Form FDACS-15104 "Internal Audit of an Existing Sovereignty Submerged Land Shellfish Aquaculture Lease" - Florida

Form FDACS-15104 or the "Internal Audit Of An Existing Sovereignty Submerged Land Shellfish Aquaculture Lease" is a form issued by the Florida Department of Agriculture and Consumer Services.

Download a fillable PDF version of the Form FDACS-15104 down below or find it on the Florida Department of Agriculture and Consumer Services Forms website.

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Download Form FDACS-15104 "Internal Audit of an Existing Sovereignty Submerged Land Shellfish Aquaculture Lease" - Florida

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Florida Department of Agriculture and Consumer Services
Division of Aquaculture
INTERNAL AUDIT OF AN EXISTING SOVEREIGNTY
SUBMERGED LAND SHELLFISH AQUACULTURE LEASE
ADAM H. PUTNAM
COMMISSIONER
253.71, Florida Statute
LEASE AUDIT YEAR:
LEASE NUMBER:
LESSEE NAME:
LEASE TYPE:
Bottom Leases – Authorize use of no more than six inches off bottom.
Water Column Leases – Require all off-bottom gear be properly marked with identifying information.
FDACS STAFF USE ONLY
DATE OF AUDIT:
DUE DATE:
SECOND REQUEST DATE:
DATE RECEIVED:
CONTACT INFORMATION
Contact Full Name:
Aquaculture Certificate No.
AQ-
Mailing Address:
City:
State:
Zip Code:
Telephone Number with Area Code:
Email Address:
*Important - If the Division of Aquaculture is unable to contact you, it could result in your lease being
cancelled. If the information above is different from your current lease agreement documents, please
check the following box
and your contact information will be updated.
LEASE ACTIVITY
1. Are you currently subleasing to another certified Aquaculturist?
*All sublease transactions must be approved and executed by the Florida Department of Agriculture and
Consumer Services, Division of Aquaculture.
Yes
No
If "Yes", to whom:
Full Name of Person Subleased To:
Mailing Address:
Telephone Number with Area Code:
Date Sublease Expires:
FDACS-15104 Rev. 12/17
Page 1 of 4
Florida Department of Agriculture and Consumer Services
Division of Aquaculture
INTERNAL AUDIT OF AN EXISTING SOVEREIGNTY
SUBMERGED LAND SHELLFISH AQUACULTURE LEASE
ADAM H. PUTNAM
COMMISSIONER
253.71, Florida Statute
LEASE AUDIT YEAR:
LEASE NUMBER:
LESSEE NAME:
LEASE TYPE:
Bottom Leases – Authorize use of no more than six inches off bottom.
Water Column Leases – Require all off-bottom gear be properly marked with identifying information.
FDACS STAFF USE ONLY
DATE OF AUDIT:
DUE DATE:
SECOND REQUEST DATE:
DATE RECEIVED:
CONTACT INFORMATION
Contact Full Name:
Aquaculture Certificate No.
AQ-
Mailing Address:
City:
State:
Zip Code:
Telephone Number with Area Code:
Email Address:
*Important - If the Division of Aquaculture is unable to contact you, it could result in your lease being
cancelled. If the information above is different from your current lease agreement documents, please
check the following box
and your contact information will be updated.
LEASE ACTIVITY
1. Are you currently subleasing to another certified Aquaculturist?
*All sublease transactions must be approved and executed by the Florida Department of Agriculture and
Consumer Services, Division of Aquaculture.
Yes
No
If "Yes", to whom:
Full Name of Person Subleased To:
Mailing Address:
Telephone Number with Area Code:
Date Sublease Expires:
FDACS-15104 Rev. 12/17
Page 1 of 4
2. Have you authorized or agreed to allow another party to use all or a portion of your lease?
Yes
No
If "Yes", to whom:
Full Name of Authorized Person:
Mailing Address:
Telephone Number with Area Code:
3. Have you submitted a current Authorized User Form (
) to FDACS?
Yes
No
FDACS-15107
4. Have you transferred the lease parcel to another party?
*All lease transfers must be reviewed and approved in writing by the Florida Department of Agriculture and
Consumer Services, Division of Aquaculture.
Yes
No
If "Yes", to whom:
Full Name of Person Transferred To:
Mailing Address:
Telephone Number with Area Code:
Date of Transfer:
If lease was transferred during the audit year, please complete the audit for the time period
you were the leaseholder.
ANNUAL CULTIVATION
5. Please complete the section below by filling in the number(s) of each species of shellfish that
were planted during January 1st through December 31st of the specified audit year.
AUDIT YEAR
CLAMS
OYSTERS
PLANTED
PLANTED
6. Please list certified hatcheries/nurseries from whom you purchased seed stock:
Name of Hatchery/Nursery:
Street Address:
Telephone Number with Area Code:
Name of Hatchery/Nursery:
Street Address:
Telephone Number with Area Code:
7. For all shellfish planted, the following documents are required to be submitted with this Audit:
a. Florida hatchery shellfish seed stock bill of sale/receipts that shows the number
of shellfish species sold to you with verification of Florida broodstock. If oysters,
please check which Florida coast broodstock is from
east or
west.
b. Out of state hatchery shellfish seed stock bill of sale/receipts with address
information.
An Official Certificate of Veterinary Inspection attesting to the health of the
stock, diagnostic results and if diploid shellfish, a statement attesting that the stock came
from Florida broodstock are required.
FDACS-15104 Rev. 12/17
Page 2 of 4
8. Please complete the section below by filling in the number(s) of each species of shellfish
that were harvested during January 1st through December 31st of the specified audit year:
AUDIT YEAR
CLAMS
OYSTERS
HARVESTED
HARVESTED
9. Please list the certified shellfish processing facility/facilities that your product(s) were sold to:
Name of Processing Facility:
Street Address:
Telephone Number with Area Code:
Name of Processing Facility:
Street Address:
Telephone Number with Area Code:
10. If your response to question 5 or 8 above was “0”, please enter an explanation below.
FDACS-15104 Rev. 12/17
Page 3 of 4
You are required by your lease agreement to provide a complete audit response (the form must
be completely filled out, signed and dated, with the required supporting documentation
attached.). Cancellation of the lease agreement may occur if no audit response is received, if
the audit response received is incomplete, or if the lease is not effectively cultivated.
CERTIFICATION
I hereby certify:
i.
that the information contained herein is true and correct;
ii.
that I, _____________________________________, have personal knowledge of the
requirements associated with the use of subject state-owned lands;
iii.
that the provided address shall be used for conducting official business with the subject
state lands account; and
iv.
that I am authorized to execute this Audit and to perform aquaculture activities as
authorized by subject lease.
Lessee
Individual Lessee Signature:
Date:
Or Representative On Behalf of Lessee
Representative of Lessee Signature:
Date:
Signing capacity: _________________________________________________________________
(Please enter capacity in which signing the audit. If Lessee is a company or LLC, please enter
corporate or partner title; If signing on behalf of an estate, or power of attorney, please indicate that
authority).
FDACS-15104 Rev. 12/17
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