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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY fa WASHINGTON, DC 20460 Form Approved aw, EPA THIRTY (30)-DAY ADVERSE INCIDENT WRITTEN REPORT FOR OMB No. Yd THE PESTICIDE GENERAL PERMIT (PGP) 2040-NEW FoR DISCHARGES FROM THE APPLICATION OF PESTICIDES This form is for Operators required to submit a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state lead agency for pesticide regulation. Where multiple Operators are authorized for a discharge that results in an adverse incident, reporting by any one of the Operators constitutes compliance for all of the Operators, provided a copy of this report is also provided to all of the other authorized Operators within 30 days of the reportable adverse incident. A. Reportable Adverse Incident. Is the adverse incident reportable? Reporting of adverse incidents is not required under the PGP in the following situations: (a) An Operator is aware of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application; (b) An Operator has been notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents; (c) An Operator receives information of an adverse incident, but that information is clearly erroneous; or (d) An adverse incident occurs to pests that are similar in kind to potential target pests identified on the FIFRA label. CI Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation. LC] No. STOP. You are not required to complete this report. However, you may consider using this form to document the incident and your rationale for why reporting of the adverse incident is not required. This information may be useful to support your rationale should you be questioned on such. B. Information from the 24-Hour Adverse Incident Notification When an Operator observes or is otherwise made aware of an adverse incident, which may have resulted from a discharge from a pesticide application, the Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at www.epa.gov/npdes/pesticides. This notification must be made by telephone within 24 hours of the Operator becoming aware of the adverse incident. Operators must include in the written report the information provided to EPA in the 24-hour adverse incident notification (PGP Part 6.4.1.1). Attach additional information if necessary. 1. Caller’s Contact Information: a name [I/II ITI IIIT TIE T III TTP EE EE b. Telephone Number: | | | |-| | | |-| | | | | Ext | | | | | 2. Operator Information: a. OperatorName: | | | | | | LI} I II IIIT ITI III I TTI ETI Itt ty b. Mailing Address: sweet | ||| {//{II/IIIIIITLITI ITT Itt TI ttt ty cys LL ELIT ELT EEE T TELE EJ sete LE} apcode |] | | | |-LE| || 3. NOI NPDES Permit Tracking Number: | | | | | | | | | | (Enter “NA” if not applicable) 4. Contact person, if different than the person providing the 24-hour notice under item 1 above: aname | | TTI IIIT IIIT TTT TIT TT EE EEE b. Telephone Number: | | | |-| | | |-| | | | | Ext | | | | | 5. Describe how and when the Operator became aware of the adverse incident: 6. Describe the location of the adverse incident: EPA FORM 6100-24 Page 1 of 6 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, which 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 report was prepared by someone other than the certifier (for example, if the report was prepared by a consultant for the certifier’s signature), include the name, organization, phone number and e-mail address of the report preparer and the date that the report was prepared. Paperwork Reduction Act Notice The public reporting and recordkeeping burden for this collection of information is estimated to average 4 hours or 240 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 Adverse Incident Report to this address. EPA FORM 6100-24 Page 6 of 6