Dealer Report for Landing and Sale

Southeast Region Aquaculture Program

12 - Dealer Report for Landing and Sale (2-4-2014)

Dealer Report for Landing and Sale

OMB: 0648-0703

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OMB Control No. 0648-XXXX

Expiration Date:


DEALER REPORT FOR LANDING AND SALE OF CULTURED FISH


Shape1

This form must be received by NMFS within 24 hours of landing and sale. Use a new form for each separate transaction.


Form must be faxed to: (727) XXX-XXXX or emailed to XXXXXXX@noaa.gov.


FOR OFFICE USE ONLY


Date Received




Gulf Aquaculture Permit Number




Reviewer Initials and Date










Part 1 – Dealer Information


LAST NAME FIRST NAME MIDDLE NAME Suffix (Sr., II, etc.)

Shape2 Shape3 Shape4 Shape5


Shape6 Shape7 MAILING ADDRESS Apt/Suite #



Shape9 Shape10 Shape11 Shape8 CITY STATE COUNTY ZIP CODE



Shape13 Shape14 Shape12 HOME TELEPHONE NUMBER CELL PHONE NUMBER DEALER PERMIT NUMBER



BUSINESS NAME BUSINESS PHONE NUMBER


Shape15 Shape16




Part 2 – Seller Information (Gulf Aquaculture Permit Holder)



NAME OF SELLER GULF AQUACULTURE PERMIT NUMBER


Shape18 Shape17



BUSINESS NAME BUSINESS PHONE NUMBER


Shape20 Shape19




Part 3 – Landing Information


LOCATION (CITY, STATE) OF PORT1 DATE OF LANDING (MM/DD/YYYY)

Shape21 Shape22

/ /




TIME OF LANDING2 DEALER VESSEL DOCUMENTATION #

Shape23 Shape24

: A.M / P.M.



Part 4 – Transaction Information


Provide the following information for each species purchased from the vessel listed in Part 2. Report the estimated average weight for each species to the nearest tenth of a pound.


Species #1


SCIENTIFIC NAME (GENUS AND SPECIES) TOTAL WHOLE WEIGHT (LBS) EST. AVERAGE WHOLE WEIGHT (LBS)


Shape26 Shape25 Shape27



TOTAL PRICE PAID AVERAGE PRICE PAID PER POUND NOTES

Shape28 Shape30 Shape29

$

$




Species #2


SCIENTIFIC NAME (GENUS AND SPECIES) TOTAL WHOLE WEIGHT (LBS) EST. AVERAGE WHOLE WEIGHT (LBS)


Shape32 Shape31 Shape33



TOTAL PRICE PAID AVERAGE PRICE PAID PER POUND NOTES

Shape34 Shape36 Shape35

$

$




Species #3


SCIENTIFIC NAME (GENUS AND SPECIES) TOTAL WHOLE WEIGHT (LBS) EST. AVERAGE WHOLE WEIGHT (LBS)


Shape38 Shape37 Shape39



TOTAL PRICE PAID AVERAGE PRICE PAID PER POUND NOTES

Shape40 Shape42 Shape41

$

$




Species #4


SCIENTIFIC NAME (GENUS AND SPECIES) TOTAL WHOLE WEIGHT (LBS) EST. AVERAGE WHOLE WEIGHT (LBS)


Shape44 Shape43 Shape45



TOTAL PRICE PAID AVERAGE PRICE PAID PER POUND NOTES

Shape46 Shape48 Shape47

$

$




Species #5


SCIENTIFIC NAME (GENUS AND SPECIES) TOTAL WHOLE WEIGHT (LBS) EST. AVERAGE WHOLE WEIGHT (LBS)


Shape50 Shape49 Shape51



TOTAL PRICE PAID AVERAGE PRICE PAID PER POUND NOTES

Shape52 Shape54 Shape53

$

$




Dealers must maintain sales records for at least 3 years after the receipt date. Records must be made available for inspection by NMFS personnel or authorized officers upon request.



Part 5 – Signature


I hereby declare under penalty of perjury that the foregoing information is true and correct (28 U.S.C. section 1746; 18 U.S.C. section 1621; 18 U.S.C. section 1001).


DEALER SIGNATURE PRINTED NAME DATE SIGNED (MM/DD/YYYY)

Shape55 Shape57 Shape56





Public reporting burden for this collection of information is estimated to average 30 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 other suggestions for reducing this burden to PRA Officer, National Marine Fisheries Service. F/SER26, 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 NMFS 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.

1 Landing of allowable aquaculture species is prohibited at non-U.S. ports, unless first landed at a U.S. port.

2 Species cultured at an aquaculture facility can only be landed ashore between 6 a.m. and 6 p.m., local time.

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