Form 1 ADVERSE INCIDENT WRITTEN REPORT

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
THIRTY (30)-DAY ADVERSE INCIDENT WRITTEN REPORT FOR
THE PESTICIDE GENERAL PERMIT (PGP)
FOR DISCHARGES FROM THE APPLICATION OF PESTICIDES

Form Approved
OMB No.
XXXX-XXXX

A. 24-hour Adverse Incident Notification
Information to be submitted for the 24-hour adverse incident notification (PGP Part 6.4.1.1). This notification must be made by telephone within 24
hours of the Operator becoming aware of the adverse incident. Please attach additional information if necessary.
1. Caller’s Contact Information:
a. Name:
–

b. Telephone Number:

–

ext

2. Operator Information:
a. Operator
Name:
b. Mailing Address:
Street:
City:

State:

ZIP Code:

–

3. NOI NPDES Permit Tracking Number:
4. Contact person, if different than the person providing the 24-hour notice under item 1 above:
a. Name:
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: _______________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
7. Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7a below, for each product
applied in the area of the adverse incident: _________________________________________________________________________________
____________________________________________________________________________________________________________________
a. Pesticide Registration Number:

Pesticide Registration Number:

8. Describe any steps the Operator has taken or will take to correct, repair, remedy, clean up, or otherwise address any adverse effects: _________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
9. Identify any other Operators authorized for coverage under this permit for discharges from the pesticide application activities
that resulted in the adverse incident (if known): ______________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

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B. Date and time the Operator Notified EPA of the Adverse Incident
1. Date EPA was contacted:

/

/

2. Time EPA was contacted: ___________________________ EST
3. Name and/or title of the person the Operator spoke with at EPA:
a. Name:

b. Title:

4. Instructions received from EPA: __________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
C. Rationale Why Adverse Incident Notification Not Required
Provide an explanation of why the Operator believes the adverse incident could not have been caused by exposure to the pesticide, if applicable :
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Consistent with permit requirements, Operator must also complete Part D below if unable to justify why adverse incident notification is not required.
D. Thirty (30) Day Adverse Incident Report
Information to be submitted within 30 days of a reportable adverse incident (PGP Part 6.4.2). This information must be provided to the appropriate EPA
Regional office and includes sections A and B above. Please attach additional information if necessary.
1. Location of incident, including the names of any waters affected and appearance of those waters (sheen, color, clarity, etc):
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
2. Describe the circumstances of the adverse incident including species affected, estimated number of individuals and approximate size of dead or
distressed organisms: __________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
3. Describe the magnitude and scope of the affected area (e.g. aquatic square area or total stream distance affected): ________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
4. Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name
of pesticide product and EPA registration number.
Pesticide
application rate:

Pesticide
application rate:

Intended use site:

Intended use site:

Method of application:

Method of application:

Product:

Product:

EPA Reg. No.:

EPA Reg. No.:

5. Describe the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for
pesticides applied): ____________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Provide an indication of which laboratory test(s), if any, were performed, and when. (Note: A summary of the test results must be provided within 5
days after they become available, if not available at the time of submission of this report.): ____________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

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7. Describe the actions to be taken to prevent recurrence of adverse incidents: _______________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

D. Certification (Appendix B, Subsection B.11)
I 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. I am aware that there are significant penalties for submitting false information, including the
possibility of fine and imprisonment for knowing violations.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:

Date:

/

/

Adverse Incident Report Preparer (Complete if Adverse Incident Report was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:

–

–

Ext

Date:

/

/

E-Mail:

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Instructions for Completing and Submitting the Thirty (30) Day Adverse Incident Written Report for the Pesticide General
Permit (PGP) for Discharges from the Application of Pesticides

Who Must Submit a 30-day Adverse Incident Report?
Except as provided for in the PGP Part 6.4.4, if an Operator observes or is
otherwise made aware of a reportable adverse incident pursuant to Part 6.4.1 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. Adverse incident, as defined in the PGP Appendix
A, is an unusual or unexpected incident that an Operator has observed upon
inspection or of which the Operator otherwise become aware, in which: (1) There is
evidence that a person or non-target organism has likely been exposed to a
pesticide residue, and (2) The person or non-target organism suffered a toxic or
adverse effect. See the PGP Appendix A, for the full definition of adverse incident.
Where multiple Operators are authorized for a discharge that results in an adverse
incident, notification and reporting by any one of the Operators constitutes
compliance for all of the Operators, provided a copy of the written report required in
Part 6.4.2 is also provided to all of the other authorized Operators within 30 days of
the reportable adverse incident.
When to File the Adverse Incident Report
This notification must be made by telephone within 24 hours of the Operator
becoming aware of the adverse incident and must include at least the information in
Part A above. Except as provided for in the PGP Part 6.4.4, within 30 days of a
reportable adverse incident pursuant to Part 6.4.1, Operators must provide a written
report of the adverse incident to the appropriate EPA Regional office at the address
listed in Part 8 of the PGP and to the state lead agency for pesticide regulation (see
http://npic.orst.edu/state1.htm). The adverse incident report must include at least the
information contained above.
When is reporting of adverse incidents NOT required under this permit?
Reporting of adverse incidents is not required under this permit 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 notifying the Operator 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.
Where to File the 30-day Adverse Incident Report
The Operator must immediately notify the appropriate EPA Incident Reporting
Contact, as identified at www.epa.gov/npdes/pesticides of the adverse incident. The
Operator(s) must provide a written report of the adverse incident to the appropriate
EPA Regional office at the address listed in Part 8 of the PGP and to the state lead
agency for pesticide regulation (see http://npic.orst.edu/state1.htm).
If an Operator becomes aware of an adverse incident affecting a federally listed
threatened or endangered species or its federally designated critical habitat which
may have resulted from a discharge from the Operator’s pesticide application, the
Operator must immediately notify the National Marine Fisheries Service (NMFS) in
the case of an anadromous or marine species, or the United States Fish and Wildlife
Service (FWS) in the case of a terrestrial or freshwater species.
Completing the 30-day Adverse Incident Report
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
appropriate EPA Regional office.
Section A. 24-hour Adverse Incident Notification
1. Provide contact information for the person that called EPA to report the adverse
incident.
a. Enter the legal name of the caller.
b. Enter the phone number of the caller.
2. Provide the Operator’s contact information.
a. Enter the legal name of the Operator.

b. Enter the mailing address of the Operator.
3. Enter the permit number under which you are reporting the adverse incident.
Appendix C of the PGP identifies permit numbers in the states for each EPA
Region.
4. Provide contact information for a contact person if different than the person that
called EPA to report the adverse incident.
a. Enter the legal name of the contact person.
b. Enter the phone number of the contact person.
5. Provide a description of how and when the operator became aware of the
adverse incident.
6. Provide a description of the location of the adverse incident.
7. Provide a description of the adverse incident and the pesticide product used in
the adverse incident.
a. Include the EPA pesticide registration number for each product applied in the
area of the adverse incident.
8. Provide a description of any steps the Operator has taken to correct, repair,
remedy, clean up or otherwise address the adverse effects of the incident.
9. Identify any other Operators authorized for coverage under the permit for
discharges from the pesticide application activities that resulted in the adverse
incident, if known.
Section B. Date and time the Operator Notified EPA of the Adverse Incident
1. Enter the date that EPA was contacted to report the adverse incident.
2. Enter the time that EPA was contacted to report the adverse incident.
3. Provide the name and title of the person contacted at EPA.
a. Enter the legal name of the person contacted at EPA
b. Enter the title of the person contacted at EPA.
4. Provide a description of the instructions received by EPA.
Section C. Thirty (30) Day Adverse Incident Notification
1. Enter the location of the adverse incident and include the names of any waters
affected. Please include the appearance of those waters (sheen, color, clarity,
etc.).
2. Provide a description of the circumstances of the adverse incident including
species affected, estimated number of affected individuals and approximate
dead or distressed organisms.
3. Provide a description of the magnitude and scope of the affected area. Include
aquatic square area or total stream distance affected if possible.
4. Provide a description of the pesticide application rate, intended use site (e.g., on
the bank, above waters, or directly to water), method of application, and the
name of pesticide product and EPA registration number.
5. Provide a description of the habitat and the circumstances under which the
adverse incident occurred (including any available ambient water data for
pesticides applied).
6. Indicate which test(s) were performed and when. The summary of the test results
must be provided within 5 days after they become available, if laboratory tests
were performed.
7. Provide an explanation of why the Operator believes the adverse incident could
not have been caused by exposure to the pesticide, if applicable.
8. Provide a description of the actions to be taken to prevent recurrence of adverse
incidents.
Section D. Certification
Enter the certifier’s printed name, title, and e-mail address. Sign and date the form.
For more information about the certification statement and signature, see Appendix
B of the PGP. (CAUTION: An unsigned or undated form will prevent the granting of
permit coverage.) Federal statutes provide for severe penalties for submitting false
information on this application form. 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

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(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 facility 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 the PDMP contact or a consultant for the certifier’s
signature), include the name, organization, phone number and e-mail address of the
report preparer.
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.

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