NPDES General Permit for Discharges from Pesticide Applications

Annual Report

Instructions: Annual reports must be completed each year and submitted no later than the date specified in Part V.C. of the NPDES General Permit (February 15 of the following year). Mail the completed annual reports to: Ohio EPA, DSW, Permits & Compliance Section, P.O. Box 1049, Columbus, OH 43216-1049.

Operator’s Information
Date:
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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