1. (a) Governmental agencies, or their designees, shall complete and submit form SP-MOS “Application for a Special Permit for Governmental Agency Mosquito Control” by providing the following:

   1. (1) The applicant’s:

      1. a. Name;
      2. b. Business address;
      3. c. Telephone number;
      4. d. Fax number;
      5. e. Cell phone number, if the applicant wishes to provide it;
      6. f. Electronic mail address, if the applicant wishes to provide it; and
      7. g. Pesticide license number, if the applicant is the licensed pesticide applicator;

   2. (2) If the licensed pesticide applicator is not the applicant, the licensed pesticide applicator’s:

      1. a. Name;
      2. b. Address;
      3. c. Telephone number;
      4. e. Fax number;
      5. f. Cell phone number, if the licensed pesticide applicator wishes to provide it; and
      6. g. Pesticide applicator license number;

   3. (3) If the client on whose behalf the treatment is made is not the individual identified per (1) or (2), the client’s:

      1. a. Name;
      2. b. Address;
      3. c. Telephone number;
      4. d. Fax number; and
      5. e. Electronic mail address, if the client wishes to provide it;
   4. (4) A yes or no indication on whether any previous special permits were issued to conduct pesticide treatments at this site;
   5. (5) If applicable, the permit number and year of the most recent permit issued to conduct pesticide treatment at this site;

   6. (6) The reason for the pesticide application, including:

      1. a. Factors used to determine the need for treatment, on or attached to the application, including:

         1. 1. Target species survey data; and
         2. 2. Public health threat information;
      2. b. The name of the individual making the determination to apply pesticides;

   7. (7) A description of the application including:

      1. a. Target organism(s);
      2. b. Types of equipment and nozzles for adulticiding and/or larviciding;
      3. c. Method and frequency of calibration of equipment used;
      4. d. Pesticides to be used, either listed on the form or attached to it;

      5. e. Application schedule, including:

         1. 1. Approximate number and date(s) of applications; and
         2. 2. Potential application sites and acreage; either listed on the form or attached to it; and

      6. f. Environmental considerations, including:

         1. 1. Pesticide management techniques for environmental protection; and
         2. 2. Justification for the use of pesticides which have label precautions pertaining to groundwater or surface water, risk to pollinators, aquatic organisms, or other risks to the environment; and
         3. 3. A list of threatened and endangered species from the natural heritage bureau, pursuant to Ncr 312, that identifies the species the treatment area encompasses;

   8. (8) A description of the treatment and monitoring area(s) including:

      1. a. Detailed map(s), at a scale of 1:24000 or greater, identifying the treatment and surrounding areas including:

         1. 1. Proposed treatment area(s);

            1. (i) Adulticiding routes; and
            2. (ii) Larviciding locations
         2. 2. Survey site(s);
         3. 3. Adjacent area(s);
         4. 4. Land types and vegetation;
         5. 5. Surface waters;
         6. 6. Public water supply surface waters and wells;
         7. 7. Topographic features; and
         8. 8. State-owned lands;

      2. b. A description of the treatment area(s) including:

         1. 1. The location and description of the treatment area(s); and
         2. 2. The location of the survey site(s);
      3. c. List activities in the treatment area or water uses that might be affected by the pesticide treatment;
      4. d. A yes or no indication on whether there are potential treatment areas on state-owned land;
      5. e. If there are potential treatment areas on state-owned land, a list of such sites and reference of sites on the map pursuant to (8)a., above;
      6. f. The name(s) and location(s) of any nearby public water supply wells or surface waters;
      7. g. A yes or no indication on whether a setback easement from any public water supply is needed;
      8. h. If a setback easement from any public water supply is needed, a list of the water supplies and location of the nearest distance from the water supplies to the treatment areas;
      9. i. The name(s) and location(s) of any nearby surface waters not used for public water supply; and
      10. j. Yes or no indication on whether a setback easement from any surface waters not used for public water supply is needed and the nearest approach listed individually;
   9. (9) An indication of the type of notifications used pursuant to Pes 505.06(q);
   10. (10) Copies attached to the application of sample notifications used to satisfy Pes 505.06(q);
   11. (11) A yes or no indication on whether the applicant has received any requests from persons objecting to the application of pesticides to or in the vicinity of their property; and
   12. (12) The signatures of the applicant, pesticide applicator, and the client, as applicable.

2. (b) The applicant shall mail or hand-deliver the completed application to:

   NH Division of Pesticide Control

   1 Granite Place South Suite 211

   Concord, NH 03301

3. (c) Information submitted in support of the form in (a) above shall be complete and any falsification of information shall result in the denial or revocation of the special permit.

Source. #1547, eff 3-13-80; ss by #2209, eff 12-13-82; ss by #2781, eff 7-26-84; ss by #4867, eff 7-19-90; EXPIRED: 7-19-96 New. #6316, eff 8-13-96; ss by #8131, eff 8-13-04, EXPIRED: 8-13-12 New. #10585, INTERIM, eff 5-13-14, EXPIRED: 11-10-14 New. #10875, eff 7-8-15; ss by #14332, eff 8-1-25, EXPIRES: 8-1-35