Request For Permission To Use Toxic Materials For Aquatic Life Management Purposes Form - Maryland Department Of The Environment Page 2

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MARYLAND DEPARTMENT OF THE ENVIRONMENT
G. PROPOSED DATE(S) OF TREATMENT
J.
USE OF WATER AREA
Public water supply
Livestock water supply
Recreational
Commercial finfish
Wildfowl management
H. NUMBER OF TREATMENTS
Industrial water supply
Irrigation water
_______________________________________
Sport fishing
Oysters, clams, crabs
I.
PROJECT AREA DESCRIPTION
Fur bearers
Street Address:
Other – specify: _____________________
City:
Zip:
Name of water area: _____________________________
K. TOXIC SUBSTANCES PROPOSED TO
Receiving waterway: ____________________________
BE USED
County: _______________________________________
Trade Name: ________________________________
ADC map coordinates or Latitude/Longitude:
Manufacturer: _______________________________
_____________________________________________
Active Ingredient: ____________________________
(Please provide a vicinity map that accurately shows the
Formulation (pellets, liquid, emulsion):
treatment area)
___________________________________________
Approximate Size of project area (square feet or acres):
Percent Active Material: _______________________
_____________________________________________
Application Method: __________________________
Depth of water: _________________________________
NOTE: Activities which result in the fill or disturbance of non-tidal wetland areas and their 25-foot buffer
areas through the movement of soil, changes in hydrology, or destruction of vegetation may require a Nontidal
Wetlands and Waterways Permit from the Department of the Environment (COMAR 26.23). Disturbances in
tidal wetland areas may require a Tidal Wetlands License from the Department of the Environment (COMAR
26.24). State agencies must insure that all actions, including permit actions, carried out by them do not
jeopardize the continued existence of species which are listed by the State as endangered, threatened, or in need
of conservation (DNR Statute 10-2A-04).
MARYLAND DEPARTMENT OF NATURAL RESOURCES REVIEW
No objection
No objection with conditions
Need additional information
Objection
Comments:
Signature of Reviewer: ______________________________________
Date: ______________________________
2
2
Form Number: MDE/WMA/PER.015
of
Revision Date: September 17, 2014
TTY Users 1-800-735-2258
Recycled Paper

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