Form DEEP-PEST-APP-200 "Permit Application for the Use of Pesticides in State Waters" - Connecticut

What Is Form DEEP-PEST-APP-200?

This is a legal form that was released by the Connecticut Department of Energy and Environmental Protection - a government authority operating within Connecticut. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on November 20, 2018;
  • The latest edition provided by the Connecticut Department of Energy and Environmental Protection;
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  • Fill out the form in our online filing application.

Download a printable version of Form DEEP-PEST-APP-200 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Energy and Environmental Protection.

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Permit Application for the Use of
CPPU USE ONLY
Pesticides in State Waters
App #:________________________________
Please complete this form in accordance with section 22a-66z CGS
and the
instructions
(DEEP-PEST-INST-200) in order to ensure the
Doc #:________________________________
proper handling of your application. Print or type unless otherwise
noted. You must submit the initial fee along with this form.
Check #:______________________________
______________________________________
Program: Aquatic Pesticides
Part I: Application Type and Description
This application is to request (check one):
One year permit
Two year permit
Three year permit
Note: Multi-year permits will be issued at the Department of Energy and Environmental Protection’s (DEEP) discretion.
Check here if DEEP has previously issued an Aquatic Pesticide Permit for this site.
Permit Number for most recent permit:
Check here if the information contained in this application is identical to the last application and the
chemicals, quantities and number of treatments requested are identical to the chemicals, quantities
and number of treatments permitted by the most recent permit issued.
Town where site is located:
Brief Description of Project:
Part II: Fee Information
An application fee of $200.00
is to be submitted with each permit that you are applying for. Each site
[#1009]
requires a separate permit. The application will not be processed without payment of the fee. If you are
applying for a multi-year permit, see Part II of the
instructions
for information on fee payment. There is no
discount for municipalities. The fee shall be non-refundable and shall be paid by check or money order to the
Department of Energy and Environmental Protection.
Part III: Site Location
Name of Waterbody:
Street address and/or description of location:
City/Town:
State:
Zip Code:
DEEP-PEST-APP-200
Page 1 of 9
Rev. 11/20/18
Permit Application for the Use of
CPPU USE ONLY
Pesticides in State Waters
App #:________________________________
Please complete this form in accordance with section 22a-66z CGS
and the
instructions
(DEEP-PEST-INST-200) in order to ensure the
Doc #:________________________________
proper handling of your application. Print or type unless otherwise
noted. You must submit the initial fee along with this form.
Check #:______________________________
______________________________________
Program: Aquatic Pesticides
Part I: Application Type and Description
This application is to request (check one):
One year permit
Two year permit
Three year permit
Note: Multi-year permits will be issued at the Department of Energy and Environmental Protection’s (DEEP) discretion.
Check here if DEEP has previously issued an Aquatic Pesticide Permit for this site.
Permit Number for most recent permit:
Check here if the information contained in this application is identical to the last application and the
chemicals, quantities and number of treatments requested are identical to the chemicals, quantities
and number of treatments permitted by the most recent permit issued.
Town where site is located:
Brief Description of Project:
Part II: Fee Information
An application fee of $200.00
is to be submitted with each permit that you are applying for. Each site
[#1009]
requires a separate permit. The application will not be processed without payment of the fee. If you are
applying for a multi-year permit, see Part II of the
instructions
for information on fee payment. There is no
discount for municipalities. The fee shall be non-refundable and shall be paid by check or money order to the
Department of Energy and Environmental Protection.
Part III: Site Location
Name of Waterbody:
Street address and/or description of location:
City/Town:
State:
Zip Code:
DEEP-PEST-APP-200
Page 1 of 9
Rev. 11/20/18
Part IV: Applicant Information
If an applicant is a corporation, limited liability company, limited partnership, limited liability partnership, or a statutory
trust, it must be registered with the Secretary of State. If applicable, the applicant’s name shall be stated exactly as it is
registered with the Secretary of State. This information can be accessed at CONCORD. (www.concord-
sots.ct.gov/CONCORD/index.jsp)
If an applicant is an individual, provide the legal name (include suffix) in the following format: First Name; Middle Initial;
Last Name; Suffix (Jr, Sr., II, III, etc.).
If there are any changes or corrections to your company/facility or individual mailing or billing address or contact
information, please complete and submit the
Request to Change Company/Individual Information
to the address
indicated on the form. If there is a change in name of the entity holding a DEEP license or a change in ownership,
contact the Office of Planning and Program Development (OPPD) at 860-424-3003. For any other changes you must
contact the specific program from which you hold a current DEEP license.
1. Applicant Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
*By providing this e-mail address you are agreeing to receive official correspondence from DEEP, at this electronic
address, concerning the subject application. Please remember to check your security settings to be sure you can
receive e-mails from “ct.gov” addresses. Also, please notify DEEP if your e-mail address changes.
a) Applicant Type (check one):
individual
*business entity
federal agency
state agency
municipality
tribal
*If a business entity:
i)
check type:
corporation
limited liability company
limited partnership
limited liability partnership
statutory trust
Other:
ii) provide Pesticide Application Business Registration Number and Registration expiration date:
iii) provide Secretary of the State business ID #:
This information can be accessed at
CONCORD
Check here if your business is NOT registered with the Secretary of State’s office.
iv)
b) Applicant's relationship to the property at which the proposed activity is to be located:
site owner
option holder
lessee
easement holder
operator
pesticide applicator
other (specify):
Check if any co-applicants. If so, attach additional sheet(s) with the required information as requested above.
2. Billing contact, if different than the applicant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
DEEP-PEST-APP-200
Page 2 of 9
Rev. 11/20/18
Part IV: Applicant Information (continued)
3. Primary contact for departmental correspondence and inquiries, if different than the applicant.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
4. Owner Information
a. If known, list the name and address of all owners of the area(s) to be treated. If unsure, go to item #4b.
You can add rows to this table by using “tab” in the last row, in the last column.
Name of Owner
Address
*If an area(s) to be treated is owned or controlled by the state of Connecticut, see
instructions
for submitting an
application to the DEEP Land Acquisition and Management Unit (LAM) for review and approval of the proposed
treatment on state property. A LAM Authorization letter must be submitted as Attachment G for any application
involving treatment of a waterbody that is owned or controlled by the state of Connecticut.
DEEP-PEST-APP-200
Page 3 of 9
Rev. 11/20/18
Part IV: Applicant Information (continued)
4b. If the applicant is unsure of who owns an area(s) to be treated, provide the name and address for all shoreline
property owners located 200 feet or less from such area.
You can add rows to this table by using “tab” in the last row, in the last column.
Name of Shoreline Property Owner
Address
5. List the person or company applying the pesticides.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
E-mail:
Certification Number:
Certification Expiration Date:
Part V: Additional Information
If the applicant is submitting this application on behalf of someone else, identify the person(s) or organization(s)
seeking to have pesticides applied to the treatment area(s) and provide the following information. If more than
one person or organization is being represented, attach additional sheets providing the information requested
below.
Name:
Mailing Address:
City/Town:
State:
Zip Code:
Business Phone:
ext.:
Contact Person:
Phone:
ext.
*E-mail:
DEEP-PEST-APP-200
Page 4 of 9
Rev. 11/20/18
Part VI: Site Information
1. COASTAL AREA: Is the pesticide application located in a municipality within the coastal area?
Yes
No
(check town list in the instructions)
If yes, is the water being treated subject to the ebb and flow of the tides, or inundated by saline or brackish
water at least once a month?
Yes
No
If the water being treated is subject to the ebb and flow of the tides, or is inundated by saline or brackish
water at least once a month, you must submit a
Coastal Consistency Review Form
(DEEP-APP-004) with
your application as Attachment C.
For assistance in determining if the water being treated is affected by tidal water as described above or in
completing the Coastal Consistency Review form, contact the Office of Long Island Sound Programs
(OLISP) at 860-424-3034.
2. NATURAL DIVERSITY DATA BASE (NDDB) - ENDANGERED OR THREATENED SPECIES: According
to the most current "Natural Diversity Data Base Areas Maps”, will the activity which is the subject of this
application, including all impacted areas, be located within an area identified as, or otherwise known to be,
a habitat for state listed endangered, threatened or special concern species?
Yes
No
Date of Map:
If yes, complete and submit a
Request for NDDB State Listed Species Review Form
(DEEP-APP-007) to
the address specified on the form, prior to submitting this application. Please note NDDB review generally
takes 4 to 6 weeks and may require the applicant to produce additional documentation, such as ecological
surveys, which must be completed prior to submitting this permit application. A copy of the NDDB
Determination response letter that has not expired must be submitted with this completed application as
Attachment D. Include a copy of any mitigation measures developed for this activity and approved by
NDDB. Be aware that you must renew your NDDB Determination if it expires before project work
commences. If the required NDDB documents are not submitted as Attachment D, your application will be
deemed incomplete and may be subject to denial.
For more information visit the DEEP website at
www.ct.gov/deep/nddbrequest
or call the NDDB at 860-
424-3011.
3. AQUIFER PROTECTION AREAS: Is the site located within a town required to establish Aquifer
Protection Areas, as defined in section 22a-354a through 354bb of the General Statutes (CGS)?
Yes
No
To view the applicable list of towns and maps visit the DEEP website at
www.ct.gov/deep/aquiferprotection
If yes, is the site within an area identified on a Level A or Level B map?
Yes
No
If your site is on a Level A or Level B map, you are not required to register under the Aquifer Protection
Program, however you must follow proper spill control measures to prevent potential contamination of
drinking water. If you should have a spill, please call the emergency hotline immediately at 860-424-3338.
4. CONSERVATION OR PRESERVATION RESTRICTION: Is the property subject to a conservation or
preservation restriction?
Yes
No
If Yes, proof of written notice of this application to the holder of such restriction or a letter from the holder
of such restriction verifying that this application is in compliance with the terms of the restriction must be
submitted as Attachment F.
5. Type of area to be treated:
Tidal Waters
Pond or Lake
Stream
6. Is the waterbody located in a public water supply watershed? (See instructions)
Yes
No
If Yes, DPH comments may be required as Attachment I to this application.
7. Is the waterbody potentially located 200 ft. or less from a public water supply well?
Yes
No
(See instructions) If Yes, DPH comments must be submitted as Attachment I to this application.
8. Where does the waterbody flow to (Name of receiving stream or waterbody)?
Is the outflow usually flowing?
Yes
No
Can outflow be stopped?
Yes
No
DEEP-PEST-APP-200
Page 5 of 9
Rev. 11/20/18