Government of Ontario: Ministry of the Environment

Application for a Permit to Perform a Water
Extermination in Surface Water for West Nile Virus Control

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

Legal Name of Land Owner
Contact Name

Telephone Number Extension

Mailing Address

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

Treatment site address if different than land owner

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)
Rate Requested
Quantity Requested
Date Range of Treatments
Estimated Number of Treatments

Has a permit been issued previously?

Yes No

Last Permit Number

Has any site information changed since previous permit?

No Yes , specify

Area to be treated (attach a map or digital mapping coordinates; see Appendix 9 in applicant guide)

Approximate size of treatment area(s) ha
Estimated number of treatment sites
Street boundaries enclosing treatment area
Township
District/County/Municipality

Use of surface water receiving outflows

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

Letter of support from Medical Officer of Health attached?

Yes No

Form of Public Notification

Newspaper
Flyer
Pesticide use sign

Exterminator

Name
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)

Government of Ontario: Ministry of the Environment

Application for a Permit to Perform a Water Extermination in Surface Water for West Nile Virus Control

Application for a Permit to Perform a Water
Extermination in Surface Water for West Nile Virus Control