6100-24 Adverse Incident Report Template

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.
2040-0284

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.
Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation.
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 https://www.epa.gov/npdes/pesticide-permitting.
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:
–

b. Telephone Number:

–

Ext

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

City:

ZIP Code:

–

(Enter “NA” if not applicable)

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:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-0024 (REVISED October 24, 2016)

Page 1 of 6

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. EPA Pesticide Registration Number:

EPA 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 and if so, provide details of your notification of those other Operator(s):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
C. Date and Time the Operator Notified EPA of the Adverse Incident
1. Date EPA was contacted:

/

/

2. Time EPA was contacted: ______________________________

3. Name and/or title of the person the Operator spoke with at EPA:
a. Name:

b. Title:

4. Instructions received from EPA:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________

EPA FORM 6100-0024 (REVISED October 24, 2016)

Page 2 of 6

D. Other Information Required in the Thirty (30) Day Adverse Incident Report
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 affected 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 pesticide registration number (EPA Reg. No.).
Pesticide
application rate:

Pesticide
application rate:

Intended use site:

Intended use site:

Method of application:

Method of application:

Pesticide Product:

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

EPA FORM 6100-0024 (REVISED October 24, 2016)

Page 3 of 6

E. 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:

/

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:

EPA FORM 6100-0024 (REVISED October 24, 2016)

Page 4 of 6

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?

Section B. Information from the 24-hour Adverse Incident Notification

All Operators who observe or are otherwise made aware of a reportable adverse
incident pursuant to Part 6.4 of the permit must submit on adverse incident report.

1. Provide contact information for the person who 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. If an NOI was filed as required in Part 1.2 of the permit, enter the NPDES Permit
Tracking Number assigned by eNOI or the EPA’s Pesticides Processing Center.
You can find the tracking number assigned to your NOI using EPA’s eNOI
System (https://www.epa.gov/npdes/pesticide-permitting). If no NOI submitted,
enter “NA” for not applicable.
4. Provide information for a contact person, if different than the person who 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. Include the EPA pesticide registration number for each
product applied in the area of the adverse incident. Attach additional pages if
necessary.
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 other Operators are authorized under this permit, provide details of
your notification of those other Operator(s).

However, even for those identified adverse incidents for which the Operator is not
required to report, EPA recommends that Operators consider using this form to
document the incident and the rationale for why reporting of the adverse incident is
not required. This information may be useful to support a rationale should this
determination be questioned.
An adverse incident, as defined in the Appendix A of the permit, is an unusual or
unexpected incident that an Operator has observed upon inspection or of which the
Operator otherwise became 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 Appendix A of
the permit, for the complete 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 of the permit 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
Operators must provide a written report of any reportable adverse incidents to the
appropriate EPA Regional office and to the state lead agency for pesticide
regulation within 30 days of the adverse incident pursuant to Part 6.4.1.1 of the
permit.
Where to File the 30-day Adverse Incident Report
The Operator must immediately notify the appropriate EPA Incident Reporting
Contact, as identified at https://www.epa.gov/npdes/pesticide-permitting, of the
adverse incident within 24 hours. 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 permit 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 federally designated critical habitats 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, (see http://www.nmfs.noaa.gov) or
the United States Fish and Wildlife Service (FWS) in the case of a terrestrial or
freshwater species (see http://www.fws.gov).
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. Reportable Adverse Incident
The Operator is required to submit this Adverse Incident Report if the adverse
incident is reportable. Check yes if the adverse incident is reportable. If an Adverse
Incident Report is not required, check no. No further action is needed on this form.
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 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.

EPA FORM 6100-0024 (REVISED October 24, 2016)

Section C. Date and Time the Operator Notified EPA of the Adverse Incident
1.
2.
3.
4.

Enter the date that EPA was contacted to report the adverse incident.
Enter the time EPA was contacted to report the adverse incident.
Provide the legal name and title of the person contacted at EPA.
Provide a description of the instructions received by EPA.

Section D. Other Information Required in the Thirty (30) Day Adverse Incident
Report
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 size
of 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 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 pesticide 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 laboratory test(s) were performed and when, if laboratory tests
were performed. The 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.
7. Provide a description of the actions to be taken to prevent recurrence of adverse
incidents.

Page 5 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 6100-0024 (REVISED October 24, 2016)

Page 6 of 6