V. ALGAECIDE AND AQUATIC HERBICIDE APPLICATION INFORMATION A. Target Organisms: ____ B. Algaecide and Aquatic Herbicide Used: List Name and Active ingredients

IV. RECEIVING WATER INFORMATION A. Algaecide and aquatic herbicides are used to treat (check all that apply): 1. Canals, ditches, or other constructed conveyance facilities owned and controlled by Discharger. Name of the conveyance system: ________________________________________________ 2. Canals, ditches, or other constructed conveyance facilities owned and controlled by an entity other than the Discharger. Owner’s name:________________________________________________________________ Name of the conveyance system: ________________________________________________