Trawl Rationalization Quota Share Permit Renewal

OMB 0648-0203, expires

QS permit renewal form Pacific Coast Groundfish Limited Entry Permit

UNITED STATES DEPARTMENT OF COMMERCE National Oceanic and Atmospheric Administration N ational Marine Fisheries Service Northwest Region , Fisheries Permits Office 7600 Sand Point Way NE, Bldg. 1 Seattle, WA 98115-0070 Phone (206) 526-4353 Fax (206) 526-4461 www.nwr.noaa.gov

Please make any changes as appropriate to the addresses, phone and fax number and email address listed below. The QS permit owner name cannot be changed. Please provide an ownership interest form with your renewal form. Also, you must have submitted a completed Economic Data Collection survey to NOAA/NMFS/Northwest Science Center.

Permit Number:

Permit Owner's name(s):

Business Address:

City, State, Zip Code

Business Phone Number :

Fax Number:

Email address:
QS Account Manager Name (if different from permit owner):
QS Account Manager Address (if different from permit owner):
QS Account Manager Business Phone(if different from permit owner):
QS Account Manager Email Address (if different from permit owner):

Please sign below to certify that the above information is true, correct and complete (edit if necessary) to the best of your knowledge and return this form with a check or money order for $XXXX made payable to U.S. Department of Commerce, NOAA. Mail to: NOAA/NMFS/Northwest Region, Sustainable Fisheries Division, 7600 Sand Point Way NE, Bldg. #1 Seattle, WA 98115-0070.

____________________________________________________________________________

Signature of owner(s) Title (If corporate officer) Date

Print Name of Signatory: __________________________

Warning Statement: A false statement on this form is punishable by permit sanctions (revocation, suspension, or modification) under 15 CFR Part 904, a civil penalty up to $100,000 under 16 USC 1858, and as a federal crime under 18 USC 1001.

PRIVACY ACT STATEMENT: Phone number, fax and email information are not released to the public. The permit sale/lease information and the amount of sablefish landed to date given on a transfer form are considered confidential. Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act. It is also confidential under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics.

The information collected is part of a Privacy Act System of Records, COMMERCE/NOAA #19, Permits and Registrations for United States Federally Regulated Fisheries. A notice was published in the Federal Register on April 17, 2008 (73 FR 20914) and became effective on June 11, 2008 (73 FR 33065).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.33 hours per response, including the time for reviewing the 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 aspect of this collection of information, including suggestions for reducing the burden, to NOAA/National Marine Fisheries Service, Northwest Region, Attn: Assistant Regional Administrator, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act. It is also confidential under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Phone number, fax and email information are not released to the public.