FWS Form 3-2163 (Rev. 05/2021) OMB Control No. 1018-####
U.S. Fish and Wildlife Service Expires ##/##/####
INVENTORY
FORM FOR USE WITH CARBON DIOXIDE-CARP
Carbon Dioxide – Carp Program Management
1. Applicator must supply information immediately after treatment.
2. This information is required for reports submitted to the EPA.
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1.a. Last name |
1.b. First name |
1.c. Middle name or initial |
1.d. Suffix |
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2 Date of birth (mm/dd/yyyy) |
5.a. Telephone number |
5.b. Alternate telephone number |
6. E-mail address |
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1.a. Name of business, agency, Tribe, or institution |
1.b. Doing business as (dba) |
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2. Tax identification no. |
3.a. Description of business, agency, Tribe, or institution |
3.b. Website URL (if applicable) |
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4.a. Principal officer (P.O.) last name |
4.b. P.O. first name |
4.c. P.O. middle initial |
4.b. P.O. Title |
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5. Primary contact name |
6. Primary e-mail address |
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7.a. Business telephone number |
7.b. Alternate phone no. |
8.a. Primary contact telephone no. |
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1.a. Physical address (Street address; Apartment #, Suite #, or Room #; no P.O. Boxes) |
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1.b. City |
1.c. State |
1.d. Zip code/Postal code |
1.e. County/Province |
1.f. Country |
2.a. Mailing Address (include if different than physical address; include name of contact person if applicable) |
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2.b. City |
2.c. State |
2.d. Zip code/Postal code |
2.e. County/Province |
2.f. Country |
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The individual/principal officer of the business must print and sign the application. (No photocopied or stamped signatures) Date (mm/dd/yyyy) |
E. Report on Receipt of Label
Date |
Amount of Carbon Dioxide-Carp Applied |
Label # |
Label Return Date |
Adverse Incident |
Applicator and Affiliation |
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NOTICES
PRIVACY ACT STATEMENT
Authority: The information requested is authorized by the following: the Bald and Golden Eagle Protection Act (16 U.S.C. 668), 50 CFR 22; the Endangered Species Act (16 U.S.C. 1531-1544), 50 CFR 17; the Migratory Bird Treaty Act (16 U.S.C. 703-712), 50 CFR 21; the Marine Mammal Protection Act (16 U.S.C. 1361, et seq.), 50 CFR 18; the Wild Bird Conservation Act (16 U.S.C. 4901-4916), 50 CFR 15; the Lacey Act: Injurious Wildlife (18 U.S.C. 42), 50 CFR 16; Convention on International Trade in Endangered Species of Wild Fauna and Flora (TIAS 8249), 50 CFR 23; General Provisions, 50 CFR 10; General Permit Procedures, 50 CFR 13; and Wildlife Provisions (Import/export/transport), 50 CFR 14.
Purpose: The collection of contact information is to verify the individual has an eligible permit to conduct activities which affect protected species. This helps FWS monitor and report on protected species and assess the impact of permitted activities on the conservation and management of species and their habitats.
Routine Uses: The collected information may be used to verify an applicant’s eligibility for a permit to conduct activities with protected wildlife; to provide the public and the permittees with permit related information; to monitor activities under a permit; to analyze data and produce reports to monitor the use of protected wildlife; to assess the impact of permitted activities on the conservation and management of protected species and their habitats; and to evaluate the effectiveness of the permit programs. More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.
Disclosure: The information requested in this form is voluntary. However, submission of requested information is required to process applications for permits authorized under the listed authorities. Failure to provide the requested information may be sufficient cause for the U.S. Fish & Wildlife Service to deny the request.
PAPERWORK REDUCTION ACT STATEMENT
We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the U.S. Fish and Wildlife Service the information necessary, under the applicable laws governing the requested activity, for which a permit is requested. Information requested in this form is purely voluntary. However, submission of requested information is required in order to process applications for permits authorized under the applicable laws. Failure to provide all requested information may be sufficient cause for the U.S. Fish and Wildlife Service to deny the request. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1018-####.
ESTIMATED BURDEN STATEMENT
We estimate public reporting for this collection of information to average 12 minutes for electronic submissions and 15 minutes for hard copy submissions, including time for reviewing instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of the form to the Service Information Clearance Officer, Fish and Wildlife Service, U.S. Department of the Interior, 5275 Leesburg Pike, MS: PRB (JAO/3W), Falls Church, VA 22041-3803, or via email at [email protected]. Please do not send your completed form to this address.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Newberry, Gretchen N |
File Modified | 0000-00-00 |
File Created | 2021-06-17 |