"Notice of Intent (Noi) to Discharge Pesticides on or Near Waters of the State Under the Updes General Permit No. Utg-170000" - Utah

Notice of Intent (Noi) to Discharge Pesticides on or Near Waters of the State Under the Updes General Permit No. Utg-170000 is a legal document that was released by the Utah Department of Environmental Quality - a government authority operating within Utah.

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STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY
Mailing Address: P.O. Box 144870, Salt Lake City, Utah 84114-4870
Physical Address: 195 North 1950 West (801) 536-4300
NOI
Notice of Intent (NOI) to Discharge Pesticides on or Near Waters of the State Under the UPDES
General Permit No. UTG-170000
Submission of this Notice of Intent constitutes notice that the party(s) identified in this form intends to be authorized
by UPDES General Permit No. UTG-170000 issued for pesticide discharges associated with pest control in the State of
Utah. Becoming a permittee obligates such discharger to comply with the terms and conditions of the permit. ALL
NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM.
OPERATOR INFORMATION:
_____________
NOI Submission Date: ____________________ General Permit Expiration Date:
Establishment Name (Operator): _____________________________ Phone: ________________
Responsible Contact Person: _________________________________ Phone: ________________
Physical Address: ___________________________________________________________________
Mailing Address: ___________________________________________________________________
City: _________________________________
State: ______
Zip: _______________________
Email Address: _____________________________________________________________________
If the pesticide application takes place on any Indian country land, coverage is not available under
this permit. Please contact Dave Rise of the EPA at (406) 457-5012, or Lisa Luebke at (303) 312-6256
6-digit NAICS code for primary industry activity of this establishment: _______________
Location of UPDES Records for this establishment (check one):
□ Same as Establishment Name (Operator) address:
□ Other: ____________________________________
Pesticide Use Patterns for this establishment (check all that apply):
□ Mosquitoes and other insect pests
□ Weed and Algae Control
□ Nuisance Animal Control
□ Forest Canopy Pest Control
Receiving Waters:
□ A map is provided for the location(s) of pesticide application;
□ A description of the locations of pesticide application sites; as a minimum, county,
city, and major water body(s) below for this use, the hydrologic unit code (HUC) if
available, the name of major.water body(s), and latitude and longitude of any major
unnamed water body(s).
Lat and Long of Unnamed
County
City
Water Body
Hydrologic Unit Code
Water Body (if available)
(if available)
STATE OF UTAH, DEPARTMENT OF ENVIRONMENTAL QUALITY, DIVISION OF WATER QUALITY
Mailing Address: P.O. Box 144870, Salt Lake City, Utah 84114-4870
Physical Address: 195 North 1950 West (801) 536-4300
NOI
Notice of Intent (NOI) to Discharge Pesticides on or Near Waters of the State Under the UPDES
General Permit No. UTG-170000
Submission of this Notice of Intent constitutes notice that the party(s) identified in this form intends to be authorized
by UPDES General Permit No. UTG-170000 issued for pesticide discharges associated with pest control in the State of
Utah. Becoming a permittee obligates such discharger to comply with the terms and conditions of the permit. ALL
NECESSARY INFORMATION MUST BE PROVIDED ON THIS FORM.
OPERATOR INFORMATION:
_____________
NOI Submission Date: ____________________ General Permit Expiration Date:
Establishment Name (Operator): _____________________________ Phone: ________________
Responsible Contact Person: _________________________________ Phone: ________________
Physical Address: ___________________________________________________________________
Mailing Address: ___________________________________________________________________
City: _________________________________
State: ______
Zip: _______________________
Email Address: _____________________________________________________________________
If the pesticide application takes place on any Indian country land, coverage is not available under
this permit. Please contact Dave Rise of the EPA at (406) 457-5012, or Lisa Luebke at (303) 312-6256
6-digit NAICS code for primary industry activity of this establishment: _______________
Location of UPDES Records for this establishment (check one):
□ Same as Establishment Name (Operator) address:
□ Other: ____________________________________
Pesticide Use Patterns for this establishment (check all that apply):
□ Mosquitoes and other insect pests
□ Weed and Algae Control
□ Nuisance Animal Control
□ Forest Canopy Pest Control
Receiving Waters:
□ A map is provided for the location(s) of pesticide application;
□ A description of the locations of pesticide application sites; as a minimum, county,
city, and major water body(s) below for this use, the hydrologic unit code (HUC) if
available, the name of major.water body(s), and latitude and longitude of any major
unnamed water body(s).
Lat and Long of Unnamed
County
City
Water Body
Hydrologic Unit Code
Water Body (if available)
(if available)
County
City
Water Body
Hydrologic Unit Code
Lat and Long of Unnamed
Water Body (if available)
(if available)
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 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 and imprisonment for knowing violations.
I further certify that the applicant has sufficient title, right or interest in the property where the proposed
activity occurs.
Signature:
Date:
_____________________________
__________________
Printed Name: (Person Responsible for, or Supervising the Pesticide Application)
______________________________________________________________________________
Title:
______________________________________________________________________________
Email Address:
______________________________________________________________________________
This space for office use only:
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