1. APPLICATION FOR USE OF AN ALGICIDE, HERBICIDE OR FISH CONTROL CHEMICAL
    2. IN WATERS OF THE COMMONWEALTH


3800-PM-BCW0094b 3/2017  COMMONWEALTH OF PENNSYLVANIA
Application  DEPARTMENT OF ENVIRONMENTAL PROTECTION

 
BUREAU OF CLEAN WATER
 FISH AND BOAT COMMISSION
 
 
 
3800-PM-BCW0094b 3/2017
Application
 
 


APPLICATION FOR USE OF AN ALGICIDE, HERBICIDE OR FISH CONTROL CHEMICAL


IN WATERS OF THE COMMONWEALTH

 
Submit one copy of the completed application to the Pennsylvania Department of Environmental Protection (DEP). One copy of the application must also be sent to the Pennsylvania Fish and Boat Commission (PFBC) if the applicant proposes aquatic plant management in free flowing waters or the use of fish control chemicals (see instructions for addresses).
 
This application will be reviewed by DEP and, where applicable, PFBC. If acceptable, a permit will be issued under DEP’s regulations at 25 Pa. Code §91.38 and PFBC’s Fishing and Boating regulations at 58 Pa. Code, §51.61. The permit will be effective for three (3) years for treatments to waters classified as High Quality or Exceptional Value and five (5) years for treatments to all other waters, unless one or more of the conditions identified in Section I.4 of the instructions occur.
 

 
Application is for (check one): New Permit Renewal Amendment  Permit No.:        

 

 
Applicant Information (if completing on behalf of a corporation, association or club, that entity is the applicant)
1.   Name of Applicant (owner or lessee):

       

Daytime Telephone:         

Email:         

Is the applicant the owner or lessee of all the land on which the water to be treated is located? Yes or No
Address -  Street:         

 City:           State:           Zip Code:         

2.   Person or organization conducting treatment (if other than applicant)

       

Daytime Telephone:         

Email:         

PA Dept. Agriculture Pesticide Certification #           
Address -  Street:         

 City:           State:           Zip Code:         

Water Body Information
3.  Name of water body to be treated:         
4.  County Location:        
Municipality:        

Check one:  City Borough Township

5.  Type of Water Body (Check one)   Pond, Lake, Impoundment, Canal, Other (specify)        
 
6.  Water Body Uses: Water supply: Municipal Private Industrial Livestock Irrigation
  Other uses: Fishing Fire protection Swim Water skiing Other

       

Chapter 93 Classification (see instructions):        
7.   Does the impoundment contain fish or other aquatic organisms? (Check one) Yes or No

If yes, check those that apply: Warmwater species   Coldwater species (trout)   Triploid grass carp

8.  Is the water open to public fishing?

(Check one)  Yes or No

Stocked by PFBC?

(Check one) Yes or No

9.  Does the water body have an overflow of water? (Check one) Yes or No

If yes, indicate time of year:        

10.  Name of receiving stream: (If unnamed, indicate “unnamed tributary to insert name Creek”)

       

 
11.  Water Body Characteristics: Total area:       acres Average depth:       feet
Treatment Location
12.  Attach an 8.5” x 11” photocopy of a topographical map to show the location of the water body to be treated (note - applications without map(s) will be returned as incomplete).
Provide the latitude and longitude of the outlet for the water body to be treated.

Latitude:        Degrees        Minutes        Seconds North OR Decimal Degrees:       

Longitude:        Degrees        Minutes        Seconds West OR Decimal Degrees:       

Treatment Information
13.  Proposed Annual Treatment(s)
 

Pesticide
Dose
Treatment
Area
Treatment
Depth
Amount each Treatment
No. Treatments
Target Organism(s)
1.       

Manufacturer:      

EPA Reg. #      

     
     

acres

     

feet

     
     
     
2.       

Manufacturer:      

EPA Reg. #      

     
     

acres

     

feet

     
     
     
3.       

Manufacturer:      

EPA Reg. #      

     
     

acres

     

feet

     
     
     
4.       

Manufacturer:      

EPA Reg. #      

     
     

acres

     

feet

     
     
     
14.  Proposed date or dates of treatment:

       

15.  Additional information for reviewer consideration:

       

Notification and Applicant Certification
16.  Notification of potential users of treated water:  Has occurred   or Will occur prior to treatment

Potential users of treated water must be notified at least one day in advance of treatment.

Are you aware of any objections to treatment from potential users of treated water? Yes or No

If yes, describe:        

17. The applicant (a) is responsible for any damages incurred as a result of pesticide treatment and (b) certifies the truth of the above statements.

Applicant Signature:

 

 

 

     
 

Signature

 

Date
 

     

 

     
 

Name (print or type)

 

Title
 


 
 
 
 
 
 
 
 
 

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