ADEM Form 29 "ADEM Npdes Pesticide Adverse Incident Report Form" - Alabama

What Is ADEM Form 29?

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 November 1, 2012;
  • 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 fillable version of ADEM Form 29 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 29 "ADEM Npdes Pesticide Adverse Incident Report Form" - Alabama

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ADEM NPDES PESTICIDE ADVERSE INCIDENT REPORT FORM
PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH 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 INK.
Complete this form, attach additional information as necessary, and send report to the ADEM central office in Montgomery.
I. REPORTABLE ADVERSE INCIDENT
Is the adverse incident reportable?
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 about the incident.
Pursuant to Part VI.D.1 of the permit, the reporting of adverse incidents is not required under the PGP in the following situations: (1) The Operator is
aware of facts that clearly establish that the adverse incident was not related to toxic effects or exposure from the pesticide application; (2) The
Operator has been notified by the Department that the reporting requirement has been waived for this incident or category of incidents; (3) The
Operator receives information of an adverse incident but that information is clearly erroneous; or (4) An adverse incident occurs to pests that are
similar in kind to pests identified on the FIFRA label.
II. INFORMATION FROM THE 24-HOUR ADVERSE INCIDENT NOTIFICATION
Pursuant to Part VI.D.2(a) of the permit, Operators that observe or are otherwise made aware of an adverse incident must include in this report the
information provided to the Department in the 24-hour adverse incident notification (Part VI.D.1). Attach additional information if necessary.
Caller’s Name
Caller’s Phone Number
Operator Name
Operator Mailing Address
NPDES Permit Number
City, State, Zip Code
ALG87
Contact Person (if different from Caller)
Contact Person Phone Number (if different from Caller)
How and when did the Operator become aware of the adverse incident?
Describe the location of the adverse incident:
Describe the adverse incident identified and the pesticide name for each product applied in the area of the adverse incident.
Describe any steps that have been or will be taken to correct, repair, remedy, cleanup, or otherwise address any adverse effects.
III. DATE/TIME OPERATOR NOTIFIED DEPARTMENT OF THE ADVERSE INCIDENT
Date the Department was Notified
Time the Department was Notified
Name and/or Title of the Person the Operator Contacted at the Department
Instructions Received from the Department (if any)
ADEM Form 29 11/12
Page 1 of 2
Print Form
ADEM NPDES PESTICIDE ADVERSE INCIDENT REPORT FORM
PLEASE COMPLETE ALL QUESTIONS. RESPOND WITH “N/A” AS APPROPRIATE. FORMS WITH 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 INK.
Complete this form, attach additional information as necessary, and send report to the ADEM central office in Montgomery.
I. REPORTABLE ADVERSE INCIDENT
Is the adverse incident reportable?
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 about the incident.
Pursuant to Part VI.D.1 of the permit, the reporting of adverse incidents is not required under the PGP in the following situations: (1) The Operator is
aware of facts that clearly establish that the adverse incident was not related to toxic effects or exposure from the pesticide application; (2) The
Operator has been notified by the Department that the reporting requirement has been waived for this incident or category of incidents; (3) The
Operator receives information of an adverse incident but that information is clearly erroneous; or (4) An adverse incident occurs to pests that are
similar in kind to pests identified on the FIFRA label.
II. INFORMATION FROM THE 24-HOUR ADVERSE INCIDENT NOTIFICATION
Pursuant to Part VI.D.2(a) of the permit, Operators that observe or are otherwise made aware of an adverse incident must include in this report the
information provided to the Department in the 24-hour adverse incident notification (Part VI.D.1). Attach additional information if necessary.
Caller’s Name
Caller’s Phone Number
Operator Name
Operator Mailing Address
NPDES Permit Number
City, State, Zip Code
ALG87
Contact Person (if different from Caller)
Contact Person Phone Number (if different from Caller)
How and when did the Operator become aware of the adverse incident?
Describe the location of the adverse incident:
Describe the adverse incident identified and the pesticide name for each product applied in the area of the adverse incident.
Describe any steps that have been or will be taken to correct, repair, remedy, cleanup, or otherwise address any adverse effects.
III. DATE/TIME OPERATOR NOTIFIED DEPARTMENT OF THE ADVERSE INCIDENT
Date the Department was Notified
Time the Department was Notified
Name and/or Title of the Person the Operator Contacted at the Department
Instructions Received from the Department (if any)
ADEM Form 29 11/12
Page 1 of 2
IV. OTHER INFORMATION
Location of incident, including the names of any waters affected and the appearance of those waters (sheen, color, clarity, etc.)
Describe the circumstances of the adverse incident including species affected, estimated number of individuals and approximate size of dead or
distressed organisms.
Describe the magnitude and scope of the affected area (e.g. aquatic acres or total stream distance affected).
Provide the following Information for Each Pesticide used in the Affected Area(s):
Pesticide Application Rate -
-
Intended Use Site (e.g. banks, above waters, or directly to waters)
-
Method of Application
-
Name of Pesticide Product
-
Species Targeted
Describe the habitat and the circumstances under which the adverse incident occurred. Include any available ambient water data for pesticide
applied.
If laboratory tests were performed, indicate which tests were performed, when they were performed, and provide a summary of the test results
within 5 days of them becoming available.
Describe the action(s) to be taken to prevent a recurrence of adverse incidents.
V. 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.
Name (type or print)
Official Title
Signature
Date Signed
ADEM Form 29 11/12
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