1. PERMIT APPLICANT INFORMATION
AQV (11/2016). FOR DEC USE: Application Number ___________________. NEW YORK STATE DEPARTMENT OF ENVIRONMENTAL CONSERVATION (DEC) Water Body Name ____________________. DIVISION OF MATERIALS MANAGEMENT - BUREAU OF PEST MANAGEMENT APPLICATION FOR A PERMIT TO USE A PESTICIDE Date Received _______________________. FOR THE CONTROL OF AN AQUATIC PEST - TITLE 6 NYCRR PART 327/328/329. Fee Receipt Number __________________. Type of Application ____________________. SUBMIT THE APPLICATION 3 MONTHS BEFORE THE PROPOSED TREATMENT. New ___ Previous # ___________________. A CHECK OF $100 MUST ACCOMPANY THE PERMIT APPLICATION REFER TO THE ATTACHED APPLICATION INSTRUCTIONS NYCDEP/APA/Other __________________. 1. PERMIT APPLICANT INFORMATION . Name of PERMIT APPLICANT /Association/Agency: Name of Authorized Person signing the Application: (if on behalf of an Association/Organization). Mailing Address City: State: Zip Code: Telephone Email: Website: Number: The PERMIT APPLICANT is a (check appropriate): Riparian Owner: Lessee: Association of Riparian Owners: If the PERMIT APPLICANT is an Association of Riparian Owners/Lessees, a copy of the Board of Directors resolution in support of the proposed pesticide application must be attached Other: (please explain).
If there is more than one riparian owner, or vested riparian users, these riparian owners and users must be notified in writing of the application and the water use restrictions, and their right to object.
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