Government of Ontario: Ministry of the Environment

Application for a Permit to Perform a Water Extermination

Personal information requested on this form is collected under the authority of the Pesticides Act, R.S.O., 1990, Ontario Regulation 63/09. It is used to evaluate applications for permits to use restricted pesticides according to the requirements of the Pesticides Act.

Questions regarding completion and submission of this application should be directed to the Pesticides Specialist in the local Regional Office of the Ministry of the Environment. Regional Office contact information is available on the Ministry of the Environment website at. http://www.ene.gov.on.ca/en/contact/index.php.

Information contained in this application form is not considered confidential and will be made available to the public upon request. Information submitted as supporting information maybe claimed as confidential but will be subject to the Freedom of Information and Protection of Privacy Act (FOIPPA) and the Environmental Bill of Rights (EBR). If you do not claim confidentiality at the time of submitting the information, the Ministry of the Environment may make the information available to the public without further notice to you. If you are identifying confidential material, please indicate why you believe the information is confidential.

For Ministry Use Only
Client Number

Applicant Information

Name of Applicant

Home Telephone Number

Business Telephone Number Extension

Mailing Address

Unit Number
Street Number
Street Name
PO Box
City/Town
Municipality
Province
Postal Code

Pesticide and Site Information

Name of Pest
Name of Pesticide
Pest Control Products Act Number
Active Ingredient(s)

Type of application

Ground Air Both

Rate Requested
Quantity Requested
Date of Treatment
Number of Treatments
Number of Properties to be treated

Has a permit been previously issued for this proposed treatment site?

Yes No

Last Permit Number
Amount of pesticide left over from last treatment

Is the treatment to be done by an exterminator?

No Yes , specify

Area to be treated (attach a map and indicate access route)

Length (frontage)
Width
Depth (average)

If for Black fly treatment

Stream flow (m³ /sec)
Current speed (m/sec)

Name of property owner(s) of proposed treatment site
Name of body of water

Address of treatment site(s) (if different than address of applicant)

Township
District/County/Municipality
Lot
Concession

Water in the vicinity of the treated area is to be used for

Swimming
Drinking
Crop irrigation
Livestock watering
Boating
Fishing (specify)
Other (specify)

Have all adjacent landowners, lessees or affected parties been notified of the
proposed treatment, realizing use of the water may be temporarily restricted?

Yes Date of notification
No Explain

Are there any objections to the proposed treatment from adjacent landowners, lessees or affected parties?

Yes No

Have all objectors been made aware that any comments and submissions on
the proposed treatments can be made to the Director under the Act at your
nearest Ministry of the Environment Regional Office within 5 days of being
notified of the proposed treatment?

Yes No

Name of Exterminator
Exterminator’s Licence Number

Telephone Number

Address

Unit Number
Street Number
Street Name
PO Box
City/Town
Municipality
Province
Postal Code

Operator Name
Operator Licence Number
Name of Applicant (please print)
Signature of Applicant

Date (yyyy/mm/dd)