npdes general permit for pesticide applications 30 day adverse incident report instructions: as required in part iv.c.4 of the gener


NPDES General Permit for Pesticide Applications
30 Day Adverse Incident Report
Instructions: As required in Part IV.C.4 of the general permit, the
permittee must fill out this form within thirty (30) days of becoming
aware of an adverse incident. Submittal of this form does not
substitute the submittal of the Adverse Incident Report Form which is
to be submitted within 24 hours of discovery. “Adverse Incidents” are
defined under Part VII of the general permit.
Permittee Information
Facility Permit # (if applicable):  
Permittee Name:  
Mailing Address:  
City:  
State:  
Zip:  
Contact Information
Contact Name and Title:  
Phone:  
Fax:  
E-mail:  
Incident Information
When did you become aware of the incident?
Date:  
Time:  
What was the duration of the incident?
Start Date:  
End Date (if applicable):  
When was Ohio EPA notified of the incident?
Date:  
Time:  
Incident Location:  
Total Stream Distance Affected:   units
Aquatic Square Area Affected:   units
Magnitude: Description of organisms dead or injured from application,
damage to plants, etc.
Water(s) affected:  
Appearance of Affected Waters: (e.g. sheen, color, clarity, etc.)
EPA Product Registration Number(s) of the pesticide that allegedly
caused the incident:
 
Produce Use Purpose:  
 
Produce Use Purpose:  
 
Produce Use Purpose:  
Certification (Must be signed by the responsible official – See Part
VI.S. of the general permit)
I certify under penalty of law that I have personally examined any am
familiar with the information in this report and all attachments.
Based on my inquiry of those persons immediately responsible for
obtaining the information contained in the report, I believe that the
information is true, accurate and complete. I am aware that there are
significant penalties for submitting false information, including the
possibility of fine and imprisonment.
Signature:
Title:   Date:  
Operator’s Information
Facility Permit # (if applicable):  
Permittee
Operator’s Name:  
Operator’s Mailing Address:  
City:  
State:  
Zip:  
Contact Name and Title:  
Phone:  
Fax:  
E-mail:  
Certification (Must be signed by the responsible official – See Part
VI.S. of the general permit)
I certify under penalty of law that I have personally examined any am
familiar with the information in this report and all attachments.
Based on my inquiry of those persons immediately responsible for
obtaining the information contained in the report, I believe that the
information is true, accurate and complete. I am aware that there are
significant penalties for submitting false information, including the
possibility of fine and imprisonment.
Signature:
Title:   Date:  
Were pesticides applied over the threshold during the reporting
period? Yes No
Please complete as many tables below for each pesticide use pattern as
applicable. You can extend tables as necessary and delete tables for
use patterns that are not applicable.
Mosquito and Other Nuisance Insect Control
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Weed and Algae Control
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Nuisance Animal Control
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Forest Canopy Pest Control
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intrusive Vegetation Control
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Invasive Plant Management in Resource Conservation Areas and
Mitigation Areas
EPA product registration number(s) for each product used:
Amount of each product used
(include units):
Names of waters to which pesticides are discharged (including any
8-digit HUC identifiers, if known):
Pests controlled:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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