Aquacultured Live Rock Report (harvesting activity)

U.S. DEPT OF COMMERCE, NOAA

OMB No. 0648-205 Form
Approval expires 10/31/2006

NMFS PERMITS BRANCH, F/SER1
263 13TH Avenue South

Form revised 12/16/2005

AQUACULTURED LIVE ROCK REPORT

St. Petersburg, FL 33701
727/824-5326 (8 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

Date Entered and
Initials

FOR OFFICE USE ONLY

1. PERMIT OWNER INFORMATION
LAST NAME OR NAME OF BUSINESS

FIRST NAME

MAILING ADDRESS

BUSINESS
TELEPHONE
NUMBER

MIDDLE NAME

CITY

AREA CODE/TELEPHONE NUMBER

FEDERAL ID NUMBER (FEIN) if a Company Owns Permit

HOME
TELEPHONE
NUMBER

OR

Suffix (Sr., Jr. II, etc)

STATE

ZIPCODE

STATE

ZIPCODE

AREA CODE/TELEPHONE NUMBER

SOCIAL SEC. NUMBER if person(s) own Permit

2. DEPOSIT INFORMATION
NAME OF SOURCE OF DEPOSITED MATERIAL

MAILING ADDRESS

CITY

GEOGRAPHIC ORIGIN OF DEPOSITED MATERIAL

PERMIT NUMBER

Size in Inches; i.e 12 x 12

Deposit Date MM/DD/YYYY

Pounds Depsited

Using the reverse of the form, sketch a diagram showing actual configurations and locations of deposited materials, the distance
from exsisting hard bottom habitat, submerged aquatic vegetation and the height of material deposited.

3. HARVEST INFORMATION - if landed outside Florida
Harvest Date
MM/DD/YYYY

Pounds Harvested

Unit Price

Total Dollar Value

NAME OF DEALER

MAILING ADDRESS

FEDERAL ID NUMBER (FEIN) of the Dealer

CITY

STATE

ZIPCODE

4. SIGNATURE
Signature of Reporting Permit Holder
Printed Name

Date Signed
Position in Company