5 Pesticide Discharge Evaluation Worksheet

UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
WASHINGTON, DC 20460
PESTICIDE DISCHARGE EVALUATION WORKSHEET FOR THE
PESTICIDE GENERAL PERMIT (PGP) FOR DISCHARGES FROM THE
APPLICATION OF PESTICIDES

Form Approved
OMB No.
XXXX-XXXX

This worksheet is for any decision-maker required to submit a Notice of Intent (NOI) and a small entity, as defined in Appendix A of the Pesticide
General Permit (PGP). The information on this worksheet must be retained for each pesticide application activity.
A. General Information
1. Operator Name:
2. Worksheet Preparer Name:

3. Pest Management Area:

#__ of ## ____

4. Pest Management Area Name: ___________________________________________________________________________________________
5. Indicate the pesticide use pattern for the pest management area:
a.

Mosquito and Other Flying Insect Pests

b.

Weed and Algae Pests

c.

Animal Pests

d.

Forest Canopy Pests

6. 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: ____________________________________________
________________________________________________________________________________________________________________
B. Pest Evaluation
1. Identify the target pest(s) and explain why control is needed: ____________________________________________________________________
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________

2. Describe pest management measure(s) implemented before the first pesticide application: _____________________________________________
_____________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________
3. Name or location of any Waters of the United States to which discharges occurred: ________________________________________________

______________________________________________________________________________________________________________________
C. Pesticide Application
1. Operator name(s) and contact information for pesticide applicator(s):
Operator Name:
Street:
City:

State:

Zip Code:

-

Contact Name:
Phone:

Ext

E-mail:

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2. Pesticide application start date:

/

/

/

Pesticide application end date:

/

3. Name of each pesticide product used, EPA registration number, and quantity of pesticide applied (as packaged or as formulated): Circle lbs or gallons.
Product Name

Product Name

Product Name

EPA Reg. No.

EPA Reg. No.

EPA Reg. No.

Quantity
(lbs or gallons)

Quantity
(lbs or gallons)

Quantity
(lbs or gallons)

Application method: _______________________ Application method: _______________________ Application method: _______________________

4. Visual monitoring was conducted during pesticide application and/or post-application?

Yes.

No. If no, describe why not? ________________

_______________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________
5. Any adverse effects identified during visual monitoring?

Yes.

No. If yes, describe. _______________________________________________

______________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

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 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 contained is, to the best of my knowledge
and belief, true, accurate, and complete. I am aware that there are significant penalties for recording false information, including the possibility of fine
and imprisonment for knowing violations. I further certify that the applicant has sufficient title, right, or interest in the property where the proposed
activity occurs.
Printed Name:
Title:
E-Mail:
Signature/Responsible Official:

Date:

/

/

Pesticide Discharge Evaluation Worksheet Preparer (Complete if worksheet was prepared by someone other than the certifier)
Preparer Name:
Organization:
Phone:

–

–

Ext

Date:

/

/

E-Mail:

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Instructions for Completing the Pesticide Discharge Evaluation Worksheet (PDEW) for Discharges from the Application
of Pesticides to Waters of the United States under the NPDES Pesticides General Permit
Who Must File a PDEW with EPA?
Any owner/operator who is also a decision-maker, as described in the PGP Part
1.2.2, who is required to submit a Notice of Intent (NOI) and who is a small entity
as defined in Appendix A of EPA’s NPDES Pesticide General Permit (PGP) must
complete this Pesticide Discharge Evaluation Worksheet (PDEW) for each
treatment area.
Pest management area, as defined in Appendix A of the permit, can be a large
area (e.g., an entire town) or a very specific well-defined management area (i.e., a
lake). Thus, a pest management area can have one or more treatment areas.
Decision-makers should retain a copy of a completed worksheet for each treatment
area. For treatment areas with the same or similar pests, decision-makers can use
one worksheet to document pest management activities for those multiple
treatment areas.
When to File the PDEW
Before any pesticide application, the decision maker must complete Part B of this
worksheet. Part C, except for the pesticide application end date and total quantity
of pesticide applied, must be completed as soon as possible but no later than 14
days after the first pesticide application. The total quantity of pesticide applied and
the pesticide application end date must be completed as soon as possible but no
later than 14 days after completion of pesticide application for this project.
Where to File the PDEW
Decision-makers must retain this worksheet for at least 3 years from the date that
coverage is granted under the PGP or when the permit expires or is terminated.
Decision-makers must make this worksheet available to EPA, including an
authorized representative of EPA, upon request.
Completing the PDEW Form
To complete this form, type or print in uppercase letters in the approriate areas
only. Make sure you complete all questions.
Section A. General Information
1. Enter the decision-maker’s full legal name.
2. Enter the full legal name of the person completing the PDEW form.
3. Provide a brief description of the treatment area(s).
4. Provide the size of the treatment area in acres or linear feet.
5. Identify the pesticide use pattern(s) for the treatment area.

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 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 PDEW was prepared by someone other than the certifier (for example, if the
PDEW 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 PDEW preparer.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is
estimated to average 1 hour or 60 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 Pesticide
Discharge Evaluation Worksheet to this address.

Section B. Pest Evaluation
As required in section 7.2 of the PGP, provide information about the treatment area
to which pesticides are discharged.
1. Identify the target pest(s) and provide a brief description of why pest control is
needed.
2. Provide a brief description of any pest management measure(s) implemented
before pesticide application.
3. Identify any Waters of the United States by name or location to which
pesticide(s) are discharged.
Section C. Pesticide Application
1. Provide the company name and contact information of the pesticide applicator.
2. Enter the date that the pesticide application began and ended.
3. Enter the name of each pesticide product used including the EPA Registraion
Number and quanity of pesticide applied.
4. Indicate if visual moniotoing was conducted during the pesticide application
and/or post-application. If visual monitoring was not performed, provide a brief
descrition of why visual monitoring was not conduted.
5. Indicate if there were any adverse effects identifed during visual monitoring.
Provide a brief decription of any adverse effects that were identified.
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 NOI 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:

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