2 Annual Reporting Form

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
ANNUAL REPORTING FORM FOR THE PESTICIDE GENERAL PERMIT (PGP) FOR
DISCHARGES FROM THE APPLICATION OF PESTICIDES

Form Approved
OMB No.
XXXX-XXXX

Decision-makers who are required to submit an NOI and are defined as a large entity in Appendix A, or Decision-makers who are required to submit an NOI for discharges
to Waters of the United States containing NMFS Listed Resources of Concern, as defined in Appendix A, must submit an annual report to EPA each calendar year for the
duration of coverage under the PGP, whether or not the Decision-maker has discharges from the application of pesticides in any subsequent calendar year. The annual
report must be submitted no later than February 15 of the following year for all pesticide activities covered under the PGP occurring during the previous calendar year.
Decision-makers who are required to submit an NOI based on an annual treatment area threshold 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 Decision-makers exceeded the annual treatment area threshold. If the Decisionmaker first exceeds an annual treatment area threshold after December 1, an annual report is not required for that first partial year but an annual report is required
thereafter, with the first annual report submitted also including information from the first partial year. When Decision-makers terminate permit coverage, as specified in Part
1.2.5, 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 next year.

Electronic Submission Waiver
I hereby acknowledge my waiver request from the use of EPA’s electronic Notice of Intent system (eNOI) because my use of eNOI will incur undue burden or expense
over my use of this paper Notice of Termination 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:
3. Operator Contact Information:
a. Street:
b. City:

c. State:

–

e. Telephone:

–

ext

f. Fax:

d. ZIP Code:

–

–

–

4. Contact Information:
a. Contact Name:
b. Title:
c. E-mail:

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 PGP?
a.

No adverse incidents were observed or corrective action was taken. (Proceed to question 6)

b.

Yes, an adverse incident was observed and/or a corrective action was taken. (Complete questions 2-5 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, enter any adverse incidents as a result of those treatment(s), as described in the PGP Part 6.4 (use additional pages, if needed):
a.

Date of adverse incident observation:

4. Date and time the
any instructions

/

/

Operator contacted EPA to notify the Agency of the adverse incident, who the Operator spoke with at EPA, and
received from EPA.
/

/

a.

Date:

b.

Time: ___________________________________________

c.

Who the Operator spoke with at EPA _______________________________________________________

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 _________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
NOTE: Copy this page and attach additional pages as necessary

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____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

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.

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.

Yes. Proceed to question 2.

2. Indicate the pesticide use pattern for the Pest Management Area:
a.

Mosquito and Other Flying Insect Pest Control b.
Control

Weed and Algae Pest Control

c.

Animal Pest Control

d.

Forest Canopy Pest

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.

Identify pesticide application activities that resulted in a point source discharge to Waters of the United States containing NMFS Listed Resources of Concern:
Yes

No

4. Operator name(s) and contact information for pesticide application(s) (or check here if same as provided in Section A):
Operator Name:
Street:
City:

State:

Contact Name:

-

Zip Code:

Title:

Phone:

Ext

E-mail:
5. Was this pest control activity addressed in your Pesticide Discharge Monitoring Plan (PDMP) before pesticide application:

Yes

No

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 lbs or gallons:
Product Name __________________________
–

Product Name ___________________________
Quantity Applied (lbs or gallons
of product):

Application method:

–

Quantity Applied (lbs or gallons
of product):

Application method:

a.

Aerially by fixed-wing

______ lbs or gallons

a.

Aerially by fixed-wing

______ lbs or gallons

b.

Aerially by rotary aircraft

______ lbs or gallons

b.

Aerially by rotary aircraft

______ lbs or gallons

c.

Land-based sprayer (includes backpack, land
vehicle mounted sprayers, high pressure
canopy sprayer)

______ lbs or gallons

c.

Land-based sprayer (includes backpack,
land vehicle mounted sprayers, high
pressure canopy sprayer)

______ lbs or gallons

d.

Aquatic vehicle mounted sprayer

______ lbs or gallons

d.

Aquatic vehicle mounted sprayer

______ lbs or gallons

e.

Direct mixture (includes metering, subsurface
applications)

______ lbs or gallons

e.

Direct mixture (includes metering,
subsurface applications)

______ lbs or gallons

f.

Chemigation

______ lbs or gallons

f.

Chemigation

______ lbs or gallons

g.

Other (specify): _________________

______ lbs or gallons

g.

Other (specify): _________________

______ lbs or gallons

NOTE: Copy this page and attach additional pages as necessary

Page 2 of 5

Product Name __________________________

Product Name ___________________________
Quantity Applied (lbs or gallons
of product):

–
Application method:

Quantity Applied (lbs or gallons
of product):

–
Application method:

Aerially by fixed-wing

______ lbs or gallons

a.

Aerially by fixed-wing

______ lbs or gallons

b.

Aerially by rotary aircraft

______ lbs or gallons

b.

Aerially by rotary aircraft

______ lbs or gallons

c.

Land based sprayer (includes backpack, land
vehicle mounted sprayers, high pressure
canopy sprayer)

______ lbs or gallons

c.

Land based sprayer (includes backpack,
land vehicle mounted sprayers, high
pressure canopy sprayer)

______ lbs or gallons

d.

Aquatic vehicle mounted sprayer

______ lbs or gallons

d.

Aquatic vehicle mounted sprayer

______ lbs or gallons

e.

Direct mixture (includes metering, subsurface
applications)

______ lbs or gallons

e.

Direct mixture (includes metering,
subsurface applications)

______ lbs or gallons

f.

Chemigation

______ lbs or gallons

f.

Chemigation

______ lbs or gallons

g.

Other (specify): _________________

______ lbs or gallons

g.

Other (specify): _________________

______ lbs or gallons

a.

D. Certification
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:

/

/

/

/

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

–

–

Ext

Date:

E-Mail:

NOTE: Copy this page and attach additional pages as necessary

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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 owner/operator who is also a decision-maker, as described in the PGP Part
1.2.2 and is required to submit a Notice of Intent (NOI) and that is also a large entity
as identified in the PGP Part A, must submit an annual report to EPA each calendar
year. An annual report must be filed whether or not you have discharges from the
application of pesticides in accordance with the PGP section 7.6.
When to File an Annual Report
The annual report must be submitted no later than February 15 of the following year
for all pesticide activities covered under this permit occurring during the previous
calendar year. 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 you exceeded the annual treatment area
threshold. If you first exceed an annual treatment area threshold after December 1,
you are not required to submit an annual report for that first partial year but must
submit annual reports thereafter, with the first annual report submitted also including
information from the first partial year. When you terminate permit coverage, as
specified in the PGP Part 1.2.5, you must submit an annual report for the portion of
the year up through the date of your termination.
When decision-makers terminate permit coverage, as specified in Part 1.2.5, 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.

applications described in this application. An operator is the decision-maker 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.
3. Enter the address, telephone number, and fax number of the operator.
4. 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 incidents were observed and corrective actions were taken
for any Pest Management Area for which you have coverage under the PGP.
1a. Check if no adverse incidents were observed and no corrective actions were
taken for any Pest Management Area for which you have coverage under the
PGP.
1b. Check if an adverse incidents were observed and/or a corrective actions were
taken for any Pest Management Area for which you have coverage under the
PGP.
For each Pest Management Area for which an adverse incident was observed or
corrective action was taken, complete questions 2-5.
2. Enter any adverse incidents (incidents) resulting from the treatments, as
described in the PGP Part 6.4.
2a. Enter the date of the adverse incident.

Where to File the Annual Report
The owner/operator must prepare and submit the Annual Report using EPA’s
electronic Notice of Intent (eNOI) system available on EPA’s website
(www.epa.gov/npdes/pesticides/eNOI) unless eNOI is otherwise unavailable or the
owner/operator has obtained a waiver from the requirement to use eNOI for
submitting the Annual Report. The Electronic Submission Waiver is at the top of this
form. Owner/operators waived from the requirement to use eNOI 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.

3. 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 PGP.

If you do receive a waiver from using eNOI; you must send the Annual Report to
one of the addresses listed below.

5. 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.

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, please 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.
Section A. General Information
1. Enter your permit tracking number.
2. Provide the legal name of the person, firm, public organization or any other
public entity that operates or who is the decision-maker for the pesticides

NOTE: Copy this page and attach additional pages as necessary

3a. Indicate the date of the contact
3b. Indicate the time of the contact
3c. Indicate who the Operator spoke with at EPA
3d. Indicate any instructions received from EPA
4. Enter the date that the Thirty (30)-Day Adverse Incident Written Report was
submitted, pursuant to Part 6.4.2 of the PGP.

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.
1a.Check here if you had 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.
1b. Check here if you had discharge from pest control activities this calendar year.
2. Select the box for the type of pesticide use pattern for the pest management
area. Options are: Mosquitoes and Other Flying Insect Pests, Weed and Algae,
Animal Pest Control, and Forest Canopy Pests.
3. Provide a description of the treatment area (use additional pages for each
treatment area).
3a. Provide a description of the treatment area, including a description of the
location.
3b. Provide the size of the treatment area in acres or linear feet.
3c. Provide the name or location of any Waters of the United States to which
discharges occur.
3d. Provide a description of the target pest(s).
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.

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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.
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
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, 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 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 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 4800 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

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