Form_3_NCS000250_2015 NCDOT DAILY PESTICIDE APPLICATION FORM

NCDOT DAILY PESTICIDE APPLICATION FORM (revised Jan. 2015)
A new form shall be completed each day or each time the route is changed. This record shall be maintained for 3 years. The form shall be
completed on the day of the application with a copy given to the local Division Roadside Environmental Engineer within one week following
treatment.
Applicator(s) Name(s): NCDA&CS Pesticide License Number:
Applicator(s) Name(s): NCDA&CS Pesticide License Number:
On November 1, 2011, North Carolina adopted General Permit NCG560000 to discharge pesticide products under the National Pollutant
Discharge Elimination System (NPDES) to waters of the State. Conditions of this permit include advanced record keeping (see Page 2 of this
form. These conditions are in addition to those required by NCDA&CS. If the application associated with this report is an aquatic application
(i.e., made directly to or over water), or is an application at water's edge, or if the application could reach water, YOU ARE REQUIRED to
report the amount of treated area in linear feet. These reports will be accumulated quarterly to determine a statewide annual total.
Division
County
WBS
Date of
Application Timina:
Tarciet Vegetation:
Type of Treatment:
(Turf, Ornamental,
{Selective: (Pre-, Post-),
Element
Application
Start: O AM O PM
Daylilies, Brush,
PGR, Aquatic, Insect,
Finish: O AM O PM
Other)
Disease, other}
OR
(Non -selective)
SPECIFIC ROUTES TREATED:
Weather Conditions:
Temperature: (° F) Wind: Speed (mph) Direction From
O Sunny O Cloudy O Overcast, No Rain O Light, scattered showers O Hard Showers
Application Information: #Gallons Used Tank Size Truck Speed GPA Pressure
Does this application meet the qualifications of one or more of the `Covered Activities' listed on page two of this
report? YES or NO
Application Treatment
Herbicide(s)
Amount of
Tank
Number of Units
Application System:
Width
(check one treatment under the
Used
each
Size:
Treated
(Boom, Boomless
of
appropriate function code below)
(Include
product
Head, Handgun,
Target
Adjuvants)
per tank
Backpack, other)
Area
2904 TURF MANAGEMENT
O Annual & Perennial Grass Control,
O PGR, O Broadleaf Weed Control,
ACRES
O WSR, O Fire Ant Control
2906 CONTROL OF INVASIVE
TERRESTRIAL PLANTS
ACRES
O Kudzu, O Miscanthus, O Other
2907 CONTROL OF AQUATIC SPECIES
Linear Feet
2908 BRUSH AND TREE CONTROL /
HERBICIDES
O Woody Growth, O Dormant Stem
Shoulder Miles
2914 VEGETATION MANANGEMENT AT
STATIONARY OBJECTS
O sign posts, O bridge ends,
O on paved surfaces, O guardrails,
Linear Feet
O barriers
2916 ROADSIDE VEGETATION
ENHANCEMENT
O Roadside Vegetation Establishment,
O Renovation and Plant Maintenance
Square Yards
2920 REST AREA & WELCOME
DOLLARS; does
CENTERS
not require an
O Herbicide work at Rest Areas or Welcome
entry
Centers
OTHER:
Pesticide applications not directly applicable
to functions listed above (i.e., applications of
insecticides, fungicides, stormwater and
BMP maintenance, or OTHER describe

NPDES Pesticide Permit
Covered Activities
This permit allows discharge to waters of the state from the application of (1) biological pesticide products or
(2) chemical pesticide products that leave a residue (hereinafter collectively "pesticides"), when the pesticide
application is for one of the following pesticide use patterns:
a) Mosquito and Other Flying Insect Pest Control - to control public health/nuisance and other flying insect
pests in or above standing or flowing water. Public health/nuisance and other flying insect pests in this use
category include but are not limited to mosquitoes and black flies.
b) Aquatic Weed and Algae Control — to control invasive or other nuisance weeds and algae in water and at
water's edge, including irrigation ditches and/or irrigation canals.
c) Aquatic Animal Pest Control — to control invasive or other pest animals in water and at water's edge.
Animals in this use category include. But are not limited to fish, lampreys, and mollusks.
d) Forestry Canopy Pest Control — aerial application of a pesticide over a forest canopy to control the
population of a pest species where to target the pests effectively a portion of the pesticide unavoidably will be
applied over and deposited to water.
e) Intrusive Vegetation Control — to control vegetation along roads, utility rights of way, canals or ditches where
to target the intrusive species effectively a portion of the pesticide will unavoidably be applied over or
deposited into Waters of the State.
You are not eligible for coverage under this permit for any discharges from a pesticide application to Waters of the
State if the water is identified as impaired (i.e., on the 303d list) by that pesticide or its degradates.
Annual Treatment
Area Thresholds
Mosquito and Other Flying Insect Pests
15,000 acres of treatment area
Aquatic Weed and Algae Control
- In Water
1,000 acres of treatment area
- At Water's Ede
200 linear miles of treatment area at water's edge
Aquatic Nuisance Animal Control
- In Water
200 acres of treatment area
- At Water's Ede
200 linear miles of treatment area at water's edge
Forestry Canopy Pest Control
10,000 acres
Intrusive Vegetation Control
500 linear miles
Conditions of this permit include keeping records related to: pesticide application rates and those rates should
be below the highest rate allowed by the pesticide label; performing and recording regular equipment
maintenance activities to reduce leaks, spills, or other unintended discharges of pesticides; maintaining
pesticide application equipment in proper operating condition, and by calibrating, cleaning, and repairing
equipment on a regular basis to ensure effective pesticide application and pest control; and post -application
surveillance.
ADDITIONAL REQUIRED INFORMATION
EQUIPMENT MAINTENANCE RECORDS
DATE COMPLETED and BRIEF DESCRIPTION of activity
Calibration
Cleaning
Repairing
POST -APPLICATION SURVEY
ADDITIONAL INFORMATION ( Facility
Inspection, and Mixing & Loading Forms)