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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY fh WASHINGTON, DC 20460 Form Approved 2 PESTICIDE DISCHARGE EVALUATION WORKSHEET FOR THE OMB No. Wd PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE 2040-NEW APPLICATION OF PESTICIDES 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 tperatorName: | | | | | TV TUT TTT ET EE EE EE EE I 2.worksheetPreparer Name: | | | | | | | | | ||} III IIIT I II II II II yyy yt yy | 3. Pest Management Area: #__ of ## 4. Pest Management Area Name: 5. Indicate the pesticide use pattern for the Pest Management Area: a. L] Mosquito and Other Flying Insect Pests b. [] Weed and Algae Pests c. L] Animal Pests d. L] 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: | | | || || IIIT TILT TIT ET TT ey Ed tI LT state: | | | zipcode: | | | | | |-L 1 | || Street: | | | | contact Name: | | | || |||} TI II It tt tt | Phone: | | | J-L I} J-LL LT Jel tt | emait 11 | TTT TTTTI TIT T TT EE ET EY J EPA FORM 6100-26 Page 1 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 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 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.