6100-25 Annual Report Template

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.
2040-0284

This form is for any Operator who 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.

Approval to Use Paper Annual Report Form (Electronic Submission Waiver)
Has the EPA Regional Office granted you a waiver from electronic reporting*?

YES

NO

If yes, check which waiver you have been granted, the name of the EPA Regional Office staff person who granted the waiver, and the date of approval:
Waiver granted:

The Decision-maker is physically located in a geographical area (i.e., ZIP code or census tract) that is identified as under-served for broadband
Internet access in the most recent report from the Federal Communications Commission.
The Decision-maker has limitations regarding available computer access or computer capability.

Name of EPA staff person who granted
the waiver:
/

Date approval obtained:

/

*Note: You are required to obtain approval from the applicable EPA Regional Office prior to using this paper annual reporting form. If you have not obtained a
waiver, you must file this form electronically using the NPDES eNOI system at https://www.epa.gov/npdes/pesticide-permitting.

A. General Information - For pesticides activities in calendar year:
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 permit?
a.

No adverse incidents were observed or no corrective action was taken. (Proceed to Section C)

b.

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 additional Pest Management Areas).

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:

/

/

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:

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:
____________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________

EPA FORM 6100-25 (Revised October 24, 2016)

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.

For each treatment area (use additional pages for each treatment area):
2. Indicate the pesticide use pattern for the treatment area:
a.

Mosquito and Other Flying Insect Pest Control

b.

Weed and Algae Pest Control

c.

Animal Pest Control

d.

Forest Canopy Pest Control

3. Description of treatment area:
a. Provide a map or 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?
Yes

No

If yes, approximate date(s) of any discharges: ___________________________________________________________________________

4. Name and contact information of pesticide Applicator(s) (or check here if same as provided in Section A):
Company 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 Pesticide Registration Number(s) and by application method.
Circle if quantity indicated is in lbs or gallons, or briquettes, if applicable. Use additional pages if necessary.
Product Name ___________________________

Product Name __________________________

EPA Pesticide Registration Number :

EPA Pesticide Registration Number :

Application method:

Quantity Applied (lbs or
gallons of product):

Application method:

Aerially by fixed-wing

______ lbs or gallons

a.

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

d.

Aquatic vehicle mounted sprayer

e.

Quantity Applied (lbs or
gallons of product):

Aerially by fixed-wing

______ 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

______ lbs or gallons

d.

Aquatic vehicle mounted sprayer

______ lbs or gallons

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 or
briquettes

g.

Other (specify): ___________________

______ lbs or gallons or
briquettes

a.

EPA FORM 6100-25 (Revised October 24, 2016)

NOTE: Copy this page and attach additional pages as necessary

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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:

EPA FORM 6100-25 (Revised October 24, 2016)

NOTE: Copy this page and attach additional pages as necessary

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Instructions for Completing the Annual Reporting Form for the Pesticide General Permit (PGP) for
Discharges from the Application of Pesticides
Who Must File an Annual Report with EPA?
Any Operator who 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 (eNOI) system available on EPA’s website
(https://www.epa.gov/npdes/pesticide-permitting) unless the Operator is granted a
waiver from the requirement to use eNOI for submitting the Annual Report. See Part
8 of the PGP for EPA Regional contacts. The Electronic Submission Waiver is at the
top of this form.
If you are granted 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.

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
(https://www.epa.gov/npdes/pesticide-permitting).
2. 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.
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 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.
2. Enter the name of the Pest Management Area.
3. 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.
4. 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.
6. 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
2. Select the box for the type of pesticide use pattern for the treatment area (use
additional pages for each treatment area).
3. Provide a description of the treatment area.

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.

a. Provide a map or description of the treatment area, including a description of
the location.

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.

b. Provide the size of the treatment area in acres or linear feet.

Approval to Use Paper Annual Reporting Form: You must indicate whether you
have been granted a waiver from electronic reporting from the EPA Regional Office.
Note that you are not authorized to use this paper Annual Reporting form unless the
EPA Regional Office has approved its use. Where you have obtained approval to
use this form, indicate the waiver that you have been granted, the name of the EPA
staff person who granted the waiver, and the date that approval was provided.

EPA FORM 6100-25 (Revised October 24, 2016)

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 https://www.epa.gov/npdes/pesticidepermitting.

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4. Provide the company name(s), mailing address, a contact person, contact
person’s title, telephone number and e-mail address of 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 Pesticide Registration Number(s) and by application
method. Circle whether the quantity applied is in pounds or gallons or briquettes,
if applicable. 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 Report
Form to this address.

EPA FORM 6100-25 (Revised October 24, 2016)

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