ADEM Form 28 "Notice of Intent - General Permit Number Alg870000" - Alabama

What Is ADEM Form 28?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2016;
  • The latest edition provided by the Alabama Department of Environmental Management;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 28 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 28 "Notice of Intent - General Permit Number Alg870000" - Alabama

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NOTICE OF INTENT – GENERAL PERMIT NUMBER ALG870000
NPDES PERMIT NUMBER ALG870000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES FROM THE
APPLICATION OF PESTICIDES
FOR OFFICE USE ONLY
Mail to: Alabama Department of Environmental Management
Water Division
NPDES PERMIT NUMBER
Post Office Box 301463
Montgomery, Alabama 36130-1463
RECEIPT NUMBER
PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR
MISSING SIGNATURES WILL DELAY PROCESSING. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS
NECESSARY. ATTACH OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN BLUE OR BLACK INK.
PURPOSE OF THIS APPLICATION
Initial Application
Reissuance of General Permit ALG87______________
Modification of General Permit No. ALG87______________
Other________________________________________
Transfer of General Permit No. ALG87__________________
I. OPERATOR INFORMATION
Operator Name
County (ies) of Application
Operator Mailing Address
City, State, Zip Code
Operator Physical Address
City, State, Zip Code
Operator Phone Number
Operator E-Mail Address
Contact Name and Title
Contact Phone Number
II. LOCATION, IN ALABAMA, OF NPDES RECORDS STORAGE
Street Address
City, State, Zip
III. PESTICIDE USE PATTERNS
Check all that apply:
(a)
Mosquito and Other Flying Insect Pest Control
(c)
Animal Pest Control
(b)
Weed and Algae Pest Control
(d)
Forest Canopy or Other Area-Wide Pest Control
For each use pattern checked above, provide the following information (attach additional pages if necessary):
Use Pattern from above:
Receiving Waters (check one):
(1)
Coverage requested for specific waters of the State within the areas identified on the location map. Complete Section IV. below.
(2)
Coverage requested for all waters of the State within the areas identified on the location map, or
(3)
Coverage requested for all waters of the State within the areas identified on the location map, except the following:
(If you checked either Box (2) or (3) for Receiving Waters box above, skip Section IV. below)
ADEM Form 28 08/16 m1
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NOTICE OF INTENT – GENERAL PERMIT NUMBER ALG870000
NPDES PERMIT NUMBER ALG870000 IS A GENERAL PERMIT AUTHORIZING DISCHARGES FROM THE
APPLICATION OF PESTICIDES
FOR OFFICE USE ONLY
Mail to: Alabama Department of Environmental Management
Water Division
NPDES PERMIT NUMBER
Post Office Box 301463
Montgomery, Alabama 36130-1463
RECEIPT NUMBER
PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. INCOMPLETE OR INCORRECT ANSWERS, OR
MISSING SIGNATURES WILL DELAY PROCESSING. IF SPACE IS INSUFFICIENT, CONTINUE ON AN ATTACHED SHEET(S) AS
NECESSARY. ATTACH OTHER INFORMATION AS NEEDED. PLEASE TYPE OR PRINT LEGIBLY IN BLUE OR BLACK INK.
PURPOSE OF THIS APPLICATION
Initial Application
Reissuance of General Permit ALG87______________
Modification of General Permit No. ALG87______________
Other________________________________________
Transfer of General Permit No. ALG87__________________
I. OPERATOR INFORMATION
Operator Name
County (ies) of Application
Operator Mailing Address
City, State, Zip Code
Operator Physical Address
City, State, Zip Code
Operator Phone Number
Operator E-Mail Address
Contact Name and Title
Contact Phone Number
II. LOCATION, IN ALABAMA, OF NPDES RECORDS STORAGE
Street Address
City, State, Zip
III. PESTICIDE USE PATTERNS
Check all that apply:
(a)
Mosquito and Other Flying Insect Pest Control
(c)
Animal Pest Control
(b)
Weed and Algae Pest Control
(d)
Forest Canopy or Other Area-Wide Pest Control
For each use pattern checked above, provide the following information (attach additional pages if necessary):
Use Pattern from above:
Receiving Waters (check one):
(1)
Coverage requested for specific waters of the State within the areas identified on the location map. Complete Section IV. below.
(2)
Coverage requested for all waters of the State within the areas identified on the location map, or
(3)
Coverage requested for all waters of the State within the areas identified on the location map, except the following:
(If you checked either Box (2) or (3) for Receiving Waters box above, skip Section IV. below)
ADEM Form 28 08/16 m1
Page 1 of 2
IV. RECEIVING WATERS
For each use pattern checked in Section III. above, where coverage is requested for specific waters, provide the following information (attach
additional pages if necessary):
Use Pattern:
List the name of each receiving water for the indicated Use Pattern above (attach additional pages if necessary).
Receiving Water(s)
Receiving Water(s)
V. ONRW Waters and Water Quality Impaired Waters
Is/are the receiving water(s) classified as a ONRW water, as defined by Part VII.Q.40 of the general permit and
ADEM Admin. Code r. 335-6-10-.10?
Yes
No
If yes, please list the ONRW water(s) below:
NOTE: ONRW waters are identified in ADEM Admin. Code r. 335-6-11-.02
Pursuant to Part I.B.2(a) of the general permit, discharges from a pesticide application to a water of the State are not authorized by this permit if the
water is identified as being impaired by that pesticide or its degradates. For the purposes of this permit, impaired waters are those that have been
identified by the State, pursuant to Section 303(d) of the CWA, as not meeting applicable State water quality standards and those waters with EPA-
approved or EPA-established Total Maximum Daily Loads (TMDLs) for a pesticide or its degradates.
Is/are the receiving water(s) impaired for the pesticide(s) being used, an active ingredient of the pesticide, or a degradate of an active ingredient of the
pesticide(s)?
Yes
No
Current lists of 303(d) and TMDL waters are available on the ADEM website at http://www.adem.state.al.us/programs/water/waterquality.cnt
VI. PESTICIDE APPLICATION TREATMENT AREA MAP
Please attach a USGS or equivalent topographic map outlining the pesticide application treatment area. If multiple use patterns with different
treatment areas are to be permitted, please provide a map for each use pattern and each different treatment area.
VII. CERTIFICATION OF OPERATOR RESPONSIBLE OFFICIAL
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 gather and evaluate 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 am aware that there are significant penalties for submitting false information including the possibility of
fine or imprisonment for knowing violations. I further certify that the applicant has sufficient title, right or interest in the property where the
proposed activity occurs.
Name (type or print)
Official Title
Signature
Date Signed
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