EM System Certification Form

OMB Control No. 0648-XXXX, Expires on: DATE

Electronic Monitoring System Certification Form Pacific Coast Groundfish Trawl Rationalization Program

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

This form must be completed by the EM service provider installing the EM system to certify that the EM system has been tested and conforms to the performance standards in the regulations. The completed form must be provided to the vessel owner and submitted as part of the vessel owner’s final application to the National Marine Fisheries Service (NMFS) at the address given above to qualify for an electronic monitoring (EM) authorization.

Section A – Vessel Information
1. Vessel Name			2. Vessel Registration Number
3. Name of Vessel Representative Present at Installation			4. Phone Number ( )
5. Date of Installation			6. Port (City, State)
Section B – EM Service Provider Information
1. EM Service Provider Name			2. Technician Name
2. Business Mailing Address (PO Box not acceptable) Street			3. Business Phone Number ( )
			4. Business Fax Number (optional) ( )
City	State	Zip Code	5. Business Email
Section C – EM Installation This section is to be completed by the employee of the EM service provider that installed the EM system and associated equipment.
The EM system installed must meet the performance standards below as required by 50 CFR 660.604(j). The specifications (e.g., image resolution, frame rate, user interface) and configuration of an EM system and associated equipment (e.g., number and placement of cameras, lighting) must be sufficient to: Allow easy and complete viewing, identification, and quantification, of catch items discarded at sea, including during low light conditions; Continuously record vessel location (latitude/longitude coordinates), velocity, course, and sensor data (i.e, hydraulic and winch activity); Allow the identification of the time, date, and location of a haul/set or discard event; Record and store image data from all hauls/sets and the duration that fish are onboard the vessel until offloading begins; Continuously record and store raw sensor data (i.e., GPS and gear sensors) for the entire fishing trip; Prevent radio frequency interference (RFI) with vessel monitoring systems (VMS) and other equipment; Allow the vessel operator to test and monitor the functionality of the EM system prior to and during the fishing trip to ensure it is fully functional; Prevent tampering or, if tampering does occur, show evidence of tampering; and, Provide image and sensor data in a format that enables their integration for analysis. Please Note: All of the questions below must be answered for the application to considered complete. If you cannot affirm any of these statements or are unsure, check “No” and attach to the application relevant information to enable NMFS to make a decision.
				Yes	No
Does the EM system and associated equipment installed meet the performance standards above?
Was the EM system turned on?
Were the sensors and cameras tested for functionality?
Was the system turned on while the vessel was underway?
Was the system tested for interference with VMS?
Was the system tested for interference with radar (short and long range)?
Was the lighting tested to ensure that it did not impair camera imagery?
Has Pacific States Marine Fisheries Commission accepted the camera views?

Section D – Certification of EM Service Provider This section must be completed by a representative of the EM service provider that installed the EM system and associated equipment.
By signing and dating the form below, the applicant or authorized representative certifies that all information set forth in the form is true, correct and complete to the best of the applicant’s knowledge or belief. The form will not be considered without the applicant or authorized representative’s signature. NMFS may request that the authorized representative for a business entity include a copy of the corporate resolution or other document authorizing the individual to sign and certify on behalf of the business entity. Under penalties of perjury, I hereby declare that I, the undersigned, am authorized to certify this installation on behalf of the EM service provider and completed this form, and the information contained herein is true, correct, and complete to the best of my knowledge and belief.
Signature of Authorized Representative	Date
Printed Name of Authorized Representative

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/or criminal penalties including, but not limited to, fines or imprisonment or both under 18 USC 1001.

PRIVACY ACT STATEMENT: Some of the information collection described above is confidential under section 402(b) of the Magnuson-Stevens Act and under NOAA Administrative Order 216-100, Protection of Confidential Fisheries Statistics. Business phone number, fax number, and email, and the names of individuals listed as contacts are not released to the public. 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 August 7, 2015 (81 FR 47457) and became effective on September 15, 2015 (80 FR 55327).

PRA STATEMENT: Public reporting burden for this collection of information is estimated to average 0.50 hours per response for new applicants. Send comments regarding this burden estimate or any other suggestions for reducing this burden to NOAA/National Marine Fisheries Service, West Coast Region, Attn: Program Manager, Sustainable Fisheries Division, 7600 Sand Point Way NE, Seattle, WA 98115. 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.

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