3800-PM-BPNPSM0025c
Checklist
Rev. 4/2015
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
PERMIT APPLICATION FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES
APPLICANT’S  CHECKLIST
APPLICANT NAME
Check the following list to make sure you have included all the required information. Place a checkmark in
the box provided for all items completed and/or provided. Failure to provide all of the requested information
will delay the processing of the application for coverage.
ENCLOSE THIS CHECKLIST WITH YOUR COMPLETED APPLICATION FORM
REQUIREMENTS FOR ALL DISCHARGES
1.
Three (3) copies of the completed, signed application form
(3800-PM-BPNPSM0025b)
2.
Three (3) copies of the completed, signed General Information Form (GIF)
(1300-PM-BIT0001)
3.
Application Fee ($1,000 new permits, $500 for reissuance), unless exempt
from fees under 25 Pa. Code 92a.26(i)
4.
Topographic Map(s) Delineating Treatment Areas and Water Bodies
5.
Pesticide Discharge Management Plan (PDMP)
6.
Antidegradation Module for each treatment area (3800-PM-BPNPSM0025e)
Check 
If
Included
DEP Use
Only