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pdfU.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS BRANCH, F/SER1
263 13TH Avenue South
St. Petersburg, FL 33701
727/824-5326 (8 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov
APPLICATION FOR FEDERAL PERMIT
FOR THE HARVEST OF
AQUACULTURED LIVE ROCK
OMB No. 0648-205 Form
Approval expires 10/31/2006
Check or Money
Order Number:
Reviewer Initials and
Date
Violation Date:
Violation Clear Date:
New Application $175.00
Renewal Application $31.00
All Information is REQUIRED. Incomplete or
unreadable applications will be returned.
New Expiration Date:
Articles of Inc. on file?
YES
NO
PERMIT NUMBER
SITE NUMBER
FOR OFFICE USE ONLY
1. APPLICANT (PERMIT OWNER) INFORMATION
Individual or Partnership
PERMIT IS OWNED BY:
LAST NAME OR NAME OF BUSINESS
FIRST NAME
MAILING ADDRESS
BUSINESS
TELEPHONE
NUMBER
Business
MIDDLE NAME
CITY
AREA CODE/TELEPHONE NUMBER
FEDERAL ID NUMBER (FEIN) if a Company Owns Permit
HOME
TELEPHONE
NUMBER
OR
STATE
AREA CODE/TELEPHONE NUMBER
Suffix (Sr., Jr. II, etc)
ZIP CODE
COUNTY
DATE OF BIRTH
MONTH
OR DATE BUSINESS FORMED
DAY
YEAR
SOCIAL SEC. NUMBER if person(s) own Permit
2. SITE INFORMATION
SITE NUMBER (AS ASSIGNED BY NMFS) Leave blank if this is a new site, use the NMFS
assigned site number if a new permit owner will harvest an established site
Site Size and Position Information Note ALL Aquaculture sites are circles with a radius not to exceed 117.75 feet (0.019
NM). The total acerage of ALL sites maintained by a single permit owner must not exceed 1.0 acres.
Latitude and Longitude must be reported as Degrees Minutes to the third decimal place (i.e. 24-32.123 N 085-45.456 W)
Center Point Latitude
Radius (in feet, not to exceed 117.75 feet)
Center Point Longitude
Method of determining Latitude and Longitude
GPS
DGPS
State the site is located in:
LORAN TDs converted by manual plotting or electronics
Other ___________________________
Minimum Depth of water (in feet) to be allowed over the site at mean low water:
Page 1
3. VESSEL INFORMATION (all information is required)
INSTRUCTIONS: Provide a copy of the valid, unexpired USCG Certificate of documentation (or state registration if not documented) for each vessel
listed. Provide all information for each vessel used in the deposting/harvesting of aquacultured rock at the permitted site. If more forms are needed,
photocopy this form and number each additional vessel, or provide the required information on a seperate sheet of paper.
VESSEL 1
USCG Document Number (State Number if not documented)
Homeport City
Vessel Name
Homeport State
Total Horsepower
Length (feet)
Port of Landing City
Hold Capacity (tons)
Port of Landing State
Live Well Capacity (gallons
VESSEL 1 OWNER INFORMATION
LAST NAME OR NAME OF BUSINESS
FIRST NAME
MAILING ADDRESS
BUSINESS
TELEPHONE
NUMBER
MIDDLE NAME
CITY
AREA CODE/TELEPHONE NUMBER
STATE
HOME
TELEPHONE
NUMBER
FEDERAL ID NUMBER (FEIN) if a business owns the vessel
OR
AREA CODE/TELEPHONE NUMBER
Suffix (Sr., Jr. II, etc)
ZIP CODE
COUNTY
DATE OF BIRTH
MONTH
OR DATE BUSINESS FORMED
DAY
YEAR
SOCIAL SEC. NUMBER if person(s) owns the vessel
VESSEL 2
USCG Document Number (State Number if not documented)
Vessel Name
Homeport State
Homeport City
Total Horsepower
Length (feet)
Port of Landing City
Hold Capacity (tons)
Port of Landing State
Live Well Capacity (gallons
VESSEL 2 OWNER INFORMATION
LAST NAME OR NAME OF BUSINESS
FIRST NAME
MAILING ADDRESS
BUSINESS
TELEPHONE
NUMBER
AREA CODE/TELEPHONE NUMBER
MIDDLE NAME
CITY
HOME
TELEPHONE
NUMBER
FEDERAL ID NUMBER (FEIN) if a business owns the vessel
OR
STATE
AREA CODE/TELEPHONE NUMBER
ZIP CODE
COUNTY
DATE OF BIRTH
MONTH
SOCIAL SEC. NUMBER if person(s) owns the vessel
Page 2
Suffix (Sr., Jr. II, etc)
OR DATE BUSINESS FORMED
DAY
YEAR
4. BUSINESS OFFICER INFORMATION IS REQUIRED FOR PERMITS OWNED BY COMPANIES/BUSINESSES OR PARTNERS. FOR
ADDITIONAL PERSONS, PHOTOCOPY THIS PAGE OR USE A SEPERATE SHEET OF PAPER IF NEEDED.
OFFICER OR PARTNER #1
POSITION IN COMPANY
LAST NAME
FIRST NAME
MIDDLE NAME
Suffix (Sr., Jr. II, etc)
MAILING ADDRESS
COUNTRY
DATE OF BIRTH - MONTH DAY YEAR
CITY
BUSINESS
TELEPHONE
NUMBER
AREA CODE
STATE
TELEPHONE NUMBER
HOME
TELEPHONE
NUMBER
OFFICER OR PARTNER #2
POSITION IN COMPANY
LAST NAME
FIRST NAME
MIDDLE NAME
Suffix (Sr., Jr. II, etc)
MAILING ADDRESS
COUNTRY
DATE OF BIRTH - MONTH DAY YEAR
CITY
BUSINESS
TELEPHONE
NUMBER
AREA CODE
STATE
TELEPHONE NUMBER
HOME
TELEPHONE
NUMBER
OFFICER OR PARTNER #3
POSITION IN COMPANY
LAST NAME
FIRST NAME
MIDDLE NAME
Suffix (Sr., Jr. II, etc)
MAILING ADDRESS
COUNTRY
AREA CODE
AREA CODE
DATE OF BIRTH - MONTH DAY YEAR
CITY
BUSINESS
TELEPHONE
NUMBER
AREA CODE
STATE
TELEPHONE NUMBER
HOME
TELEPHONE
NUMBER
AREA CODE
SOCIAL SECURITY NUMBER
COUNTY
ZIP CODE
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
COUNTY
ZIP CODE
TELEPHONE NUMBER
SOCIAL SECURITY NUMBER
COUNTY
ZIP CODE
TELEPHONE NUMBER
APPLICANT SIGNATURE
Applicant Signature
Date Signed
Printed Name
Position in Company
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Send comments regarding this burden estimate or any other suggestions for reducing this burden to Carolyn Sramek, National Marine Fisheries Service,
F/SER1, 263 13th Avenue South , St. Petersburg, FL 33701.
The National Marine Fisheries Service requires this information for the conservation and management of marine fishery resources. The data reported
will be used to develop, implement, and monitor fishery management activities for a variety of other uses. Responses to this collection are required to
obtain or retain a fisheries permit under the Magnuson - Stevens Act. Name and address information will be released via a NOAA
Fisheries website. All other data submitted will be handled as confidential material in accordance with NOAA Administrative Order 216-100, Protection of
Confidential Fishery Statistics. Notwithstanding any other provisions of the law, no person is required to respond to, nor shall any person be subjected to
a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of
information displays a currently valid OMB Control Number.
Page 3
Last Form Revision 11/15/2005
| File Type | application/pdf |
| File Title | 15 NOV 05 Aquaculture Application page 1 |
| Author | Sheila Hoban |
| File Modified | 2006-04-05 |
| File Created | 2006-04-04 |