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
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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
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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.
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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.
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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
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