1. ANNUAL PESTICIDES APPLICATION REPORT

3800-PM-BPNPSM0345f 8/2012
Annual Report
Permit Number:
- 1 -
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT
ANNUAL PESTICIDES APPLICATION REPORT
Reporting Period: January 1 – December 31,
Operator Name:
Permit Number:
Contact Person Name:
Title:
Address:
Phone: (
)
Zip:
-
Email:
(Information that exceeds the available space on this form should be attached or otherwise supplied electronically)
1. Treatment Area Details:
Pesticides Treatment Area Name or
Location:
Area
Size
Units
(acres
or
feet)
Waterbody
(Name and
Location)
Municipality
County
1
2
3
4
5
Completion, submittal and receipt of this report by January 28 of following year is a requirement of this permit.
Unless DEP’s eDMR system is used, reports are to be mailed to the DEP regional office that issued your permit
and to the municipality in which the project is located.
2. Pesticides Use Pattern(s)
(i.e. mosquito or other flying pests, weeds and algae, animal pests or forest canopy)
for locations identified in table above
:
Location #:
Use Pattern:
Target Pest:
Company or Applicator(s) Name (if different than above):
Address:
Phone: (
)-
-
Location #:
Use Pattern:
Target Pest:
Company or Applicator(s) Name (if different than above):
Address:
Phone: (
)-
-

3800-PM-BPNPSM0345f 8/2012
Annual Report
Permit Number:
- 2 -
Location #:
Use Pattern:
Target Pest:
Company or Applicator(s) Name (if different than above):
Address:
Phone: (
)-
-
Location #:
Use Pattern:
Target Pest:
Company or Applicator(s) Name (if different than above):
Address:
Phone: (
)-
-
Location #:
Use Pattern:
Target Pest:
Company or Applicator(s) Name (if different than above):
Address:
Phone: (
)-
-
3. Applied Pesticides Details:
Location
Name of Pesticide
Amount
and Units
EPA
Registration
#
Application
Method
Addressed in
PDMP Prior to
Application?
1
Yes
No
2
Yes
No
3
Yes
No
4
Yes
No
5
Yes
No

3800-PM-BPNPSM0345f 8/2012
Annual Report
Permit Number:
- 3 -
4. Adverse incident(s) as a result of pesticide applications:
Location
Details of adverse incident (as described in adverse
incident notification*) or noticeable observation due to
pesticides applications
Description of corrective actions including
spill responses, if any, resulting from
pesticides activities and the rationale for
such action
1
2
3
4
5
* All adverse incident reports must be sent within 30 days of the date the Operator became aware of the adverse
incident to DEP and other related state agencies.
I certify under penalty of law and subject to the penalties of 18 Pa. C.S. Section 4904 (relating to unsworn falsification
to authorities) 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. Based on 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 further acknowledge that the facility, treatment area and operator described herein is
eligible for coverage under DEP’s General Permit. I am aware that there are significant penalties for submitting false
information, including the possibility of fine and imprisonment for knowing violations.
Signature of Permittee
Date

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