA with a recommendation within 30 days of EPA posting
on the Internet receipt of a complete and accurate NOI, authorization for these
discharges will continue. If EPA identifies additional permit conditions, or includes
additional permit conditions recommended by NMFS, as necessary to qualify
discharges as eligible for coverage beyond 60 days under the PGP, those
conditions remain in effect for the life of the permit.
EPA may authorize certain discharges in less than 30 days, but no fewer than 10
days, for any discharges authorized under Criterion B, C, or E of Part 1.1.2.4 (for
which NMFS has already evaluated the effects of these discharges).

Table 3. NOI Change of Information Submittal Deadlines and Discharge
Authorization Dates
NOI Submission
Deadline

Discharge Authorization
Date

Any Decision-maker
requiring permit coverage
for a pest management
area not identified on a
previously submitted NOI
for this permit, except for
discharges to any; (1) Tier
3 water, or
(2) Waters of the United
States containing NMFS
Listed Resources of
Concern. Except for such
waters, changes other
than identification of a new
pest management area or
a new pesticide use
pattern do not require a
revised NOI submittal.

At least 10 days before
beginning to discharge in
that newly identified area
unless discharges are in
response to a Declared
Pest Emergency Situation
in which case not later
than 30 days after
beginning discharge.

No earlier than 10 days
after EPA posts on the
Internet the receipt of a
complete and accurate
NOI unless discharges are
in response to a Declared
Pest Emergency Situation
in which case coverage is
available immediately
upon beginning to
discharge from activities
conducted in response to
Declared Pest Emergency
Situation.

Any Decision-maker
discharging to a Tier3
water not identified by
name on a previously
submitted NOI for this
permit, except for Tier 3
waters containing NMFS
Listed Resources of
Concern

Operator Type

EPA FORM 6100-22

Operator Type
Any Decision-maker with
any discharge to Waters of
the United States
containing NMFS Listed
Resources of Concern, as
defined in Appendix A, not
identified on a previously
submitted NOI for this
permit. This includes
changes in any treatment
area, pesticide product,
method or rate of
application, or
approximate dates of
applications.

NOI Submission
Deadline

Discharge Authorization
Date

At least 30 days before
beginning to discharge in
that newly identified
treatment area unless
discharges are in
response to a Declared
Pest Emergency Situation
in which case not later
than 15 days after
beginning discharge.

No earlier than 30 days
after EPA posts on the
Internet receipt of a
complete and accurate
NOI unless discharges are
in response to a Declared
Pest Emergency Situation
in which case coverage is
available immediately
upon beginning to
discharge from activities
conducted in response to
Declared Pest Emergency
Situation.

Where to File the NOI Form
The Decision-maker must prepare and submit the NOI using EPA’s electronic Notice
of Intent system (eNOI) available on EPA’s website
(www.epa.gov/npdes/pesticides/enoi) unless eNOI is otherwise unavailable or the
Decision-maker has filed a waiver from the requirement to use eNOI for submission of
the NOI. The Electronic Submission Waiver is at the top of this form. Decision-makers
waived from the requirement to use eNOI for NOI submission must certify to EPA on
this form that use of eNOI will incur undue burden or expense over the use of the
paper NOI form and then provide a basis for that determination.
EPA will immediately post on the pesticides eNOI Website all NOIs received. Late
NOIs will be accepted, but authorization to discharge will not be retroactive.
If you file a waiver from using eNOI; you must send the NOI to one of the addresses
listed below.
Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you have questions, contact EPA’s Pesticides Notice Processing Center toll free at
866-352-7755.
• If you file a paper NOI, submit the original with a signature in ink. Do not send
copies. Also, faxed copies will not be accepted.
• If you are required to develop a PDMP, that document does not need to be
submitted for review unless specifically requested by EPA. You must keep a
copy of your PDMP on-site or otherwise make it available to facility personnel
responsible for implementing provisions of the permit.
Completing the NOI Form
To complete this form, type or print in uppercase letters in the appropriate areas only.
Please make sure you complete all questions. Make sure you make a photocopy for
your records before you send the completed original form to the address above. You
may also use this paper form as a checklist for the information you will need when
filing an NOI electronically via EPA’s Pesticides eNOI System.
Section A. NOI Status
1. Indicate if this is the first time you are requesting coverage under the permit or if
this is a change of information.
a. Check this box if this is the first time you are requesting coverage under the permit
for these discharges. If this is the first time you are requesting coverage, refer to
Table 2 for NOI submittal deadlines and discharge authorization dates. Note: All
eligible discharges are authorized for permit coverage through January 12, 2012
without submission of an NOI.
Page 6 of 8

b. Check this box if this is a change of information for a discharge already covered
under the permit. If this is a change of information, supply the NPDES permit
tracking number that you received in your confirmation letter or e-mail from EPA’s
Pesticide Notice Processing Center. You can find the tracking number assigned to
your previous NOI using EPA’s eNOI System
(www.epa.gov/npdes/pesticides/enoi). For additional details regarding a change of
information, see Table 3. Also fill out Section B of this form (Operator Name and
Mailing Address) and the associated fields of information that need to be modified
on the NOI.
Section B. Operator Information
1. Provide the legal name of the person, firm, public organization or any other public
entity that is the Decision-maker for the pesticides applications described in this
notice. A Decision-maker is an Operator who has control over the decision to
perform pesticide applications including the ability to modify those decisions that
result in a discharge to Waters of the United States.
2. Provide the Employer Identification Number (EIN from the Internal Revenue Service
(IRS)), commonly referred to as your tax payer ID number. If the operator does not
have an EIN, enter “N/A” in the space provided.
3. Indicate the type of Operator: federal government, state government, local
government, mosquito control district (or similar), irrigation control district (or
similar), weed control district (or similar), or other. If other, provide brief description
of type of Operator in the space provided.
4. Indicate whether or not you are a “large entity” as defined in Appendix A of the
permit. Note that if you are a large entity, you are required to develop a Pesticide
Discharge Management Plan (PDMP) and submit future Annual Reports reflecting
all pesticide uses for which you are requesting permit coverage under this NOI.
5. Indicate which state your pest management areas are located. Specify only one
state per NOI. If there is more than one state, additional NOIs must be submitted.
6. Provide the Decision-maker’s mailing address, telephone number, fax number
(optional), name, and e-mail address. Correspondence will be sent to this address.
Section C. Pest Management Area: Information for each Pest Management Area
for which coverage under EPA’s Pesticide General Permit is desired.
1. Indicate whether you are submitting an NOI for multiple pest management areas. A
pest management area is the area of land, including any water, for which you have
responsibility and are authorized to conduct pest management activities as covered
by this permit (e.g., if you are a mosquito control district, your pest management
area is the total area of the district). You must complete a Section C for each pest
management area. If you are submitting an NOI for only one area, enter “1” of “1.” If
you are submitting NOIs for multiple pest management areas, enter the number for
the NOI for which you are requesting coverage followed by the total number of pest
management areas for which you are requesting coverage. Enter the name of the
pest management area. Attach a map of the pest management area or describe the
location of the pest management area in the space provided.
2. Indicate whether pesticide application will occur on Indian County Lands, and if so,
provide the name of the reservation, if applicable.
3. Indicate whether pesticide application will occur on a Federal Facility, as defined in
Appendix A of the permit.
4. Enter the mailing address of the contact person for the pest management area. If
this address is the same as the Decision-maker’s mailing address, indicate that by
checking the box. If it is a different address, enter the mailing address, telephone
number, fax number (optional), contact name, and e-mail address.
5. Indicate the pesticide use patterns for the pest management area for which the NOI
is required. For additional information regarding pesticide use patterns, see Part
1.1.1 of the permit. Check all the use patterns that apply to the pest management
area.
6. Indicate if permit coverage is being requested for all Waters of the United States
within the pest management area or if permit coverage is being requested to
specific Waters of the United States within the pest management area. If specific
waters are being requested, write the names of the waterbodies. If permit coverage
is being requested for all waters of the United States within the pest management
area except for specific waterbodies, name those specific waterbodies in the space
provided. EPA’s Water Locator Tool can help you identify the closest receiving
water to your facility (http://cfpub.epa.gov/npdes/stormwater/tmdltool.cfm).
7. Indicate if permit coverage is being requested to discharge to a Tier 3 (Outstanding
National Resource Water) Water of the United States. If yes, write the name(s) of
the Tier 3 water(s) in the space provided. Describe and demonstrate why it is
necessary to apply the pesticide discharge to protect the water quality,
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.

EPA FORM 6100-22

8. Verify that waters within the pest management area are either not impaired by
substances which are either active ingredients in the pesticide planned for use or
degradates of such active ingredients, OR that evidence shows that the target
waters in question are no longer impaired. See Part 1.1.2.1 of the permit for more
information on discharges to Water Quality Impaired Waters.
Section D. Endangered Species Protection. Complete Section D for each Pest
Management Area for which coverage under EPA’s PGP is desired.
Identify the Pest Management Areas, corresponding to those in Part C.
1. Coverage under the permit is available only for discharges and discharge-related
activities, as defined in Appendix A of the permit, that are not likely to jeopardize
the continued existence of any species that are federally- listed as endangered or
threatened (“listed”) under the Endangered Species Act (ESA) and not likely to
result in the adverse modification or destruction of habitat that is federallydesignated as critical under the ESA (“critical habitat”) except as provided in
criterion b, c, and for at least 60 days, d, below. For a subset of listed species and
critical habitat, identified as NMFS Listed Resources of Concern and defined in
Appendix A, there are specific criteria for determining eligibility. To demonstrate
eligibility, you must meet one or more of the six criteria (a-f) for the entire term of
coverage under the permit.
2. If you checked criterion d or criterion f, you are required to provide a description of
the location of the pest management area or a map of the location, the pest(s) to be
controlled, pesticide product(s) to be discharged and method of application,
planned quantity and rate of discharge(s) for each application method, number of
planned discharges, approximate date(s) of planned discharge(s), and the rational
supporting your determination that you meet the criterion for which the Decisionmaker is submitting this NOI and documentation demonstrating the finding of “not
likely to adversely affect.” If you certify under criteria f and do not hear from EPA
within 30 days, you may assume your discharge is authorized. For certifications
pursuant to Criterion d, indicate whether the discharge is likely to adversely affect
NMFS Listed Resources of Concern and, if so, any feasible measures to avoid or
eliminate such adverse effects. If you are certifying under criterion d (which allows
you to discharge 15 days before you even submit your NOI), your NOI should
describe both the pest emergency activities you plan to do after you submit your
NOI as well as the activities you performed in that 15 day period before you had to
submit the NOI. See Part 1.1.2.4 of the permit for more information regarding
Endangered and Threatened Species and Critical Habitat Protection. If you certify
under criterion d and do not hear from EPA, you may assume that permit
authorization continues unless notified otherwise.EPA may authorize certain
discharges in less than 30 days, but no fewer than 10 days, for any discharges
authorized under criterion b, c, or e (for which NMFS has already evaluated the
effects of these discharges). If you certify under one of these criteria and do not
hear from EPA within 30 days, you may assume your discharge is authorized.
Section E. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, means:
(i) president, secretary, treasurer, or vice-president of the corporation in charge of a
principal business function, or any other person who performs similar policy or
decision-making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management decisions that govern the
operation of the regulated activity including having the explicit or implicit duty of
making major capital investment recommendations, and initiating and directing
other comprehensive measures to assure long-term environmental compliance with
environmental laws and regulations; the manager can ensure that the necessary
systems are established or actions taken to gather complete and accurate
information for permit application requirements; and where authority to sign
documents has been assigned or delegated to the manager in accordance with
corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, federal, or other public facility: by either a principal executive or
ranking elected official.
If the NOI was prepared by someone other than the certifier (for example, if the NOI
was prepared by the PDMP contact or a consultant for the certifier’s signature), include
the name, organization, phone number and e-mail address of the NOI preparer.

Page 7 of 8

Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 2.5 hours or 150 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the Director,
Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200
Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in
any correspondence. Do not send the completed NOI form to that address.

EPA FORM 6100-22

Page 8 of 8

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT
(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES

Form Approved
OMB No.
2040-0284

Electronic Submission Waiver (skip if using eNOI)

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 Notice of Termination form.
Briefly describe the reason why use of the electronic system causes undue burden or expense.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
A. Permit Information

1. NPDES Permit Tracking Number:
2. Reason for termination (check one only):
a. You have ceased all discharges from the application of pesticides for which you obtained permit coverage and you do not expect
to discharge during the remainder of the permit term.
b. You have obtained permit coverage under an NPDES individual permit or alternative NPDES general permit for all pesticide
discharges requiring NPDES permit coverage.
c. A new Operator has taken over decision-making responsibility for the pest
control activities covered under an existing NOI. Provide the transfer date and
the new Operator information.

Date of transfer:

New Operator Name:
Street:
City:

State:
Telephone:

ZIP Code:
–

–
–

ext

E-mail:
B. Operator Information

1. Operator Name:
2. IRS Employer Identification Number (EIN):

–

3. Mailing Address:
Street:
City:

State:
Telephone:

ZIP Code:
–

–
–

ext

4. Contact Name:
E-mail:

EPA FORM 6100-23

Page 1 of 3

C. Certification
I certify under penalty of law that I have met at least one of the reasons for terminating permit coverage listed in Section A above. I understand that by
submitting this Notice of Termination, I am no longer authorized to discharge pesticides to waters of the United States. This document and all
attachments were prepared under my direction and supervision in accordance with a system designed to ensure 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 or imprisonment. Additionally, I understand
that the submittal of this Notice of Termination does not release a pesticide Operator from liability for any violations of the Clean Water Act.

Printed Name:
Title:
E-Mail:
Signature/Responsible Official:

Date:

NOT Preparer (Complete if NOT was prepared by someone other than the certifier)

Preparer Name:
Organization:
Phone:

–

Ext

E-Mail:

EPA FORM 6100-23

Page 2 of 3

INSTRUCTIONS FOR COMPLETING THE NOTICE OF TERMINATION (NOT) OF COVERAGE UNDER THE PESTICIDE GENERAL PERMIT (PGP) FOR

DISCHARGES FROM THE APPLICATION OF PESTICIDES

Who Must File an NOT Form with EPA?
Any Operator required to submit a Notice of Intent (NOI) is required to submit a
Notice of Termination (NOT) to end coverage under this permit. However, if EPA
notifies the Operator to apply for an NPDES individual permit or alternative general
permit, coverage under this permit terminates automatically. Dischargers
automatically covered under this permit as identified in Part 1.2.3 of the permit are
likewise automatically terminated upon permanent cessation of discharge consistent
with any of the criteria identified in Part 1.2.5.3 of the permit. As required in the
permit, only certain Operators that are also Decision-makers must submit NOIs.

c. Select this box if a new Operator has taken over decision-making
responsibility of pest control activities covered under an existing NOI and you
are no longer the Operator. Provide the date of transfer and the name and
contact information of the new Operator.
Section B. Operator Information
1. Provide the full legal name of the person, firm, public organization, or other entity
that is the Operator who is the Decision-maker for the pesticide application
described in this application.

If you have questions about whether you need to file an NOT or questions about
completing the form, see www.epa.gov/npdes/pesticides or contact the NOI Center
toll free at 866-352-7755.

2. Provide the Operator’s IRS Employer Identification Number.

When to File the NOT Form?
Operators must file the NOT form within 30 days after one or more of the conditions
in Part 1.2.5.2 of the permit have been met.

4. Provide a contact person’s full legal name and e-mail address. This person will
be contacted regarding any NOT communication.

Where to File the NOT Form?
Consistent with Part 1.2.5.1 of the permit, the Operator must submit the NOT using
EPA’s electronic Notice of Intent (eNOI) System available on EPA’s website
(www.epa.gov/npdes/pesticides/enoi) unless eNOI is otherwise unavailable or the
Operator files a waiver from the requirement to use eNOI for submission of the
NOT. The Electronic Submission Waiver is at the top of this NOT form. An Operator
waived from the requirement to use eNOI for any NOT submission must certify to
EPA on this form that use of eNOI will incur undue burden or expense over the use
of the paper NOT form and then provide a basis for that determination.
Filing electronically is the fastest way to terminate permit coverage and help ensure
that your NOT is complete.
If you do file a waiver from using eNOI; you must send the NOT to one of the
addresses listed below.
Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460
Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545
If you file a paper NOT, submit the original form with a signature in ink. Do not
send copies. Also, faxed copies will not be accepted.
Completing the NOI Form
To complete this form, type or print in uppercase letters in the appropriate areas
only. Make sure you complete all questions. Make sure you make a photocopy for
your records before you send the completed original form to the address above. You
can also use this paper form as a checklist for the information you will need when
filing an NOT electronically via EPA’s Pesticides eNOI system.
Section A. Permit Information
1. Enter the existing NPDES Permit Tracking Number assigned by eNOI or the EPA’s
Pesticides Processing Center. You can find the tracking number assigned to your
previous NOI using EPA’s eNOI System (www.epa.gov/npdes/pesticides/enoi).

3. Provide the Operator’s mailing address and telephone number. Correspondence
will be sent to this address.

Section C. Certification
Carefully read the certification statement. By completing and submitting the NOT,
the Operator certifies that every applicable general permit requirement will be met.
Provide the printed full legal name, title and email address of the certifier. Sign and
date the form. (CAUTION: An unsigned or undated NOT form will prevent the
termination of permit coverage.) Federal statutes provide for severe penalties for
submitting false information on this application form. Federal regulations require this
application to be signed as follows:
For a corporation: by a responsible corporate officer, which means:
(i) president, secretary, treasurer, or vice president of the corporation in charge
of a principal business function, or any other person who performs similar policy
or decision-making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management decisions that govern
the operation of the regulated activity including having the explicit or implicit duty
of making major capital investment recommendations, and initiating and directing
other comprehensive measures to assure long-term environmental compliance
with environmental laws and regulations; the manager can ensure that the
necessary systems are established or actions taken to gather complete and
accurate information for permit application requirements; and where authority to
sign documents has been assigned or delegated to the manager in accordance
with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, federal, or other public facility: by either a principal executive
or ranking elected official.
If the NOT was prepared by someone other than the certifier (for example, if the
NOT was prepared by the PDMP contact or a consultant for the certifier’s
signature), include the name, organization, phone number and e-mail address of the
NOT preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 0.5 hours or 30 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed NOT form to that
address.

2. Select the appropriate box to indicate why you are submitting an NOT to end
permit coverage. Select one of the three termination options:
a. Select this box if you have ceased all discharges from the application of
pesticides for which you obtained permit coverage and you do not expect to
discharge during the remainder of the permit term.
b. Select this box if you have obtained NPDES individual permit coverage or
alternative NPDES permit coverage.

EPA FORM 6100-23

Page 3 of 3

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.
2040-0284

This worksheet is for any Operator who is also a Decision-maker required to submit a Notice of Intent (NOI) and is 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:
Mosquito and Other Flying Insect Pests

Weed and Algae Pests

Animal Pests

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 pest control is needed:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Describe Pest Management Measure(s) implemented before the first pesticide application:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
C. Pesticide Application
1. Name and contact information for pesticide applicator(s):
Company Name:
Street:
City:

State:

Zip Code:

Contact Name:
Phone:

–

Ext

E-mail:

EPA FORM 6100-26

Page 1 of 3

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

EPA Reg. No.

Quantity
(lbs or gallons)

Application
method:

____________________________

___________________________

4. Visual monitoring was conducted during pesticide application and/or post-application?

Yes.

___________________________

No. If no, describe why not?

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.
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:

EPA FORM 6100-26

Page 2 of 3

Instructions for Completing the Pesticide Discharge Evaluation Worksheet (PDEW) for the PESTICIDE GENERAL PERMIT
(PGP) FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES
Who Must Complete a PDEW?
Any Operator, who is a Decision-maker required to submit a Notice of Intent (NOI)
and is a small entity as defined in Appendix A of the permit may complete this
Pesticide Discharge Evaluation Worksheet (PDEW) to meet the requirements of
Part 7.4 of the PGP.
Pest management area, as defined in Appendix A of the permit, can be a large
area (e.g., an entire town) or a very specific well-defined management area (e.g., a
lake). Thus, a pest management area can have one or more treatment areas.
Operators required to retain the information contained on this worksheet must do
so for each treatment area. For treatment areas with the same or similar pests, the
Operator can use one worksheet to document pest management activities for
those multiple treatment areas.
When to Complete a PDEW?
Before any pesticide application, any Operator using this form to meet its
obligations under the PGP must complete Part B of this worksheet. Part C, except
for the pesticide application end date and total quantity of pesticide applied, must
be completed as soon as possible but no later than 14 days after the first pesticide
application. The total quantity of pesticide applied and the pesticide application end
date must be completed as soon as possible but no later than 14 days after
completion of pesticide application for this project.
Any Operator using this form to meet its obligations under the PGP must retain this
worksheet for at least 3 years from the date that coverage is granted under the
PGP or when the permit expires or is terminated. These Operators must make this
worksheet available to EPA, including an authorized representative of EPA, upon
request.
Completing the PDEW
To complete this form, type or print in uppercase letters in the approriate areas
only. Make sure you complete all questions.
Section A. General Information
1. Enter the Operator’s full legal name.
2. Enter the full legal name of the person completing the form.
3. Section A should be completed for each Pest Management Area. Indicate which
Pest Management Area out of the total number of Pest Management Areas for
which the section is being completed (i.e., Pest Management Area 1 of 10 total
Pest Management Areas).
4. Enter the name of the Pest Management Area.
5. Identify the pesticide use pattern(s) for the Pest Management Area.
6. For each treatment area, provide a brief description and location description of
the treatment area within the Pest Management Area; size of the treatment
area in acres or linear feet, and name or location of any Waters of the United
States to which discharges occur.

Section D. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, means:
(i) president, secretary, treasurer, or vice-president of the corporation in charge of
a principal business function, or any other person who performs similar policy or
decision-making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management decisions that govern
the operation of the regulated activity including having the explicit or implicit
duty of making major capital investment recommendations, and initiating and
directing other comprehensive measures to assure long-term environmental
compliance with environmental laws and regulations; the manager can ensure
that the necessary systems are established or actions taken to gather complete
and accurate information for permit application requirements; and where
authority to sign documents has been assigned or delegated to the manager in
accordance with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, federal, or other public facility: by either a principal
executive or ranking elected official.
If the PDEW was prepared by someone other than the certifier (for example, if the
PDEW was prepared by a consultant for the certifier’s signature), include the
name, organization, phone number and e-mail address of the PDEW preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 1 hour or 60 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Pesticide
Discharge Evaluation Worksheet to this address.

Section B. Pest Evaluation
1. Identify the target pest(s) and provide a brief description of why pest control is
needed.
2. Provide a brief description of any Pest Management Measure(s) implemented
before pesticide application. For example, identify if you have performed
physical control techniques such as pulling weeds, removing breeding habitat,
or trapping animals.
Section C. Pesticide Application
1. Provide the company name and contact information of the pesticide applicator.
2. Enter the date that the pesticide application began and ended.
3. Enter the name of each pesticide product used including the EPA Registraion
Number, the quanity of pesticide applied, and the method used to apply the
pesticide (e.g., fixed wing aircraft, backpack sprayer).
4. Indicate if visual monitoring was conducted during the pesticide application
and/or post-application. If visual monitoring was not performed, provide a brief
description of why visual monitoring was not conducted.
5. Indicate if there were any adverse effects identifed during visual monitoring.
Provide a brief decription of any adverse effects that were identified.

EPA FORM 6100-26

Page 3 of 3

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR
DISCHARGES FROM THE APPLICATION OF PESTICIDES

Form Approved
OMB No.
2040-0284

This form is for any Operator that is a Decision-maker required to submit an NOI. The annual report must be submitted no later than February 15 of the following year for all
pesticide activities covered under the permit occurring during the previous calendar year as detailed in Part 7 of the permit.

Electronic Submission Waiver (skip if using eNOI)
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 Annual Reporting form.
Briefly describe the reason why use of the electronic system causes undue burden or expense:
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________

A. General Information
1. NPDES Permit Tracking Number:
2. Operator Name:
3. Operator Contact Information:
a. Street:
b. City:

c. State:

–

e. Telephone:

–

Ext

f. Fax:

d. ZIP Code:

–

4. Contact Information:
a. Contact Name:
b. Title:
c. E-mail:

B. Adverse Incidents and Corrective Actions
1. Was an adverse incident observed and/or corrective actions taken for any Pest Management Area for which you have coverage under the permit?
a.

No adverse incidents were observed or corrective action was taken. (Proceed to Section C)

Yes, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-6 for each Pest Management Area in which adverse
incidents were observed or corrective actions were taken. Copy this section for non-electronic submissions).

Pest Management Area #____ of ##____
2. Pest Management Area Name: ___________________________________________________________________________________________________
3. If applicable, provide the date for any adverse incidents as a result of those treatment(s), as described in Part 6.4 of the permit (use additional pages, if needed):
Date of adverse incident observation:

4. Date and time the Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, and any instructions received from EPA.
a.

Date:

Time: ___________________________________________

Who the Operator spoke with at EPA: ________________________________________

Instructions received from EPA:
________________________________________________________________________
________________________________________________________________________

5. Date of submission of Thirty (30)-Day Adverse Incident Written Report:

6. Describe any corrective action(s), including spill responses, resulting from pesticide application activities and the rationale for such action(s), subsequent to those steps
described in the Thirty (30)-Day Adverse Incident Written Report:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

EPA FORM 6100-25

NOTE: Copy this page and attach additional pages as necessary

Page 1 of 5

C. Pest Management Area(s) (use additional pages for each Pest Management Area)
Pest Management Area

of ##

1. Have any discharges from pest control activities occurred in this calendar year?
a.

No discharge from pest control activities this calendar year. Note: Checking this box completes Section C if you had no discharge from pest control activities this
year. Proceed to section D.

Yes. Proceed to question 2.

2. Indicate the pesticide use pattern for the Pest Management Area:
a.

Mosquito and Other Flying Insect Pest Control

Weed and Algae Pest Control

Animal Pest Control

Forest Canopy Pest Control

3. 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:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

Size of treatment area (in acres or linear feet): _____ acres or ______ linear feet.

Name or location of any Waters of the United States to which discharges occurred:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________

Target Pest(s): ____________________________________________________________________________________________________________________

Did any pesticide application activities result in a discharge to Waters of the United States containing NMFS Listed Resources of Concern as defined in
Appendix A of the permit?
Yes

If yes, approximate date(s) of any discharges: ___________________________________________________________________________

4. Name and contact information for pesticide applicator(s) (or check here if same as provided in Section A):
Company Name:
Street:
City:

State:

Contact Name:

Zip Code:

Title:

–

Phone:

–

Ext

E-mail:
5. Was this pest control activity addressed in your Pesticide Discharge Monitoring Plan (PDMP) before pesticide application:

Yes

Not Applicable

6. Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Registration Number(s) and by application method.
Circle if quantity indicated is in lbs or gallons: Add additional pages if necessary.
Product Name __________________________
–

Product Name ___________________________
Quantity Applied (lbs or gallons
of product):

Application method:

–

Quantity Applied (lbs or gallons
of product):

Application method:

Aerially by fixed-wing

______ lbs or gallons

Aerially by fixed-wing

______ lbs or gallons

Aerially by rotary aircraft

______ lbs or gallons

Aerially by rotary aircraft

______ lbs or gallons

Land-based sprayer (includes backpack, land
vehicle mounted sprayers, high pressure
canopy sprayer)

______ lbs or gallons

Land-based sprayer (includes backpack,
land vehicle mounted sprayers, high
pressure canopy sprayer)

______ lbs or gallons

Aquatic vehicle mounted sprayer

______ lbs or gallons

Aquatic vehicle mounted sprayer

______ lbs or gallons

Direct mixture (includes metering, subsurface
applications)

______ lbs or gallons

Direct mixture (includes metering,
subsurface applications)

______ lbs or gallons

Chemigation

______ lbs or gallons

Chemigation

______ lbs or gallons

Other (specify): _____________________

______ lbs or gallons

Other (specify): ____________________

______ lbs or gallons

EPA FORM 6100-25

NOTE: Copy this page and attach additional pages as necessary

Page 2 of 5

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 gathered and evaluated 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.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:

Date:

Annual Report Preparer (Complete if the Annual Report was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:

–

Ext

Date:

E-Mail:

EPA FORM 6100-25

NOTE: Copy this page and attach additional pages as necessary

Page 3 of 5

Instructions for Completing the Annual Report Form for the Pesticide General Permit (PGP) for

Discharges from the Application of Pesticides

Who Must File an Annual Report with EPA?
Any Operator that is a Decision-maker required to submit a Notice of Intent (NOI)
and is a large entity as defined in Appendix A of the permit and any Decision-maker
required to submit an NOI solely because of their application results in a discharge
to Waters of the United States containing NMFS Listed Resources of Concern, must
submit an annual report to EPA each calendar year. Once required to submit an
annual report for one year, an annual report must be filed each subsequent year of
this permit whether or not you have discharges from the application of pesticides in
accordance with Section 7.6 of the permit.
When to File an Annual Report?
Any Operator required to file an annual report must submit the annual report no later
than February 15 of the following year for all pesticide activities covered under this
permit occurring during the previous calendar year. If the Operator is required to
submit an NOI based on an annual treatment area threshold, the annual report must
include information for the calendar year, with the first annual report required to
include activities for the portion of the calendar year after the point at which the
Operator exceeded the annual treatment area threshold. If the Operator first
exceeds an annual treatment area threshold after December 1 in a calendar year,
an annual report is not required for that first partial year but annual reports are
required thereafter, with the first annual report submitted also including information
from the first partial year.
When Operator terminates permit coverage, as specified in Part 1.2.5 of the permit,
an annual report must be submitted for the portion of the year up through the date of
termination. The annual report is due no later than February 15 of the following year.
Where to File the Annual Report?
The Operator must prepare and submit the Annual Report using EPA’s electronic
Notice of Intent (eNOI) system available on EPA’s website
(www.epa.gov/npdes/pesticides/enoi) unless eNOI is otherwise unavailable or the
Operator has filed a waiver from the requirement to use eNOI for submitting the
Annual Report. The Electronic Submission Waiver is at the top of this form. Any
Operator waived from the requirement to use eNOI for Annual Report submission
must certify to EPA on this form that use of eNOI will incur undue burden or
expense over the use of the paper Annual Report form and then provide a basis for
that determination.
If you do file a waiver from using eNOI; you must send the Annual Report to one of
the addresses listed below.

Section A. General Information
1. Enter your permit tracking number that you received in your NOI confirmation
letter or e-mail from EPA’s Pesticide Notice Processing Center. You can find the
tracking number assigned to your NOI by using EPA’s eNOI System
(www.epa.gov/npdes/pesticides/enoi).
2. Provide the legal name of the person, firm, public organization or any other
public entity who is the Decision-maker for the pesticides applications described
in this report. A Decision-maker is an Operator who has control over the decision
to perform pesticide applications including the ability to modify those decisions
that result in a discharge to Waters of the United States.
3. Enter the address, telephone number, and fax number of the Operator.
4. Provide the full legal name, title and e-mail address of a contact person for the
Annual Report.
Section B. Adverse Incidents and Corrective Actions
1. Identify if an adverse incident was observed and corrective actions were taken
for any Pest Management Area for which you have coverage under the permit. If
no, proceed to Section C. If yes, complete Section B for each Pest Management
Area for which an adverse incident was observed or corrective action was taken.
2. Enter the name of the Pest Management Area.
3. If applicable, enter the date of any adverse incidents resulting from the
treatments, as described in Part 6.4 of the permit. Use additional pages if there
are multiple dates to be described.
4. Enter the date and time the Operator contacted EPA to notify the Agency of the
adverse incident, pursuant to Part 6.4.1.1 of the permit.
a. Indicate the date of the contact.
b. Indicate the time of the contact.
c. Indicate who the Operator spoke with at EPA.
d. Indicate any instructions received from EPA.
5. Enter the date that the Thirty (30)-Day Adverse Incident Written Report was
submitted, pursuant to Part 6.4.2 of the permit.
6. Provide a description of any corrective action(s) resulting from pesticide
application activities and the rationale for the action(s), performed subsequently
to or in addition to any actions described in the Thirty (30)-Day Adverse Incident
Written Report.

Via United States Mail:
United States Environmental Protection Agency
Office of Water, Water Permits Division
Mail Code 4203M, ATTN: NPDES Pesticides
1200 Pennsylvania Avenue, NW
Washington, DC 20460

Section C. Pest Management Area(s)
Section C should be completed for each Pest Management Area. Indicate which
Pest Management Area out of the total number of Pest Management Areas for
which the section is being completed (i.e., Pest Management Area 1 of 10 total Pest
Management Areas).

Via overnight/express delivery:
United States Environmental Protection Agency
Office of Water, Water Permits Division
EPA East Building - Room 7420, ATTN: NPDES Pesticides
1201 Constitution Avenue, NW
Washington, DC 20004
Phone: 202-564-9545

1. Identify if you had a discharge from pest control activities this calendar year.
Check yes if you had discharge from pest control activities this calendar year.
Check no if you had no discharge from pest control activities this calendar year.
Note: Checking the no box completes Section C

If you have questions, contact EPA’s Pesticides Notice Processing Center toll free
at (866) 352-7755.
If you file a paper Annual Report, please submit the original with a signature in ink.
Do not send copies. Also, faxed copies will not be accepted.
Completing the Annual Report Form
To complete this form, type or print in uppercase letters in the appropriate areas
only. Make sure you complete all questions. Make sure you make a photocopy for
your records before you send the completed original form to the address above. You
may also use this paper form as a checklist for the information you will need when
filing an Annual Report electronically via EPA’s Pesticides eNOI system.

NOTE: Copy this page and attach additional pages as necessary

2. Select the box for the type of pesticide use pattern for the Pest Management
Area.
3. Provide a description of the treatment area (use additional pages for each
treatment area).
a. Provide a description of the treatment area, including a description of the
location.
b. Provide the size of the treatment area in acres or linear feet.
c. Provide the name or location of any Waters of the United States to which
discharges occur.
d. Provide a description of the target pest(s).
e. Indicate whether any pesticide application activities resulted in a discharge to
Waters of the United States containing NMFS Listed Resources of Concern,
as defined in Appendix A of the permit. If yes, provide approximate date(s) of
the discharge. Additional information on NMFS Listed Resources of Concern
is available on EPA’s website at www.epa.gov/npdes/pesticides.

Page 4 of 5

4. Provide the company name(s), mailing address, a contact person, contact
person’s title, telephone number and e-mail address for the pesticide
applicator(s). If the information is the same as Section A, check the appropriate
box and proceed to the next question.
5. Indicate if the pest control activity was addressed in your PDMP before pesticide
application.
6. Enter the total amount of each pesticide product applied for the reporting year by
the product name, EPA Registration Number(s) and by application method.
Circle whether the quantity applied is in pounds or gallons. Copy and attach
additional pages, as necessary.
Section D. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, means:
(i) president, secretary, treasurer, or vice-president of the corporation in charge of a
principal business function, or any other person who performs similar policy or
decision making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management decisions which
govern the operation of the regulated activity including having the explicit or
implicit duty of making major capital investment recommendations, and initiating
and directing other comprehensive measures to assure long term environmental
compliance with environmental laws and regulations; the manager can ensure
that the necessary systems are established or actions taken to gather complete
and accurate information for permit application requirements; and where
authority to sign documents has been assigned or delegated to the manager in
accordance with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, Federal, or other public facility: by either a principal executive
or ranking elected official.
If the Annual Report was prepared by someone other than the certifier (for example,
if the Annual Report was prepared by the PDMP contact or a consultant for the
certifier’s signature), include the name, organization, phone number and e-mail
address of the Annual Report preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 8 hours or 480 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Annual
Reporting Form to this address.

NOTE: Copy this page and attach additional pages as necessary

Page 5 of 5

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
THIRTY (30)-DAY ADVERSE INCIDENT WRITTEN REPORT FOR
THE PESTICIDE GENERAL PERMIT (PGP)
FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES

Form Approved
OMB No.
2040-0284

This form is for Operators required to submit a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state
lead agency for pesticide regulation. Where multiple Operators are authorized for a discharge that results in an adverse incident, reporting by any one of
the Operators constitutes compliance for all of the Operators, provided a copy of this report is also provided to all of the other authorized Operators
within 30 days of the reportable adverse incident.
A. Reportable Adverse Incident.
Is the adverse incident reportable? Reporting of adverse incidents is not required under the PGP in the following situations: (a) An Operator is aware
of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application; (b) An Operator has been
notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents; (c) An Operator
receives information of an adverse incident, but that information is clearly erroneous; or (d) An adverse incident occurs to pests that are similar in kind to
potential target pests identified on the FIFRA label.
Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation.
No. STOP. You are not required to complete this report. However, you may consider using this form to document the incident and your rationale
for why reporting of the adverse incident is not required. This information may be useful to support your rationale should you be questioned on
such.
B. Information from the 24-Hour Adverse Incident Notification
When an Operator observes or is otherwise made aware of an adverse incident, which may have resulted from a discharge from a pesticide application,
the Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at www.epa.gov/npdes/pesticides. This notification
must be made by telephone within 24 hours of the Operator becoming aware of the adverse incident. Operators must include in the written report the
information provided to EPA in the 24-hour adverse incident notification (PGP Part 6.4.1.1). Attach additional information if necessary.
1. Caller’s Contact Information:
a. Name:
–

b. Telephone Number:

–

Ext

2. Operator Information:
a. Operator Name:
b. Mailing Address:
Street:
State:

City:

ZIP Code:

–

(Enter “NA” if not applicable)

3. NOI NPDES Permit Tracking Number:

4. Contact person, if different than the person providing the 24-hour notice under item 1 above:
a. Name:
b. Telephone Number:

–

Ext

5. Describe how and when the Operator became aware of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Describe the location of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-24

Page 1 of 6

7. Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7a below, for each product
applied in the area of the adverse incident:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
a. Pesticide Registration Number:

Pesticide Registration Number:

8. Describe any steps the Operator has taken or will take to correct, repair, remedy, clean up, or otherwise address any adverse effects:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
9. Identify any other Operators authorized for coverage under this permit for discharges from the pesticide application activities that resulted in the
adverse incident and if so, provide details of your notification of those other Operator(s):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
C. Date and Time the Operator Notified EPA of the Adverse Incident
1. Date EPA was contacted:

2. Time EPA was contacted: _____________________________

3. Name and/or title of the person the Operator spoke with at EPA:
a. Name:

b. Title:

4. Instructions received from EPA:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-24

Page 2 of 6

D. Other Information Required in the Thirty (30) Day Adverse Incident Report
Please attach additional information if necessary.
1. Location of incident, including the names of any waters affected and appearance of those waters (sheen, color, clarity, etc):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
2. Describe the circumstances of the adverse incident including species affected, estimated number of affected individuals, and approximate size of
dead or distressed organisms:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3. Describe the magnitude and scope of the affected area (e.g. aquatic square area or total stream distance affected):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
4. Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name
of pesticide product and EPA registration number.
Pesticide
application rate:

Pesticide
application rate:

Intended use site:

Method of application:

Product:

EPA Reg. No.:

5. Describe the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for
pesticides applied):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Provide an indication of which laboratory test(s), if any, were performed, and when. (Note: A summary of the test results must be provided within
5 days after they become available, if not available at the time of submission of this report.):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
7. Describe the actions to be taken to prevent recurrence of adverse incidents:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-24

Page 3 of 6

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 gathered and evaluated 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.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:

Date:

Adverse Incident Report Preparer (Complete if Adverse Incident Report was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:

–

Ext

Date:

E-Mail:

EPA FORM 6100-24

Page 4 of 6

Instructions for Completing and Submitting the Thirty (30) Day Adverse Incident Written Report for the Pesticide
General Permit (PGP) for Discharges from the Application of Pesticides
Who Must Submit a 30-day Adverse Incident Report?

Section B. Information from the 24-hour Adverse Incident Notification

All Operators who observe or are otherwise made aware of a reportable adverse
incident pursuant to Part 6.4 of the permit must submit on adverse incident report.

1. Provide contact information for the person that called EPA to report the adverse
incident.
a. Enter the legal name of the caller.
b. Enter the phone number of the caller.
2. Provide the Operator’s contact information.
a. Enter the legal name of the Operator.
b. Enter the mailing address of the Operator.
3. If an NOI was filed as required in Part 1.2 of the permit, enter the NPDES Permit
Tracking Number assigned by eNOI or the EPA’s Pesticides Processing Center.
You can find the tracking number assigned to your NOI using EPA’s eNOI
System (www.epa.gov/npdes/pesticides/enoi). If no NOI submitted, enter “NA”
for not applicable.
4. Provide information for a contact person, if different than the person that called
EPA to report the adverse incident.
a. Enter the legal name of the contact person.
b. Enter the phone number of the contact person.
5. Provide a description of how and when the Operator became aware of the
adverse incident.
6. Provide a description of the location of the adverse incident.
7. Provide a description of the adverse incident and the pesticide product used in
the adverse incident. Include the EPA pesticide registration number for each
product applied in the area of the adverse incident. Attach additional pages if
necessary
8. Provide a description of any steps the Operator has taken to correct, repair,
remedy, clean up or otherwise address the adverse effects of the incident.
9. Identify any other Operators authorized for coverage under the permit for
discharges from the pesticide application activities that resulted in the adverse
incident. If other Operators are authorized under this permit, provide details of
your notification of those other Operator(s).

However, even for those identified adverse incidents for which the Operator is not
required to report, EPA recommends that Operators consider using this form to
document the incident and the rationale for why reporting of the adverse incident is
not required. This information may be useful to support a rationale should this
determination be questioned.
An adverse incident, as defined in the Appendix A of the permit, is an unusual or
unexpected incident that an Operator has observed upon inspection or of which the
Operator otherwise became aware, in which: (1) there is evidence that a person or
non-target organism has likely been exposed to a pesticide residue, and (2) the
person or non-target organism suffered a toxic or adverse effect. See Appendix A of
the permit, for the complete definition of adverse incident.
Where multiple Operators are authorized for a discharge that results in an adverse
incident, notification and reporting by any one of the Operators constitutes
compliance for all of the Operators, provided a copy of the written report required in
Part 6.4.2 of the permit is also provided to all of the other authorized Operators
within 30 days of the reportable adverse incident.
When to File the Adverse Incident Report
Operators must a provide a written report of any reportable adverse incidents to the
appropriate EPA Regional office and to the state lead agency for pesticide
regulation within 30 days of the adverse incident pursuant to Part 6.4.1.1 of the
permit.
Where to File the 30-day Adverse Incident Report
The Operator must immediately notify the appropriate EPA Incident Reporting
Contact, as identified at www.epa.gov/npdes/pesticides of the adverse incident
within 24 hours. The Operator(s) must provide a written report of the adverse
incident to the appropriate EPA Regional office at the address listed in Part 8 of the
permit and to the state lead agency for pesticide regulation (see
http://npic.orst.edu/state1.htm).
If an Operator becomes aware of an adverse incident affecting a federally listed
threatened or endangered species or its federally designated critical habitat which
may have resulted from a discharge from the Operator’s pesticide application, the
Operator must immediately notify the National Marine Fisheries Service (NMFS) in
the case of an anadromous or marine species, or the United States Fish and Wildlife
Service (FWS) in the case of a terrestrial or freshwater species.
Completing the 30-day Adverse Incident Report
To complete this form, type or print in uppercase letters in the appropriate areas
only. Please make sure you complete all questions. Make sure you make a
photocopy for your records before you send the completed original form to the
appropriate EPA Regional office.
Section A. Reportable Adverse Incident
The Operator is required to submit this Adverse Incident Report if the adverse
incident is reportable. Check yes if the adverse incident is reportable. If an Adverse
Incident Report is not required, check no. No further action is needed on this form.
Reporting of adverse incidents is not required under the PGP in the following
situations:
a. An Operator is aware of facts that indicate that the adverse incident was not
related to toxic effects or exposure from the pesticide application;
b. An Operator has been notified by EPA, and retains such notification, that the
reporting requirement has been waived for this incident or category of incidents;
c. An Operator receives information notifying the Operator of an adverse incident,
but that information is clearly erroneous; or
d. An adverse incident occurs to pests that are similar in kind to potential target
pests identified on the FIFRA label.

EPA FORM 6100-24

Section C. Date and Time the Operator Notified EPA of the Adverse Incident
1. Enter the date that EPA was contacted to report the adverse incident.
2. Enter the time EPA was contacted to report the adverse incident.
3. Provide the legal name and title of the person contacted at EPA.
4. Provide a description of the instructions received by EPA.
Section D. Other Information Required in the Thirty (30) Day Adverse Incident
Report
1. Enter the location of the adverse incident and include the names of any waters
affected. Please include the appearance of those waters (sheen, color, clarity,
etc.).
2. Provide a description of the circumstances of the adverse incident including
species affected, estimated number of affected individuals and approximate size
of dead or distressed organisms.
3. Provide a description of the magnitude and scope of the affected area. Include
aquatic square area or total stream distance affected, if possible.
4. Provide the pesticide application rate, intended use site (e.g., on the bank, above
waters, or directly to water), method of application, and the name of pesticide
product and EPA registration number.
5. Provide a description of the habitat and the circumstances under which the
adverse incident occurred (including any available ambient water data for
pesticides applied).
6. Indicate which laboratory test(s) were performed and when, if laboratory tests
were performed. The summary of the test results must be provided within 5 days
after they become available, if not available at the time of submission of this
report.
7. Provide a description of the actions to be taken to prevent recurrence of adverse
incidents.

Page 5 of 6

Section E. Certification
Enter the certifier’s printed name and title. Sign and date the form. For more
information about the certification statement and signature, see Appendix B of the
permit. (CAUTION: An unsigned or undated form will not be accepted.) Federal
statutes provide for severe penalties for submitting false information. Federal
regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, which means:
(i) president, secretary, treasurer, or vice-president of the corporation in charge of a
principal business function, or any other person who performs similar policy or
decision-making functions for the corporation, or
(ii) the manager of one or more manufacturing, production, or operating facilities,
provided the manager is authorized to make management decisions that govern
the operation of the regulated activity including having the explicit or implicit duty
of making major capital investment recommendations, and initiating and directing
other comprehensive measures to assure long-term environmental compliance
with environmental laws and regulations; the manager can ensure that the
necessary systems are established or actions taken to gather complete and
accurate information for permit application requirements; and where authority to
sign documents has been assigned or delegated to the manager in accordance
with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, federal, or other public facility: by either a principal executive
or ranking elected official.
If the report was prepared by someone other than the certifier (for example, if the
report was prepared by a consultant for the certifier’s signature), include the name,
organization, phone number and e-mail address of the report preparer and the date
that the report was prepared.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 4 hours or 240 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the
provided burden estimates, and any suggested methods for minimizing respondent
burden, including through the use of automated collection techniques to the
Director, Collection Strategies Division, U.S. Environmental Protection Agency
(2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB
control number in any correspondence. Do not send the completed Adverse
Incident Report to this address.

EPA FORM 6100-24

Page 6 of 6

File Type	application/pdf
File Title	Final NPDES Pesticide General Permit for Point Source Discharges From the Application of Pesticides - Full Permit (October 31, 2
Subject	EPA's Final PGP - full permit
Author	US EPA, OW, OWM, Water Permits Division, Rural Branch
File Modified	2014-03-12
File Created	2012-10-23