<
Facility
ID>

U.
S.
EPA
Aquatic
Animal
Production
Industry
Screener
Survey
c/
o
[
undetermined]
at
Westat
1650
Research
Blvd.
Rockville,
MD
20850
<
Facility>
<
Address>
<
City,
State
Zip>

Dear
<
Name>,

The
U.
S.
Environmental
Protection
Agency
(
EPA)
is
conducting
a
two­
part
survey
of
the
aquatic
animal
production
(
aquaculture)
industry
as
part
of
its
effort
to
develop
effluent
limitations
guidelines
and
standards
for
this
industry.
The
two
parts
of
this
survey
effort
consist
of
a
short
screener
questionnaire
(
attached)
that
is
being
sent
to
a
large
number
of
farms/
facilities
in
the
industry
and
a
more
detailed
questionnaire
that
will
be
mailed
at
a
later
date
to
a
sample
of
facilities.
Response
to
this
survey
is
required
by
law,
Section
308
of
the
Clean
Water
Act
(
Federal
Water
Pollution
Control
Act,
33
U.
S.
C.
Section
1318).
Please
return
the
survey
to
the
EPA
within
15
days
of
receiving
it.

You
may
claim
the
information
included
in
the
response
to
a
question
as
confidential
by
checking
the
Confidential
Business
Information
(
CBI)
box
next
the
question
number.
Please
note
that
you
may
be
required
to
justify
any
claim
of
confidentiality
at
a
later
time.
Information
covered
by
a
claim
of
confidentiality
will
be
disclosed
by
EPA
only
to
the
extent,
and
by
means
of,
the
procedures
set
forth
in
40
CFR
Part
2,
Subpart
B.
In
general,
submitted
information
protected
by
a
CBI
claim
may
be
disclosed
to
other
employees,
officers,
or
authorized
representatives
of
the
United
States
concerned
with
implementing
the
Clean
Water
Act.

Information
covered
by
a
claim
of
confidentiality
will
be
made
available
to
EPA
contractors
and
subcontractors
under
EPA
Contract
Numbers
68­
C­
99­
263,
68­
C­
99­
233,
68­
C­
99­
242
and
68­
C6­
0022
to
enable
the
contractors
to
perform
the
work
required
by
their
contracts
with
EPA.
All
EPA
contracts
provide
that
contractor
employees
will
use
the
information
only
for
the
purpose
of
performing
the
work
required
by
their
contracts
and
will
not
disclose
any
CBI
to
anyone
other
than
EPA
without
prior
written
approval
from
each
affected
business
or
from
EPA's
legal
office.
Any
comments
you
may
wish
to
make
on
this
issue
must
be
submitted
in
writing
along
with
your
completed
survey.

Please
take
a
few
minutes
to
complete
and
return
this
questionnaire.
If
you
need
help,
call
our
Aquaculture
Survey
Helpline
at
the
toll­
free
number
1­
888­
733­
1449.
Thank
you
for
your
cooperation.

Sincerely,

Geoffrey
H.
Grubbs,
Director
Office
of
Science
and
Technology
FORM
APPROVED
{
OMB
CONTROL
NO.
XXXX
­
XXXX
{
EXPIRATION
DATE:
XX/
XX/
XX
Screener
Questionnaire
for
the
Aquatic
Animal
Production
Industry
May
2001
U.
S.
Environmental
Protection
Agency
(
EPA)
Office
of
Wastewater
Management
Washington,
DC
Notice
of
Estimated
Burden
EPA
estimates
that
completion
of
the
entire
Screener
Questionnaire
for
the
Aquatic
Animal
Production
Industry
will
require
an
average
of
1
hour
per
facility.
This
estimate
includes
time
for
reading
the
instructions
and
reviewing
the
information
necessary
to
respond
to
the
questionnaire
form.
Any
comments
regarding
EPA's
need
for
the
information,
the
accuracy
of
the
provided
burden
estimate,
and
suggested
methods
for
reducing
respondent
burden
(
including
the
use
of
automated
collection
techniques)
should
be
addressed
to:
Director,
Collection
Strategies
Division,
U.
S.
Environmental
Protection
Agency
(
2822),
1200
Pennsylvania
Ave.,
NW,
Washington,
DC
20460.
Please
include
the
OMB
Control
Number,
listed
in
the
left­
hand
margin
on
this
page,
with
any
correspondence.
Do
not
send
the
completed
survey
to
this
address.
<
Facility
ID>

EPA
Screener
Questionnaire
for
the
Aquatic
Animal
Production
Industry
1.
Do
you
produce
(
grow)
aquatic
animals
(
fish,
shellfish,
other
aquatic
animals)
at
this
facility?
(
Check
one
box)

*
Yes.
Complete
the
survey.
Sign
the
Certification,
and
return
the
survey.

*
No.
Go
to
the
last
page.
Sign
the
Certification
and
return
the
survey.

2.
Is
the
mailing
address
on
the
label
on
the
envelope
correct?
(
Check
one
box)

*
Yes,
the
mailing
address
is
correct.

*
No,
the
mailing
address
is
not
correct.
Please
correct
below.

Name
of
Facility:
__________________________________________________

Mailing
address
or
P.
O.
box:
________________________________________

City:
___________________________
State:
_______
Zip:
___________

Contact
name/
title:
________________________________________________

Telephone
number:
(
)
________________________

*
CBI
3.
Is
the
name
and
address
of
the
company,
entity,
or
proprietor
that
owns
this
facility
the
same
as
that
listed
on
the
mailing
label?
(
Check
one
box)

*
Yes,
the
owner's
mailing
address
is
the
same.
(
Please
skip
to
question
4)

*
No,
the
owner's
mailing
address
is
different
than
the
above
address.
(
Please
complete
the
owner's
mailing
address
below.)

Name
of
company:
________________________________________________

Mailing
address
or
P.
O.
box:
________________________________________

City:
______________________________
State:
_____
Zip:
__________

*
CBI
4.
Which
corporation
type
best
describes
this
company
or
entity?
(
Check
one
box)

Corporation
(
C
Corporation)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Subchapter
S
Corporation/
Limited
Liability
Corporation
.
.
.
.
.
*
Limited
partnership
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
General
partnership
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Sole
proprietor
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Federal
hatchery
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
State
hatchery
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Tribal
hatchery
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Research
facility
(
e.
g.,
university)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Other
(
please
describe
below)
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
Other:
________________________________________________
<
Facility
ID>
COPY
#
___
of
___

*
CBI
5.
Please
complete
the
following
table.
Starting
at
line
1,
use
a
separate
line
for
each
size
category
of
species
you
produced
in
2000.
Please
enter
the
appropriate
code
number
from
the
table
headings
in
each
column.
Refer
to
the
footnotes
for
clarification
on
the
different
species
codes
provided.
If
you
enter
"
Other"
for
any
of
the
codes,
please
provide
additional
descriptive
information.
If
additional
spaces
are
required,
photocopy
this
page
before
writing
on
it
and
label
each
copy
in
the
space
provided
at
the
top
left
corner
of
the
page.

Species
Size
Category
Total
Produced
in
Year
2000
Units
1
Catfish
2
Trout
3
Salmon
4
Striped
Bass1
5
Tilapia
6
Other
Finfish2
7
Baitfish3
8
Ornamentals4
9
Shrimp
10
Crawfish
11
Other
Crustaceans5
12
Molluscan
shellfish
1
Foodsize
(
over
3/
4
pound
per
fish)
2
Stockers
(
over
6
inches
or
60­
750
lb/
1000
fish)
3
Fingerlings
(
2­
6
inches
or
2­
60
lb/
1000
fish)
4
Fry
(
under
2
inches
or
less
than
2
lb/
1000
fish)
5
Eggs
6
Seed
Stock
7
Brood
Stock
(
used
for
breeding)
8
Other
(
Please
describe)
1
Pounds
(
Live
Weight)
2
Number
or
Count
3
Live
Dry
Bushels
4
Dozens
5
Dollars
sold
6
Other
(
Please
describe)

13
Other6
(
Please
describe)

Example
4
1
15,000
1
Example
4
2
10,000
1
1
2
3
4
5
6
1
Striped
bass
includes
hybrid
striped
bass
4
Ornamentals
include
koi,
ornamental
goldfish,
and
tropical
fish.
2
Other
finfish
include
other
food
fish,
sport/
game
fish,
etc.
5
Other
crustaceans
include
lobster
pounds,
softshell
crabs,
etc
3
Bait
fish
include
fathead
minnows,
golden
shiners,
feeder
goldfish,
etc.
6
Other
includes
anything
that
does
not
fit
in
the
above
categories;
e.
g.
alligators,
turtles,
frogs,
etc.
Please
describe.

*
CBI
6.
What
methods
of
production
do
you
use
at
this
facility?
(
Check
Yes
or
No
for
each)

YES
NO
Ponds
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
Flow
through
raceways,
ponds,
or
tanks
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
Recirculating
systems
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
Net
pens
or
cages
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
Floating
aquaculture
or
bottom
culture
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
Other
(
please
describe
below).
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
*
*
_
_________________________________________________________

*
CBI
7.
Does
water
from
your
aquaculture
facility
leave
your
property?
(
Check
one
box)

*
Yes.
Go
to
questions
8
and
9.
Sign
the
certification
and
return
*
No.
Skip
questions
8
and
9.
Sign
the
certification
and
return
<
Facility
ID>

*
CBI
8.
Does
any
of
this
water
go
to
a
publicly
owned
treatment
works
(
POTW)?

*
Yes.

*
No.

*
CBI
9.
What
pollutant
control
practices
do
you
use
before
water
leaves
your
property?
(
For
example,
quiescent
zones,
off
line
or
full
flow
settling
basins,
water
level
management,
feed
management,
using
vegetated
ditches,
proper
siting
practices,
etc.)
Please
be
as
specific
as
possible.
_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

CERTIFICATION
STATEMENT
I
certify
under
penalty
of
law
that
the
enclosed
survey
response
was
prepared
under
my
direction
or
supervision
in
accordance
with
a
system
designed
to
ensure
that
qualified
personnel
properly
gathered
and
evaluated
the
information
submitted.
The
information
submitted
is,
to
the
best
of
my
knowledge
and
belief,
accurate
and
complete.
In
those
cases
where
we
did
not
possess
the
requested
information,
we
provided
best
estimates
in
response
to
the
questions.
We
have,
to
the
best
of
our
ability,
indicated
what
we
believe
to
be
company
confidential
business
information
as
defined
under
40
CFR
Part
2,
Subpart
B.
We
understand
that
we
may
be
required
at
a
later
time
to
justify
our
claim
in
detail
with
respect
to
each
item
claimed
confidential.
I
am
aware
that
there
are
significant
penalties
for
submitting
false
information,
including
the
possibility
of
fines
and
imprisonment
as
explained
in
Section
308
of
the
Clean
Water
Act.

Signature
of
Certifying
Official_______________________________
Date______________________

Printed
Name
of
Certifying
Official
___________________________
Telephone
Number________________________

Title
of
Certifying
Official___________________________________

Please
return
survey
with
signed
certification
statement
to:

U.
S.
EPA
Aquatic
Animal
Production
Industry
Screener
Survey
c/
o
[
undetermined]
at
Westat
1650
Research
Blvd.
Rockville,
MD
20850
