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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY o WASHINGTON, DC 20460 Formed a a ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR A 2040-NEW DISCHARGES FROM THE APPLICATION OF PESTICIDES This form is for any Operator that is a Decision-maker required to submit an NOI. The annual report must be submitted no later than February 15 of the following year for all pesticide activities covered under the permit occurring during the previous calendar year as detailed in Part 7 of the permit. Electronic Submission Waiver (skip if using eNOl) oO | hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNO!) because my use of eNO! will incur undue burden or expense over my use of this paper Annual Reporting form. Briefly describe the reason why use of the electronic system causes undue burden or expense: A. General Information 1. NPDES Permit Tracking Number: | | | | | | | | | | 2. Operator Name LITT TTT TTT TTT EP EEE EE 3. Operator Contact Information: a a oe ee e. Telephone: || | J-| | | |-| | | | | Ext | | | |_| f. Fax: || | J-| | | |-| | | |_| 4. Contact Information: a.contactname: | | | | | {tii III III yyy | | | | b Tie LETT TTT TTT EEE EE I I cemot TTT TTT TTT EEE EE EEE EEE FY B. Adverse Incidents and Corrective Actions 1. Was an adverse incident observed and/or corrective actions taken for any Pest Management Area for which you have coverage under the permit? a. O No adverse incidents were observed or corrective action was taken. (Proceed to Section C) b. O Yes, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-6 for each Pest Management Area in which adverse incidents were observed or corrective actions were taken. Copy this section for non-electronic submissions). Pest Management Area # of ## 2. Pest Management Area Name: 3. If applicable, provide the date for any adverse incidents as a result of those treatment(s), as described in Part 6.4 of the permit (use additional pages, if needed): Date of adverse incident observation: | | |r| | || | | | | 4. Date and time the Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, and any instructions received from EPA. a. Date: | | | / | | | / | | | | | c. Who the Operator spoke with at EPA: b. Time: d. Instructions received from EPA: 5. Date of submission of Thirty (30)-Day Adverse Incident Written Report: | | | / | | | / | | | | | 6. Describe any corrective action(s), including spill responses, resulting from pesticide application activities and the rationale for such action(s), subsequent to those steps described in the Thirty (30)-Day Adverse Incident Written Report: EPA FORM 6100-25 NOTE: Copy this page and attach additional pages as necessary Page 1 of 5 C. Pest Management Area(s) (use additional pages for each Pest Management Area) Pest Management Area # of ## 1. Have any discharges from pest control activities occurred in this calendar year? a. in| No discharge from pest control activities this calendar year. Note: Checking this box completes Section C if you had no discharge from pest control activities this year. Proceed to section D. b. O Yes. Proceed to question 2. 2. Indicate the pesticide use pattern for the Pest Management Area: a. O Mosquito and Other Flying Insect Pest Control b. O Weed and Algae Pest Control Cc. oO Animal Pest Control d. O Forest Canopy Pest Control 3. 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: d. Target Pest(s): e. Did any pesticide application activities result in a discharge to Waters of the United States containing NMFS Listed Resources of Concern as defined in Appendix A of the permit? O Yes O No _ If yes, approximate date(s) of any discharges: 4. Name and contact information for pesticide applicator(s) (or check here if same as provided in Section A): oO company name: | | | TL TT ITT TT TTT EE EE EI swt | | TT TT TT TE EE EE J om EL TT TT ET ET ET ET EE EE EE ste zicode: | | | | | prone | | | -LE TL J-LE TL yet tL a 5. Was this pest control activity addressed in your Pesticide Discharge Monitoring Plan (PDMP) before pesticide application: O Yes im No im Not Applicable 6. Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Registration Number(s) and by application method. Circle if quantity indicated is in Ibs or gallons: Add additional pages if necessary. Product Name Product Name | | | | | | | _ | | | | | | Quantity Applied (Ibs or gallons | | | | | | | _ | | | | | | Quantity Applied (Ibs or gallons of product): of product): Application method: Application method: a. L] Aerially by fixed-wing ______ lbs or gallons a. L] Aerially by fixed-wing ______ lbs or gallons b. L] Aerially by rotary aircraft ____Ibs or gallons b. L] Aerially by rotary aircraft ____Ibs or gallons Cc. im Land-based sprayer (includes backpack, land Ibs or gallons c. oO Land-based sprayer (includes backpack, Ibs or gallons vehicle mounted sprayers, high pressure land vehicle mounted sprayers, high canopy sprayer) pressure canopy sprayer) d. _] Aquatic vehicle mounted sprayer _______lbs or gallons d. [J Aquatic vehicle mounted sprayer _______ Ibs or gallons e. _] Direct mixture (includes metering, subsurface ____lbs or gallons e. L] Direct mixture (includes metering, ____ Ibs or gallons applications) subsurface applications) f. O Chemigation Ibs or gallons f. O Chemigation Ibs or gallons g. oO Other (specify): Ibs or gallons g. im Other (specify): Ibs or gallons EPA FORM 6100-25 NOTE: Copy this page and attach additional pages as necessary Page 2 of 5 D. 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 gathered and evaluated 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: | | | | UIT IIIT IIIT IIT ETE EE yt yh Tie: LT TTT TTT TTT TT EE EE emai: | | TTT TT TT TTT TET T TET EE EE EE Signature/Responsible Official: Date: | | || | || | | | | Annual Report Preparer (Complete if the Annual Report was prepared by someone other than the certifier Preparer Name: | | | | ITI IIIT IIIT III III EE EE \ | ex| | | | | pate: | | iL | JL | || | ) | | Organization: | | | | | | | | | | | Phone: LL E-Mail: | || EPA FORM 6100-25 NOTE: Copy this page and attach additional pages as necessary Page 3 of 5 Instructions for Completing the Annual Report Form for the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides Who Must File an Annual Report with EPA? Any Operator that is a Decision-maker required to submit a Notice of Intent (NOI) and is a large entity as defined in Appendix A of the permit and any Decision-maker required to submit an NOI solely because of their application results in a discharge to Waters of the United States containing NMFS Listed Resources of Concern, must submit an annual report to EPA each calendar year. Once required to submit an annual report for one year, an annual report must be filed each subsequent year of this permit whether or not you have discharges from the application of pesticides in accordance with Section 7.6 of the permit. When to File an Annual Report? Any Operator required to file an annual report must submit the annual report no later than February 15 of the following year for all pesticide activities covered under this permit occurring during the previous calendar year. If the Operator is required to submit an NOI based on an annual treatment area threshold, the annual report must include information for the calendar year, with the first annual report required to include activities for the portion of the calendar year after the point at which the Operator exceeded the annual treatment area threshold. If the Operator first exceeds an annual treatment area threshold after December 1 in a calendar year, an annual report is not required for that first partial year but annual reports are required thereafter, with the first annual report submitted also including information from the first partial year. When Operator terminates permit coverage, as specified in Part 1.2.5 of the permit, an annual report must be submitted for the portion of the year up through the date of termination. The annual report is due no later than February 15 of the following year. Where to File the Annual Report? The Operator must prepare and submit the Annual Report using EPA’s electronic Notice of Intent (eNO!) system available on EPA’s website (www.epa.gov/npdes/pesticides/enoi) unless eNOI is otherwise unavailable or the Operator has filed a waiver from the requirement to use eNOI for submitting the Annual Report. The Electronic Submission Waiver is at the top of this form. Any Operator waived from the requirement to use eNO! for Annual Report submission must certify to EPA on this form that use of eNOI will incur undue burden or expense over the use of the paper Annual Report form and then provide a basis for that determination. If you do file a waiver from using eNOI; you must send the Annual Report 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. If you file a paper Annual Report, please submit the original with a signature in ink. Do not send copies. Also, faxed copies will not be accepted. Completing the Annual Report Form To complete this form, type or print in uppercase letters in the appropriate areas only. 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 Annual Report electronically via EPA’s Pesticides eNOI system. NOTE: Copy this page and attach additional pages as necessary Section A. General Information 1. Enter your permit tracking number that you received in your NOI confirmation letter or e-mail from EPA's Pesticide Notice Processing Center. You can find the tracking number assigned to your NOI by using EPA’s eNOI System (www.epa.gow/npdes/pesticides/enoi). . Provide the legal name of the person, firm, public organization or any other public entity who is the Decision-maker for the pesticides applications described in this report. 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. . Enter the address, telephone number, and fax number of the Operator. . Provide the full legal name, title and e-mail address of a contact person for the Annual Report. Section B. Adverse Incidents and Corrective Actions 1. Identify if an adverse incident was observed and corrective actions were taken for any Pest Management Area for which you have coverage under the permit. If no, proceed to Section C. If yes, complete Section B for each Pest Management Area for which an adverse incident was observed or corrective action was taken. . Enter the name of the Pest Management Area. . If applicable, enter the date of any adverse incidents resulting from the treatments, as described in Part 6.4 of the permit. Use additional pages if there are multiple dates to be described. . Enter the date and time the Operator contacted EPA to notify the Agency of the adverse incident, pursuant to Part 6.4.1.1 of the permit. a. Indicate the date of the contact. b. Indicate the time of the contact. c. Indicate who the Operator spoke with at EPA. d. Indicate any instructions received from EPA. 5. Enter the date that the Thirty (30)-Day Adverse Incident Written Report was submitted, pursuant to Part 6.4.2 of the permit. . Provide a description of any corrective action(s) resulting from pesticide application activities and the rationale for the action(s), performed subsequently to or in addition to any actions described in the Thirty (30)-Day Adverse Incident Written Report. Section C. Pest Management Area(s) Section C 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). 1. Identify if you had a discharge from pest control activities this calendar year. Check yes if you had discharge from pest control activities this calendar year. Check no if you had no discharge from pest control activities this calendar year. Note: Checking the no box completes Section C . Select the box for the type of pesticide use pattern for the Pest Management Area. . Provide a description of the treatment area (use additional pages for each treatment area). a. Provide a description of the treatment area, including a description of the location. b. Provide the size of the treatment area in acres or linear feet. c. Provide the name or location of any Waters of the United States to which discharges occur. d. Provide a description of the target pest(s). e. Indicate whether any pesticide application activities resulted in a discharge to Waters of the United States containing NMFS Listed Resources of Concern, as defined in Appendix A of the permit. If yes, provide approximate date(s) of the discharge. Additional information on NMFS Listed Resources of Concern is available on EPA's website at www.epa.govw/npdes/pesticides. 4. Provide the company name(s), mailing address, a contact person, contact person’s title, telephone number and e-mail address for the pesticide applicator(s). If the information is the same as Section A, check the appropriate box and proceed to the next question. 5. Indicate if the pest control activity was addressed in your PDMP before pesticide application. 6. Enter the total amount of each pesticide product applied for the reporting year by the product name, EPA Registration Number(s) and by application method. Circle whether the quantity applied is in pounds or gallons. Copy and attach additional pages, as necessary. 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 which 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 Annual Report was prepared by someone other than the certifier (for example, if the Annual Report 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 Annual Report preparer. Paperwork Reduction Act Notice The public reporting and recordkeeping burden for this collection of information is estimated to average 8 hours or 480 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 Annual Reporting Form to this address. NOTE: Copy this page and attach additional pages as necessary