Federal Permit Application for the Harvest of Aquacultur

OMB No. 0648-0205 Form Approval Expires: 08/31/2011

U.S. DEPT OF COMMERCE, NOAA
NMFS PERMITS OFFICE, F/SER14

FEDERAL PERMIT APPLICATION FOR
THE HARVEST OF AQUACULTURED
LIVE ROCK

263 13th Avenue South
St. Petersburg, FL 33701
Toll Free 877/376-4877 (8:00 am - 4:30 pm ET)
727/824-5326 (8:00 am - 4:30 pm ET)
http://sero.nmfs.noaa.gov

FOR OFFICE USE ONLY
Reviewer's Initials and Date
Check or Money Order
Number and Amount:
Sanction Case Number if
Sanctioned:
Non Compliance Hold Date:
Non Compliance Cleared
Date:
New Expiration Date:
Site Number
FOR OFFICE USE ONLY
Application ID

New Application $175.00

Renewal Application $31.00

1. SITE INFORMATION
Note: Aquacultured Live Rock sites must be circular with a radius not to exceed 117.75 feet (0.019NM). Aquacultured Live Rock permits for sites off the
coast of the state of Florida are issued under the U.S. Army Corps Of Engineers (USACE) General Permit SAJ-71 to deposit material. Under SAJ-71, the
total acreage of all sites maintained by a single permit holder must not exceed 1.0 acres. Applicants desiring to maintain aquacultured live rock sites with a
total area of more than 1.0 acre OR off the coast of a state other than Florida, must first obtain permits to deposit material from the USACE.
Latitude and Longitude must be reported as Degrees-Minutes to the third decimal place (i.e., 24-32.123 N 085-45.456 W)

If applying to obtain a permit for an existing deposition site:
Provide the SITE NUMBER (as assigned by NMFS) an existing site in this box. You need not fill in the other fields within the Site
Information section.

If applying to obtain a permit for a new depostion site:
Provide the deposition site center point latitude and longitude (in degrees, minutes and decimal minutes to three decimal points), the method of
determining position, site radius, coast the site is located on, and minimum depth of water at mean low water.
Latitude Center Point
Method of determining Latitude and Longitude
This site is located off the coast of
(state):

Longitude Center Point

GPS

Radius (not to exceed 117.75 feet)

DGPS

ft.

Minimum Depth of water over the site at mean
low water, reported in feet:

ft.

APPLICANT SIGNATURE - I certify that the information provided is complete and correct
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 PRA Officer, National Marine Fisheries Service, F/SER2, 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 1

Form Revision 05/17/2011

2. PERMIT HOLDER INFORMATION
Please copy this page as needed to provide information on all permit holders.

1) Please complete this section for each permit holder. If the permit holder is a business or partnership, enter the Federal
Tax ID number and date the business was filed or partnership was filed. If the permit holder(s) is/are individual(s) enter the
Social Security Number(s)(SSN) and date(s) of birth. Complete the Joint Permit Holder information for a second permit
holder if the permit is held by more than one individual. If you need more space, copy this form or provide the required
information on a separate sheet of paper.
2) Place an "X" in the Mailing Recipient block to indicate who will receive the permit and all related information.

Permit Holder
If the permit holder is an INDIVIDUAL, fill in the personal information (SSN, date of birth, etc.)
If the permit holder is a BUSINESS, fill in the business informaton (Federal Tax ID #, Date Business Filed, Name, etc.)
Mailing Recipient - Mark this box if you want this entity to receive all mail concerning this permit; mark only one person.

Mr/Mrs/Ms

Last Name or Name of Business

First Name

Middle Name

Suffix JR,SR,etc.

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (Federal Tax ID or SSN)

Date of Birth or Date Business Filed (MM/DD/YYYY

Area Code

Phone Number

Joint Permit Holder
Fill out this section only if the permit is jointly held by more than one person. Photocopy this page if needed.
Mailing Recipient - Mark this box if you want this entity to receive all mail concerning this permit; mark only one person.

Mr/Mrs/Ms

Last Name or Name of Business

First Name

Middle Name

Suffix JR,SR,etc.

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (Federal Tax ID or SSN)

Date of Birth or Date Business Filed (MM/DD/YYYY

Area Code

Phone Number

REMINDER: THE APPLICANT MUST SIGN THE APPLICATION ON PAGE 1
Page 2

3. OFFICER/SHAREHOLDER INFORMATION FOR A BUSINESS/PARTNERSHIP THAT HOLDS THE PERMIT
Please copy this page as needed for all officers/shareholders of the business that holds the permit.
1) Please complete this section for each officer or partner associated by partnership, corporation, or other business relationship to the business listed
in Section 2. You must provide the information for all officers that are shown on your most recent annual report. If your business is structured as a
corporation, you must identify all shareholders and the percentage of shares held by each individual. The total of all entries must be 100 percent.
Provide the name, address, Social Security Number (SSN), date of birth (DOB) and phone number for each individual.

Business name:

Federal Tax ID #

Position held
President/CEO

Vice President

Secretary

Treasurer

Director/Manager

Agent

Shareholder

Other

Percent (%) of Corporation Held
Mr/Mrs/Ms

Last Name

First Name

Suffix JR,SR,etc.

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Date of Birth

Tax ID # (SSN)

Area Code

Phone Number

Position held
President/CEO

Vice President

Secretary

Treasurer

Director/Manager

Agent

Shareholder

Other

Percent (%) of Corporation Held
Mr/Mrs/Ms

Last Name

First Name

Middle Name

Suffix JR,SR,etc.

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Physical Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (SSN)

Date of Birth

Area Code

Phone Number

REMINDER: THE APPLICANT MUST SIGN THE APPLICATION ON PAGE 1
Page 3

4. 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 to deposit/harvest aquacultured live 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 separate sheet of
paper. Each vessel used to harvest or deposit material MUST be listed.
VESSEL 1
OFFICIAL NUMBER FROM USCG CERTIFICATE OF
DOCUMENTATION (if the vessel is documented)

YEAR BUILT

STATE REGISTRATION NUMBER (if applicable)

Crew Size - Including the Captain
HOLD CAPACITY
(Pounds of Harvest)

LENGTH (FEET)

TOTAL HORSEPOWER

LIVE WELL CAPACITY
(Gallons)

VESSEL NAME

HULL IDENTIFICATION or IMO NUMBER

HULL MATERIAL

USCG DOCUMENTED
VESSELS ONLY

DIESEL
FIBERGLASS

GROSS TONS

HAILING PORT CITY

FUEL TYPE

GASOLINE

STEEL

HAILING PORT COUNTY or PARISH

NET TONS

OTHER
________________

WOOD

HAILING PORT STAT

TOTAL FUEL
CAPACITY
(GALLONS)

CEMENT
PORT OF LANDING CITY

OTHER
________________

PORT OF LANDING STATE

Please complete this section for each vessel owner. If the vessel is owned by a business or partnership, enter the Federal Tax ID Number and date the
business or partnership was filed. If the vessel is owned by individual(s), enter the Social Security Number(s) (SSN) and date(s) of birth (DOB).
VESSEL 1 OWNER INFORMATION as shown on the USCG Certificate of Documentation (or State Registration if not documented)

Mr/Mrs/Ms

Last Name or Name of Business

First Name

Middle Name

Suffix: JR,SR, etc.

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Street Address

Apt/Suite #

City

State

County/parish

Zip Code

Country

Check box if same as Mailing Address

Tax ID # (Federal Tax ID or SSN)

Date of Birth/Date Business Filed (MM/DD/YYYY)

Area Code

Phone Number

VESSEL 1 JOINT OWNER INFORMATION as shown on the USCG Certificate of Documentation (if not documented, then State Registration)

Mr/Mrs/Ms

Last Name or Name of Business

First Name

Middle Name

Mailing Address

Apt/Suite #

City

State

County/parish

Zip Code

Street Address

Apt/Suite #

City

State

County/parish

Zip Code

Check box if same as Mailing Address

Tax ID # (Federal Tax ID or SSN)

Date of Birth/Date Business Filed (MM/DD/YYYY)

Area Code

Photocopy this page as needed for additional vessels.

Phone Number

Page 4