Application for Coverage under the General Permit for Invasive Fish Control

Application for Coverage under the General Permit for Invasive Fish Control
Organization/Agency*
Contact Person*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Pesticide Applicator Name*
Pesticide Applicator Certification Numbers*
Treatment site
Name of waterbody/waterbodies*
Treatment site location*
Project is intended to control invasive fish species
Project is overseen or managed by the Alaska Department of Fish and Game
Waterbody characteristics*
Describe waterbody including size, streamflow, or outflow characteristics
Pesticde will be applied only to waterbodies with no functioning potable water intakes with 1/2 mile of treament area.
Treatment site has not been identified as habitat for threatened or endangered species referenced in 50 CFR 17.11-17.12.
CFT Legumine Fish Toxicant, 89459-48Prenfish Fish Toxicant, 89459-85Prentox Rotenone Fish Toxicant Powder, 89549-32
Yes, all of the information and exhibits in this application are true, accurate, and complete
Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Title*
All applications must be signed by a duly authorized employee of the Alaska Department of Fish and Game.
Please verify that you are human*
Should be Empty:

Treatment site