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
- 1 -
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:

3800-PM-BCW0094b
3/2017
Application
- 2 -
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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