1. PAG-15
      2. OF THE COMMONWEALTH OF PENNSYLVANIA FROM
      3. THE APPLICATION OF PESTICIDES
      4. NOTICE OF INTENT (NOI)

3800-PM-BPNPSM0345b 8/2012
Applicant Name:
NOI
- 1 -
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

3800-PM-BPNPSM0345b 8/2012
Applicant Name:
NOI
- 2 -
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

3800-PM-BPNPSM0345b 8/2012
Applicant Name:
NOI
- 3 -
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
Status of TMDL
1
Attach an 8.5” x 11” photocopy of a topographical map to show the location of the water body and the area to be treated. This map should be a
photocopy of a 7.5 minute USGS topographical quadrangle. The application area should be clearly identified. Provide the name of the 1:24,000
scale USGS 7.5-minute series quadrangle map which shows the application area. This information will be used to compare the proximity of the
treated body of water to receiving streams, other permitted treatment areas and other water users such as public water supplies.

3800-PM-BPNPSM0345b 8/2012
Applicant Name:
NOI
- 4 -
(Attaining Water Quality Standards or
Impaired)
(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).

3800-PM-BPNPSM0345b 8/2012
Applicant Name:
NOI
- 5 -
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
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
If yes, describe:

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