1. 1. Treatment Area Details:
      2. 3. Applied Pesticides Details:
      3. 4. Adverse incident(s) as a result of pesticide applications:

3800-PM-BPNPSM0345f 8/2012
Annual Report    Permit Number:      
 
 
 
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: (     )-     -     
 
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:      
Co mpany 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


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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