1. (a) An applicant for a permit to conduct aquatic pesticide treatments under RSA 430:31, IV (a) for surface waters as described in Pes 604.05(a) shall complete and submit Form A-2 by providing the following:

   1. (1) A yes or no indication on whether the surface water is less than 10 acres in area;
   2. (2) An indication of whether the entire surface water and shoreline is owned by one person or entity;
   3. (3) A yes or no indication on whether all owners are in agreement with the treatment;
   4. (4) A yes or no indication on whether there is a regularly flowing outlet;
   5. (5) A yes or no indication on whether the outflow can be controlled;

   6. (6) 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; and
      6. f. Pesticide license number;

   7. (7) The applicant’s contact’s:

      1. a. Name;
      2. b. Telephone number;
      3. c. Cell phone number, if the contact wishes to provide it; and
      4. d. E-mail address, if the contact wishes to provide it;

   8. (8) If the licensed pesticide applicator is not the applicant or the applicant’s contact, the licensed pesticide applicator’s:

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

   9. (9) If the client on whose behalf the treatment is made is not the individual identified per (6), (7) or (8), the client’s:

      1. a. Name;
      2. b. Address;
      3. c. Telephone number;
      4. d. Fax number;
      5. e. E-mail address, if the contact wishes to provide it;

   10. (10) If the contact or spokesperson is different than the individual identified in (9) above, that contact or spokesperson’s:

       1. a. Name;
       2. b. Telephone number;
       3. c. Cell phone number, if the contact or spokesperson wishes to provide it; and
       4. d. E-mail address, if the contact or spokesperson wishes to provide it;
   11. (11) A yes or no indication on whether any previous special permits were issued to conduct pesticide treatment at the site;
   12. (12) If applicable, the permit number and year of the most recent permit issued to conduct pesticide treatment at the site;

   13. (13) A description of the treatment area including:

       1. a. A list of treatment areas;
       2. b. A yes or no indication on whether there are activities in the treatment area or water uses that might be affected by the pesticide treatment;
       3. c. If there are activities in the treatment area or water uses that might be affected by the pesticide treatment, provide a list and description of each one;
       4. d. A yes or no indication on whether a setback easement from any public water supplies is needed;
       5. e. If a setback easement from any public water supply is needed, a list of the water supplies and the location of the nearest distance from the water supplies to the treatment area; and
       6. f. The reason or need for the pesticide treatment;

   14. (14) A detailed map showing the following:

       1. a. Treatment areas;
       2. b. Adjacent areas;

       3. c. Surface waters including:

          1. 1. The surface water to be treated;
          2. 2. Inlets labeled; and
          3. 3. Outlets labeled;
       4. d. Pertinent topographic features; and
       5. e. Land type;
   15. (15) A yes or no indication on whether or not the surface water to be treated has regularly flowing outflow;
   16. (16) If the surface water to be treated has regularly flowing outflow, include a description of how the outflow will be controlled;
   17. (17) The names and addresses of any other persons or entities that share ownership of the surface water or shoreline;
   18. (18) A yes or no indication on whether any other persons or entities that share ownership of the surface water or shoreline are in agreement with the treatment; and

   19. (19) A description of the pesticide treatment including:

       1. a. The target organism(s);
       2. b. The method(s) of treatment;

       3. c. The pesticide(s) to be used including:

          1. 1. The name(s) of the product;
          2. 2. The rate(s) of application;
          3. 3. The amount of formulation to be used; and
          4. 4. An attachment of a complete copy of the pesticide label(s) to be used;
       4. d. Planned maximum concentration in parts per million of the chemical in the treated surface water;
       5. e. The chemical formulation in which the concentration is expressed;
       6. f. Number of treatments;
       7. g. Approximate date(s) of the treatment(s); and
       8. h. Statement that treatment shall be consistent with the label recommendations of the pesticide or pesticides to be used.
2. (b) The applicant, or pesticide applicator if not the applicant, and if applicable the client, shall sign and date the form attesting that the information provided in the application is accurate and true and acknowledging that falsification of information shall result in denial of a special permit.

3. (c) 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

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 (from Pes 604.03)