EPA-HQ-OW-2020-0005-0079_PGP

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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.
2040-0004

This worksheet is for any Operator who is also a Decision-maker required to submit a Notice of Intent (NOI) and is 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:
NPDES Permit Tracking
Number:
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 pest control is needed:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
2. Describe Pest Management Measure(s) implemented before the first pesticide application:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
C. Pesticide Application
1. Name and contact information for pesticide Applicator(s):
Company Name:
Street:
City:

State:

Zip Code:

Contact Name:
Phone:

–

–

Ext.

E-mail:

EPA FORM 6100-26 (Revised September 8, 2021)

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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. Was visual monitoring conducted during pesticide application and/or post-application?

Yes.

___________________________

No. If no, describe why not?

__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
5. Were 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.
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:

EPA FORM 6100-26 (Revised September 8, 2021)

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Instructions for Completing the Pesticide Discharge Evaluation Worksheet (PDEW) for the P ESTICIDE GENERAL PERMIT (PGP) FOR
DISCHARGES FROM THE APPLICATION OF PESTICIDES
Who Must Complete a PDEW?
Any Operator, who is a Decision-maker required to submit a Notice of Intent
(NOI) and is a small entity as defined in Appendix A of the permit may complete
this Pesticide Discharge Evaluation Worksheet (PDEW) to meet the
requirements of Part 7.3 of the PGP.
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
(e.g., a lake). Thus, a pest management area can have one or more treatment
areas. Operators required to retain the information contained on this worksheet
must do so for each treatment area. For treatment areas with the same or
similar pests, the Operator can use one worksheet to document pest
management activities for those multiple treatment areas.

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 Pesticide
Registraion Number, the quanity of pesticide applied, and the method used
to apply the pesticide (e.g., fixed wing aircraft, backpack sprayer).
4. Indicate if visual monitoring was conducted during the pesticide application
and/or post-application. If visual monitoring was not performed, provide a
brief description of why visual monitoring was not conducted.
5. Indicate if there were any adverse effects identifed during visual monitoring.
Provide a brief decription of any adverse effects that were identified.

When to Complete a PDEW?
Before any pesticide application, any Operator using this form to meet its
obligations under the PGP must complete Section B of this worksheet. Section
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.

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 40 CFR
122.41(k). (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:

Any Operator using this form to meet its obligations under the PGP 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. These Operators must
make this worksheet available to EPA, including an authorized representative of
EPA, upon request.

(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

Completing the PDEW
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 Operator’s full legal name and the existing NPDES Permit
Tracking Number assigned by EPA’s NPDES eReporting Tool (NeT) or
EPA’s Pesticides Processing Center. You can find the tracking number
assigned to your previous NOI using EPA’s NeT.
2. Enter the full legal name of the person completing the form.
3. Section A 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).
4. Enter the name of the Pest Management Area.
5. Identify the pesticide use pattern(s) for the Pest Management Area.
6. For each treatment area, provide a brief description and location description
of the treatment area within the Pest Management Area; size of the
treatment area in acres or linear feet, and name or location of any waters of
the United States to which discharges occur.
Section B. Pest Evaluation
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. For example, identify if you have
performed physical control techniques such as pulling weeds, removing
breeding habitat, or trapping animals.

EPA FORM 6100-26 (Revised September 8, 2021)

For a corporation: by a responsible corporate officer, means:

(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 PDEW was prepared by someone other than the certifier (for example, if
the PDEW was prepared by 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.

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