3800-PM-BPNPSM0025b Application Rev. 8/2012 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 Before completing this form, read the step-by-step instructions provided in 3800-PM-BPNPSM0025a. Client ID# Related ID#s (If Known) APS ID# Site ID# DEP USE ONLY Date Received & General Notes Auth ID# PA APPLICATION INFORMATION Indicate whether the application is for new permit coverage, renewal of permit coverage already approved by DEP, or an amendment to a previously issued permit. If the application is for a renewal or amendment, supply the NPDES permit number. New Permit Permit Renewal Permit Amendment NPDES Permit No. DECISION-MAKER (CLIENT) INFORMATION DEP Client ID# Client Type/Code Organization Name or Registered Fictitious Name Employer ID# (EIN) Dun & Bradstreet ID# Operator/ Individual Last Name First Name MI Suffix SSN Additional Operator / Individual Last Name First Name MI Suffix SSN Mailing Address Line 1 Mailing Address Line 2 SIC Code Address Last Line – City State ZIP+4 Country + Client Contact Last Name First Name Client Contact Title E-mail Address MI Suffix Phone Ext FAX -1- 3800-PM-BPNPSM0025b Application Rev. 8/2012 TREATMENT AREA INFORMATION1 Treatment Area (No.) Latitude Municipality County Deg Sec Longitude Min Deg Sec Min 1 Treatment Area (No.) Total Area (Acres) Total Length (mi) Applicator Name and Address Certification No. 1 For each treatment area, attach an 8.5” x 11” photocopy of a topographical map (7.5-minute USGS quadrangle), or the complete map, with the treatment area and all water bodies delineated and highlighted. 1 -2- 3800-PM-BPNPSM0025b Application Treatment Area (No.) Rev. 8/2012 Pesticide Use Pattern2 Proposed Treatment Date(s) No. Treatments / Year Nearest Downstream Public Water Supply and Intake Waters 1 Treatment Area (No.) Pesticide* to be Applied per Treatment Area Name Manufacturer EPA Reg. # Maximum Annual Dose Units Target 1 * Attach the product labels (containing dosage information) with the application. 2 Indicate one of the following use patterns for each treatment area: (1) Mosquitoes and Other Flying Insect Pest Control; (2) Animal Pest Control; (3) Weeds and Algae Pest Control; or (4) Forest Canopy Pest Control. If a treatment area will be subjected to more than one use pattern, include additional use patterns on separate rows. -3- 3800-PM-BPNPSM0025b Application Rev. 8/2012 SUMMARY OF APPLICATIONS BY USE PATTERNS Use Pattern Total No. Treatment Areas Maximum Annual Pesticide Treatment Area Units Mosquitoes and Other Flying Insect Pest Control Animal Pest Control Weeds and Algae Pest Control Forest Canopy Pest Control WATER BODY AND NATURAL RESOURCE INFORMATION Treatment Area (No.) Surface Water Name Designated Use Existing Use Assessment Status TMDL Status PNDI (see below) 1 PNDI – Listed Threatened or Endangered Species (“Species”) in Pennsylvania 1 Pesticide application activities for which permit coverage is being requested will not overlap with the distribution map locations of any Species or Habitat. 2 Pesticide application activities for which permit coverage is being requested will overlap with the distribution of any Species or Habitat, and the Pennsylvania Department of Conservation and Natural Resources, the Pennsylvania Game Commission, the Pennsylvania Fish and Boat Commission, and the U.S. Fish and Wildlife Service have been consulted for all activities. 3 Pesticide application activities for which permit coverage is being requested will overlap with the distribution of any Species or Habitat, and the Pennsylvania Department of Conservation and Natural Resources, the Pennsylvania Game Commission, the Pennsylvania Fish and Boat Commission, and the U.S. Fish and Wildlife Service have not been consulted for all activities. -4- 3800-PM-BPNPSM0025b Application Rev. 8/2012 NOTIFICATION Notification of potential users of treated water: Has occurred or Will occur prior to treatment (Note: Potential users of treated water must be notified at least 24 hours in advance of treatment). Are you aware of any objections to treatment from potential users of treated water? Yes or No If yes, describe: COMPLIANCE HISTORY REVIEW Is the facility owner or operator in violation of any DEP regulation, permit, order or schedule of compliance at this or any other facility? YES NO If "YES," list each permit, order and schedule of compliance and provide compliance status. Use additional sheets to provide information on all permits. Permit Program Permit No. Brief Description of Noncompliance: Steps Taken or to be Taken to Achieve Compliance Current Compliance Status Date(s) Compliance Achieved In Compliance In Noncompliance PESTICIDE DISCHARGE MANAGEMENT PLAN A Pesticide Discharge Management Plan (PDMP) is required for all individual permit applications. Please see the instructions for information on the contents of the PDMP. CERTIFICATION I certify under penalty of law and subject to the penalties of 18 Pa. C.S. Section 4904 (relating to unsworn falsification to authorities) 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. Based on 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 further acknowledge that the facility, treatment area and operator described herein is eligible for coverage under DEP’s permit. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. Name (type or print legibly) Official Title Signature Date -5-