1. PAG-15
    2. NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
      1. NOTIFICATION

3800-PM-BPNPSM0345b 8/2012  Applicant Name:      
NOI
 
 

COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF POINT AND NON-POINT SOURCE MANAGEMENT

 



PAG-15



NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
GENERAL PERMIT FOR POINT SOURCE DISCHARGES TO WATERS
OF THE COMMONWEALTH OF PENNSYLVANIA FROM
THE APPLICATION OF PESTICIDES
NOTICE OF INTENT (NOI)
 
Before completing this form, read the step-by-step instructions provided in this NOI package.
Related ID#s (If Known)
DEP USE ONLY
Client ID#         APS ID#         Date Received & General Notes
Site ID#         Auth ID#              
        PAG-15
BASIC INFORMATION
Indicate whether the application is for new permit coverage, renewal of permit coverage already approved by DEP, or an amendment to a previously submitted NOI. If the NOI is for a renewal or amendment, supply the NPDES permit number.

  New Permit   Permit Renewal   Permit Amendment NPDES Permit No.      

Is the receiving water classification either an HQ or EV water or impaired for pesticides?
 
YES
  NO
NOTE: If the operator discharges to an HQ or EV water, or if a pesticide discharge is to a water body impaired by that particular pesticide or its degradates, coverage under the General Permit cannot be approved.
CLIENT / OPERATOR INFORMATION
DEP Client ID# Client Type/Code
           
Organization Name or Registered Fictitious Name Employer ID# (EIN) Dun & Bradstreet ID#
                 
Operator/ Individual Last Name First Name MI Suffix SSN
                             
Additional Operator / Individual Last Name First Name MI Suffix SSN
                             
Mailing Address Line 1 Mailing Address Line 2
           
Address Last Line – City State ZIP+4 Country
              +           
Client Contact Last Name First Name MI Suffix
                       
Client Contact Title   Phone Ext
                  
E-mail Address FAX
           
Person or organization conducting treatment (if other than applicant)

PA Dept. of Agriculture’s Applicator Certification #      

Business License #      

Daytime Phone:      -     -     

Address - Street:         Fax Number:      -     -     
City:       State:       Zip code:     -        
SITE INFORMATION
DEP Site ID# Site Name
           
Estimated Number of Employees to be Present at Site      
Description of Site
     
County Name Municipality State
City
Boro
Twp
                       
Site Location Line 1 Site Location Line 2 Have Multiple Site
             Attach details separately  
Site Location Last Line – City State ZIP+4
              
Detailed Written Directions to Site
     
Site Contact Last Name First Name MI Suffix
                       
Site Contact Title Site Contact Firm
           
Mailing Address Line 1 Mailing Address Line 2
           
Address Last Line – City State ZIP+4
              
Phone Ext FAX E-mail Address
                      
NAICS Codes (Two- & Three-Digit Codes – List All That Apply) 6-Digit Code (Optional)
           
Site-to-Client Relationship
     
TREATMENT AREA INFORMATION
Existing Permits. Identify all environmental quality permits (earth disturbance, NPDES, etc.) issued or applied for on behalf.
Permit Type
Permit#
Date Issued/Applied For
     
     
     
     
     
     
 

Stocked by PFBC? (Check one)   Yes or No
 

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

If yes, indicate time of year:
 

Name and list all receiving streams: (If unnamed, indicate “unnamed tributary to insert name Creek”)


     
 

Water body characteristics:


     

Total area: acres


     

Average depth: feet


     
 
Treatment area location and map are attached 1   YES   NO
USGS Quadrangle Name      
Latitude/Longitude of Discharge Point
Latitude
Longitude
 
Degrees
Minutes
Seconds
Degrees
Minutes
Seconds
     
     
     
     
     
     
     
Horizontal Accuracy Measure Feet       --or-- Meters      
Horizontal Reference Datum Code North American Datum of 1983 World Geodetic System of 1984
Reference Point Code      
Altitude Feet       --or-- Meters      
Altitude Datum Name   The North American Vertical Datum of 1988 (NAVD88)
Altitude (Vertical) Location Datum Collection Method Code          
Geometric Type Code      
Data Collection Date      
Source Map Scale Number
     
Inch(es)
=
     
Feet
--or--
     
Centimeter(s)
=
     
Meters
CHAPTER 93 CLASSIFICATION, IMPAIRMENT AND TMDL STATUS
Provide ALL requested information in this area. For point sources discharging to waters of the Commonwealth, indicate the receiving water classification(s) and water uses protected in the Chapter 93 regulations. If any receiving water is designated as an HQ or EV water or impaired by a particular pesticide or its degradates for which authorization is being asked, an individual permit application for discharges to that water must be filed.
Receiving Water(s)
Impairment Status

(Attaining Water Quality Standards or Impaired)

Status of TMDL
(Approved, Not Developed or N/A)
     
                 
                 
PESTICIDE USE PATTERNS (check all that apply):
a. Mosquitoes and Other Flying Insect Pest Control b. Weeds and Algae Pest Control
c. Animals Pest Control d. Forest Canopy Pest Control
For use patterns checked above, provide the following:
Receiving Waters (check one):

Coverage requested for all waters within locations identified above

Coverage requested for all waters within locations identified above except for:      
Coverage requested specifically for the following waters within locations identified above:
     

PNDI - Listed Threatened or Endangered Species in Pennsylvania(i.e., “Species):

Pesticide application activities for which permit coverage is being requested will not overlap with the distribution map locations of any Species or Habitat.

Pesticide application activities for which permit coverage is being requested will overlap with the distribution of any Species or Habitat but the Pennsylvania Department of Conservation and Natural Resources, the Pennsylvania Game Commission, the Pennsylvania Fish and Boat Commission, and the U.S. Fish and Wildlife Service have been consulted for all these activities for which you are requesting coverage under this permit.

Pesticide application activities for which permit coverage is being requested will overlap with the distribution of any Species or Habitat. Please list all Species or Habitat identified within the area for which permit coverage is being requested.

PROPOSED TREATMENT DOSAGE INFORMATION
Proposed Treatment
Pesticide*
Dose (gal or lbs)
Treatment
Area (acres or linear mi)
Treatment
Depth (feet)
Amount Each
Treatment (gal or lbs)
No. of
Treatments
Target
1.
Manufacturer
EPA Reg. #
     
     
     
     
     
     
2.
Manufacturer
EPA Reg. #
     
     
     
     
     
     
3.
Manufacturer
EPA Reg. #
     
     
     
     
     
     
4.
Manufacturer
EPA Reg. #
     
     
     
     
     
     
5.
Manufacturer
EPA Reg. #
     
     
     
     
     
     
* Attach the product label containing dosage information with the Notice of Intent (NOI).
 
 
Proposed date(s) of treatment:        


Additional information for reviewer consideration:        


NOTIFICATION


 

Notification of potential users of treated water: Has occurred or Will occur prior to treatment.
(Note: Potential users of treated water must be notified at least 24 hours in advance of treatment).
 
Are you aware of any objections to treatment from potential users of treated water? Yes or No

If yes, describe:      
COMPLIANCE HISTORY REVIEW
Is the facility owner or operator in violation of any DEP regulation, permit, order or schedule of compliance at this or any other facility?
  YES   NO
If "YES," list each permit, order and schedule of compliance and provide compliance status. Use additional sheets to provide information on all permits.
Permit Program       Permit No.      
Brief Description of Noncompliance
     
Steps Taken or to be Taken to Achieve Compliance
Date(s) Compliance Achieved
           
           
Current Compliance Status   In Compliance   In Noncompliance
         
PESTICIDE DISCHARGE MANAGEMENT PLAN

If required (see 3800-PM-BPNPSM0345a, NOI Instructions (page 11) and Appendix D of the General Permit), attach a Pesticide Discharge Management Plan (PDMP).

 
CERTIFICATION
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 are 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.
 
             
Name (type or print legibly)   Official Title
         
Signature   Date

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