
United States Environmental Protection Agency
Washington, DC 20460
Thirty (30)-Day Adverse Incident Written Report for The Pesticide General Permit (PGP)
For Discharges from the Application of Pesticides
Form Approved
OMB No.
2040-0004
This form is for Operators required to submit a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state lead agency for pesticide regulation. Where multiple Operators are authorized for a discharge that results in an adverse incident, reporting by any one of the Operators constitutes compliance for all of the Operators, provided a copy of this report is also provided to all of the other authorized Operators within 30 days of the reportable adverse incident.
A. Reportable Adverse Incident
Is the adverse incident reportable?  Reporting of adverse incidents is not required under the PGP in the following situations: (a) An Operator is aware of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application; (b) An Operator has been notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents; (c) An Operator receives information of an adverse incident, but that information is clearly erroneous; or (d) An adverse incident occurs to pests that are similar in kind to potential target pests identified on the FIFRA label.
  	Yes. You must complete this report and submit it to the appropriate EPA Regional office and to the state lead agency for pesticide regulation.
  	No. STOP. You are not required to complete this report. However, you may consider using this form to document the incident and your rationale for why reporting of the adverse incident is not required. This information may be useful to support your rationale should you be questioned on such. 
B. Information from the 24-Hour Adverse Incident Notification
When an Operator observes or is otherwise made aware of an adverse incident, which may have resulted from a discharge from a pesticide application, the Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at https://www.epa.gov/npdes/pesticide-permitting. This notification must be made by telephone within 24 hours of the Operator becoming aware of the adverse incident. Operators must include in the written report the information provided to EPA in the 24-hour adverse incident notification (PGP Part 6.4.1.1). Attach additional information if necessary. 
1.	Caller's Contact Information:
a.	Name:






































b.	Telephone Number:



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2.	Operator Information:
a.	Operator Name:






































b.		Mailing Address:
     Street: 


































     City:



















State:



 ZIP Code:





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3.	NOI NPDES Permit Tracking Number:









  (Enter "NA" if not applicable)
4.	Contact person, if different than the person providing the 24-hour notice under item 1 above: 
a.	Name:






































b.	Telephone Number:



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   5.	Describe how and when the Operator became aware of the adverse incident:
	
	
	
	
   6.	Describe the location of the adverse incident:
	
	
	
   7.	Describe the adverse incident identified and the pesticide product, including EPA pesticide registration number in item 7a below, for each product applied in the area of the adverse incident:
	
	
	
	
	
	
a. EPA Pesticide Registration Number: 
EPA Pesticide Registration Number: 






















                                       






















                                       
   8.	Describe any steps the Operator has taken or will take to correct, repair, remedy, clean up, or otherwise address any adverse effects:
	
	
	
	
	
	
	
   9.	Identify any other Operators authorized for coverage under this permit for discharges from the pesticide application activities that resulted in the adverse incident and if so, provide details of your notification of those other Operator(s):
	
	
	
	
	
C. Date and Time the Operator Notified EPA of the Adverse Incident
1.	Date EPA was contacted: 


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  2.	Time EPA was contacted:	
3.	Name and/or title of the person the Operator spoke with at EPA: 
                                                                       a. Name:























                                                                      b. Title:





















   4.	Instructions received from EPA:
	
	
	
	
	
	
	

D. Other Information Required in the Thirty (30) Day Adverse Incident Report
Please attach additional information if necessary.
   1. 	Location of incident, including the names of any waters affected and appearance of those waters (sheen, color, clarity, etc.):
	
	
	
   2.	Describe the circumstances of the adverse incident including species affected, estimated number of affected individuals, and approximate size of dead or distressed organisms:
	
	
	
   3.	Describe the magnitude and scope of the affected area (e.g. aquatic square area or total stream distance affected):
	
	
	
   4.	Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name of pesticide product and EPA pesticide registration number (EPA Reg. No.). 
   Pesticide 
application rate:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
Pesticide 
application rate:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

   Intended use site:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Intended use site:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

   Method of application:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Method of application:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

   Pesticide Product:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

Pesticide Product:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

   EPA Reg. No.:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

EPA Reg. No.:
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       
                                       

   5.	Describe the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for 
pesticides applied):
	
	
	
   6.	Provide an indication of which laboratory test(s), if any, were performed, and when. (Note: A summary of the test results must be provided within 5 days after they become available, if not available at the time of submission of this report.):
	
	
	
	
   7.	Describe the actions to be taken to prevent recurrence of adverse incidents:
	
	
	
	



E. Certification
I certify under penalty of law 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. On the basis of 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 am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.  
Printed Name:




































Title:











































E-Mail:









































  Signature/Responsible Official:


                                                                          Date:


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Adverse Incident Report Preparer (Complete if Adverse Incident Report was prepared by someone other than the certifier)
Preparer Name:







































Organization:







































Phone:



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                                                                          Date:


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E-Mail:











































      
Instructions for Completing and Submitting the Thirty (30) Day Adverse Incident Written Report for the Pesticide General Permit (PGP) for Discharges from the Application of Pesticides


Who Must Submit a 30-day Adverse Incident Report?
All Operators who observe or are otherwise made aware of a reportable adverse incident pursuant to Part 6.4 of the permit must submit on adverse incident report.
However, even for those identified adverse incidents for which the Operator is not required to report, EPA recommends that Operators consider using this form to document the incident and the rationale for why reporting of the adverse incident is not required. This information may be useful to support a rationale should this determination be questioned.
An adverse incident, as defined in the Appendix A of the permit, is an unusual or unexpected incident that an Operator has observed upon inspection or of which the Operator otherwise became aware, in which: (1) there is evidence that a person or non-target organism has likely been exposed to a pesticide residue, and (2) the person or non-target organism suffered a toxic or adverse effect. See Appendix A of the permit, for the complete definition of adverse incident.
Where multiple Operators are authorized for a discharge that results in an adverse incident, notification and reporting by any one of the Operators constitutes compliance for all of the Operators, provided a copy of the written report required in Part 6.4.2 of the permit is also provided to all of the other authorized Operators within 30 days of the reportable adverse incident.
When to File the Adverse Incident Report
Operators must provide a written report of any reportable adverse incidents to the appropriate EPA Regional office and to the state lead agency for pesticide regulation within 30 days of the adverse incident pursuant to Part 6.4.1.1 of the permit.
Where to File the 30-day Adverse Incident Report
The Operator must immediately notify the appropriate EPA Incident Reporting Contact, as identified at https://www.epa.gov/npdes/pesticide-permitting, of the adverse incident within 24 hours. The Operator(s) must provide a written report of the adverse incident to the appropriate EPA Regional office at the address listed in Part 8 of the permit and to the state lead agency for pesticide regulation (see http://npic.orst.edu/state1.htm).
If an Operator becomes aware of an adverse incident affecting a federally listed threatened or endangered species or federally designated critical habitats which may have resulted from a discharge from the Operator's pesticide application, the Operator must immediately notify the National Marine Fisheries Service (NMFS) in the case of an anadromous or marine species, (see http://www.nmfs.noaa.gov) or the United States Fish and Wildlife Service (FWS) in the case of a terrestrial or freshwater species (see http://www.fws.gov).
Completing the 30-day Adverse Incident Report
To complete this form, type or print in uppercase letters in the appropriate areas only. Please make sure you complete all questions. Make sure you make a photocopy for your records before you send the completed original form to the appropriate EPA Regional office.
Section A. Reportable Adverse Incident
The Operator is required to submit this Adverse Incident Report if the adverse incident is reportable. Check yes if the adverse incident is reportable. If an Adverse Incident Report is not required, check no. No further action is needed on this form. Reporting of adverse incidents is not required under the PGP in the following situations:
a.	An Operator is aware of facts that indicate that the adverse incident was not related to toxic effects or exposure from the pesticide application;
b.	An Operator has been notified by EPA, and retains such notification, that the reporting requirement has been waived for this incident or category of incidents;
c.	An Operator receives information notifying the Operator of an adverse incident, but that information is clearly erroneous; or
d.	An adverse incident occurs to pests that are similar in kind to potential target pests identified on the FIFRA label.
Section B. Information from the 24-hour Adverse Incident Notification
1.	Provide contact information for the person who called EPA to report the adverse incident.
   a.	Enter the legal name of the caller.
   b.	Enter the phone number of the caller.
2.	Provide the Operator's contact information.
   a.	Enter the legal name of the Operator.
   b.	Enter the mailing address of the Operator.
3.	If an NOI was filed as required in Part 1.2 of the permit, enter the NPDES Permit Tracking Number assigned by NeT or the EPA's Pesticides Processing Center. You can find the tracking number assigned to your NOI using EPA's NPDES eReporting Tool (NeT). If no NOI submitted, enter "NA" for not applicable.
4.	Provide information for a contact person, if different than the person who called EPA to report the adverse incident.
   a. 	Enter the legal name of the contact person.
   b. 	Enter the phone number of the contact person.
5.	Provide a description of how and when the Operator became aware of the adverse incident.
6.	Provide a description of the location of the adverse incident.
7.	Provide a description of the adverse incident and the pesticide product used in the adverse incident. Include the EPA pesticide registration number for each product applied in the area of the adverse incident. Attach additional pages if necessary.
8.	Provide a description of any steps the Operator has taken to correct, repair, remedy, clean up or otherwise address the adverse effects of the incident.
9.	Identify any other Operators authorized for coverage under the permit for discharges from the pesticide application activities that resulted in the adverse incident. If other Operators are authorized under this permit, provide details of your notification of those other Operator(s).
Section C. Date and Time the Operator Notified EPA of the Adverse Incident
1. 	Enter the date that EPA was contacted to report the adverse incident.
2. 	Enter the time EPA was contacted to report the adverse incident.
3.  Provide the legal name and title of the person contacted at EPA.
4. 	Provide a description of the instructions received by EPA.
Section D. Other Information Required in the Thirty (30) Day Adverse Incident Report
1.	Enter the location of the adverse incident and include the names of any waters affected. Please include the appearance of those waters (sheen, color, clarity, etc.).
2.	Provide a description of the circumstances of the adverse incident including species affected, estimated number of affected individuals and approximate size of dead or distressed organisms.
3.	Provide a description of the magnitude and scope of the affected area. Include aquatic square area or total stream distance affected, if possible.
4.	Provide the pesticide application rate, intended use site (e.g., on the bank, above waters, or directly to water), method of application, and the name of pesticide product and EPA pesticide registration number.
5.	Provide a description of the habitat and the circumstances under which the adverse incident occurred (including any available ambient water data for pesticides applied).
6.	Indicate which laboratory test(s) were performed and when, if laboratory tests were performed. The summary of the test results must be provided within 5 days after they become available, if not available at the time of submission of this report.
7.	Provide a description of the actions to be taken to prevent recurrence of adverse incidents.
Section E. Certification
Enter the certifier's printed name and title. Sign and date the form. For more information about the certification statement and signature, see 40 CFR 122.41(k). (CAUTION: An unsigned or undated form will not be accepted.) Federal statutes provide for severe penalties for submitting false information. Federal regulations require this application to be signed as follows:
For a corporation: by a responsible corporate officer, which means:
(i)	president, secretary, treasurer, or vice-president of the corporation in charge of a principal business function, or any other person who performs similar policy or decision-making functions for the corporation, or
(ii)	 the manager of one or more manufacturing, production, or operating facilities, provided the manager is authorized to make management decisions that govern the operation of the regulated activity including having the explicit or implicit duty of making major capital investment recommendations, and initiating and directing other comprehensive measures to assure long-term environmental compliance with environmental laws and regulations; the manager can ensure that the necessary systems are established or actions taken to gather complete and accurate information for permit application requirements; and where authority to sign documents has been assigned or delegated to the manager in accordance with corporate procedures;
For a partnership or sole proprietorship: by a general partner or the proprietor; or
For a municipal, state, federal, or other public facility: by either a principal executive or ranking elected official.
If the report was prepared by someone other than the certifier (for example, if the report was prepared by a consultant for the certifier's signature), include the name, organization, phone number and e-mail address of the report preparer and the date that the report was prepared.
Paperwork Reduction Act Notice
The public reporting and recordkeeping burden for this collection of information is estimated to average 4 hours or 240 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed Adverse Incident Report to this address.
