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VIII. REGULATORY STATUS:(Operator Information Only) <br /> 1. Dept. of Agriculture Pesticide Applicator License No. to be acquired in January, 2003 <br /> 2. Licensee has an Aquatic Endorsement or will be supervised by someone with an Aquatic Endorsement <br /> ® Yes ❑ No <br /> 3. Dept. of Agriculture Pesticide Applicator License Expiration Date January, 2004 <br /> 4. My renewal has been satisfied will be kept current. ❑ Yes 0 No <br /> IX. BMPs EMPLOYED TO REDUCE POLLUTANTS: <br /> 1. Indicate the status of your Integrated Pest Management (1PM)Plan (check one) <br /> a. IX! No plan in process,but willing to develop one. <br /> b. 0 In process of being developed. <br /> c. 0 Accepted and is being implemented. <br /> 2. What is date of Plan acceptance: <br /> 3.Has the Plan been revised: 0 YES 0 NO <br /> a.Date of revised Plan acceptance: <br /> 4.Do you have a Spill Plan that is Complete and Up-to-Date? 0 YES 0 NO <br /> 5. ® I will follow all label directions and requirements, unless Ecology has further restrictions. <br /> X. MONITORING AND REPORTING REQUIREMENTS <br /> This permit includes a requirement to develop and implement an individual Pesticide Monitoring Plan or <br /> participate in a Group Pesticide Monitoring Program. Check the applicable Box. <br /> 1. I plan to develop an individual Pesticide Monitoring Plan in accordance with the permit requirements. <br /> 2. I plan to participate in a Group Pesticide Monitoring Program developed in accordance with the permit <br /> requirements ❑ <br /> XL CERTIFICATION <br /> "I certify under penalty of law that this document and all attachments were prepared under my direction and <br /> supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate <br /> the information submitted. Based on my inquiry of the person or persons who manage the system,or those <br /> persons directly responsible for gathering the information, the information submitted is,to the best of my <br /> knowledge and belief,true, accurate, and complete. I am aware that there are significant penalties for submitting <br /> false information, including the possibility of fine or imprisonment.Additionally, I certify that the provisions of <br /> the permit,including developing and implementing a monitoring program, will be complied with." <br /> Printed Name of Responsible Official: <br /> Signature: Date: <br /> -3- 0 <br />