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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY fa WASHINGTON, DC 20460 Form Approved a NOTICE OF INTENT (NOI) OF COVERAGE UNDER THE PESTICIDE OMB No. LWA GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE APPLICATION 2040-NEW OF PESTICIDES 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) oO | hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNO! 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. L] original NOI Submission b. L] No! 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 t-operatorome: TT | TT TTT TT TY 3. Operator Type (check one): a. | Federal government b. | State government c. oO Local government d. | Mosquito control district (or similar) - | Irrigation control district (or similar) fo} Foal oO Weed control district (or similar) Ko} . LJ 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 | No 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: esr TTT TTT TTT TTT TTT TE EY boty LTT T TT TT TTT ET este azpcose | | | | | J-[ | | | | e-teteprone: | | TILE ILE d eeLi ty tre LEE I-LE IT I-LE LLY g.contactame: | | | | | iti Tit I I III tty yy | | nema 1 TTT TTT TTT EE EE EE EE | 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. 2. Are any of your activities for which you are requesting coverage under this NOI occurring on Indian Country Lands? O Yes O No 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? O Yes O No 4. Mailing address and contact information of the pesticide applicator (or check here O if same as provided in Section B): eset | | | | | | IIT IIIT | roy LT TT TTT UE EA © Sate azpoode: | | | | | |-[ | | | | e-terephone = | | | JL E T -L ET | JeeL PPE prem EE LY -LE TT a-contactname | | | | | | | IT TU TTT TTT tT a 5. Pesticide Use Patterns to be included in this Pest Management Area (check all that apply): a. im Mosquito and Other Flying Insect Pest Control c. oO Animal Pest Control b. im Weed and Algae Pest Control d. oO Forest Canopy Pest Control 6. Receiving Waters (check one): a. O Coverage requested for all Waters of the United States within the Pest Management Area identified above. b. O Coverage requested specifically for the following Waters of the United States within the Pest Management Area identified above. c. oO 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? LlyYes oO No If yes, answer a and b: 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. oO 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 b. oO 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. O 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. b. oO 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. c. O 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).) d. O 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. e. oO 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 likelinood of adverse effects to NMFS Listed Resources of Concern. f. im 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: b. — Pest(s) to be controlled: c. Pesticide product(s) to be discharged and method of application: d. Planned quantity and rate of discharge(s) for each method of application: e. | Number of planned discharges: f. Approximate date(s) of planned discharge(s): g. 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 | 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. | am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. printedName: | | | | TTT T FETT TTT TTY te: [TTT TTT T EE EEE ETT emai: | | | | ITT TTT ITT TTI IIIT EE Ey Signature/Responsible Official: pate: | | iL | ||| | | NOI Preparer (Complete if NOI was prepared by someone other than the certifier) PreparerName: | | | | | { {IIIT III IIIT TTT T IIIT yy yy ee ee eee organization: | | | TILT IIIT TTT TTT EE EE phone: | | | J-| | | J-LL dd Jel} | | pate: | | |i] | ||| | | | a a 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 NOls. Table 1. Decision-Makers Required to Submit NOls 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, NOls 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 ‘ 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 Date? Any Decision-maker with any __| At least 30 days No earlier than 30 days discharge to Waters of the before any discharge | after EPA posts on the United States containing NMFS | to Waters of the Internet a receipt of a Listed Resources of Concern, | United States complete and accurate except for those discharges in | containing NMFS NOI.5 response to a Declared Pest Emergency Situation, as Listed Resources of Concern, as defined defined in Appendix A. in Appendix A.5 Any Decision-maker with a At least 30 days after | Immediately upon discharge in response to a beginning discharge. | beginning to discharge for 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. 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 PGP Part/ Which Decision-Makers Must For Which Pesticide Pesticide Use Submit NOIs? Application Activities? All four use Any Decision-maker with an Activities resulting in a patterns eligible discharge to a Tier 3 discharge to a Tier 3 water identified in water (Outstanding National Part 1.1.1 Resource Water) consistent with Part 1.1.2.2 All four use Any Decision-maker with an Activities resulting in a patterns eligible discharge to Waters of _| discharge to Waters of the identified in the United States containing United States containing NMFS Part 1.1.1 NMFS Listed Resources of Listed Resources of Concern, Concern, as defined in as defined in Appendix A Appendix A 1.1.1(a) - Any Agency for which pest All activities resulting in a Mosquito and | management for land resource _| discharge for which the Federal Other Flying —_| stewardship is an integral part of | or State agency is responsible Insect Pest the organization’s operations. for pest control Control Mosquito control districts, or All activities resulting in a similar pest control districts discharge for which the Decision-maker is responsible for pest control Local governments or other Adulticide treatment if more than entities that exceed the annual | 6,400 acres during a calendar treatment area threshold year identified here 1.1.1(b) - Any Agency for which pest All activities resulting in a Weed and management for land resource _| discharge for which the Federal Algae Pest stewardship is an integral part of | or State agency is responsible Control the organization’s operations. for pest control Irrigation and weed control All activities resulting in a districts, or similar pest control —_| discharge for which the districts Decision-maker is responsible for pest control Local governments or other Treatment during a calendar entities that exceed the annual _| year if more than either: treatment area threshold 20 linear miles identified here OR 80 acres of water (i.e., surface area) 1.1.1(c) - Any Agency for which pest All activities resulting in a Animal Pest management for land resource _| discharge for which the Federal Control stewardship is an integral part of | or State agency is responsible the organization’s operations. for pest control Local governments or other Treatment during a calendar entities that exceed the annual _| year if more than either: treatment area threshold 20 linear miles identified here OR 80 acres of water (i.e., surface area) 1.1.1.(d) - Any Agency for which pest All activities resulting in a Forest Canopy | Management for land resource _| discharge for which the Federal Pest Control | stewardship is an integral part of | or State agency is responsible the organization’s operations. for pest control Local governments or other Treatment if more than 6,400 entities that exceed the annual | acres during a calendar year treatment area threshold identified here 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. If you have questions about whether you need to file an NOI or questions about 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 completing the form, see www.epa.gov/npdes/pesticides or contact the NOI Center toll free at 866-352-7755. EPA FORM 6100-22 NOI. nN wo 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 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, 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. NOI Submission Discharge Authorization Operator Type Deadline Date Any Decision-maker with | At least 30 days before No earlier than 30 days any discharge to Waters of | beginning to discharge in | 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 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. a 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. a 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 fora 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 anew pesticide use pattern do not require a revised NOI submittal. 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. NOI Submission Discharge Authorization Operator Type Deadline Date Any Decision-maker At least 10 days before No earlier than 10 days requiring permit coverage | beginning to discharge in | 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 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. EPA FORM 6100-22 method or rate of application, or approximate dates of applications. 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 (eNOl) 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 eNO! for submission of the NOI. The Electronic Submission Waiver is at the top of this form. Decision-makers waived from the requirement to use eNO! for NOI submission must certify to EPA on this form that use of eNO! 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 NOls received. Late NOls 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. e Ifyou file a paper NOI, submit the original with a signature in ink. Do not send copies. Also, faxed copies will not be accepted. e Ifyou 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 eNO! 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. 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 eNO! 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 NOls 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 federally- designated 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 Decision- maker 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. 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