Aquaculture Stewardship Council (Asc)

APPLICATION FORM FOR AQUACULTURE STEWARDSHIP COUNCIL (ASC) FOR CUP INSPECTION & CERTIFICATION with this form you can apply for a free offer for the audit and certification of your aquaculture operation for the farm ASC certification programme

NAME OF COMPANY APPLYING AND LEGAL ADDRESS OF COMPANY STATUS (Street, post code, town, province, country, P.O. (please use full name of company with e.g. Ltd., Inc, Box) SAC, SA, SARL, BV)

COMPANY’S LEGAL REPRESENTATIVE COMPANY’S CONTACT PERSON (name of person and function) (complete if different from Legal Representative, position)

TELEPHONE / FAX NUMBER E-MAIL (and/or website)

Our company is applying for the first time Our company wishes to indicate changes/update information to our existing project(s) Our company is already certified and wants to transfer Our company is applying for recertification

Our company is applying for :

ASC single site (single aquaculture site, applicant is capable of signing a binding contract that is legally enforceable) ASC multi-site (applicant is a legal entity; all of the sites have a common management structure at a central office that has management responsibility over all sites and for which all ASC requirements are binding for each site, facility or operation; All of the operations are subject to the same standard)

Tilapia Latin name: Abalone Latin name: Salmon Latin name: Shrimp Latin name: Pangasius Latin name: Bivalves Latin name: Fresh water trout Latin name: Cobia/Seriola Latin name:

1. Company background

Please describe below a brief description of the activities you wish to have certified (hatchery, grow out, processing, trading, production system). Describe the legal information (List of entities). Make a list of towns or populations near to the farm.

Attach extra sheets if needed 1/4 ASCAPPL.F01 (04.2) Control Union Peru SAC Av. Petit Thouars 4653, Piso 6 – Miraflores • Lima • Perú Tel.: + 511-7190400 Fax: +511-7190410 www.cuperu.com [email protected] 2. Production Units

Please describe below all production units that will undergo to the ASC farm certification. If it concerns changes mention all the units and indicate which one is changed, added or withdrawn. NOTE: Sites that are contiguous will not be audited or certified as separated units.

Name of unit Production Production Total Area Location Receiving water body Changed, system (i.e. (Ton) (ha) (Detail the location with (RWB) added or cages, ponds, GPS coordinates and attach (Detail the name of the withdrawn tanks,beds, a satellite image or map RWB and attach a satellite (if raceways etc) were the location of the image or map were the applicable) unit(s) is described) location of the receiving water is described) GPS Coordinates:

If there are production units owned by the same legal entity and that would not undergo to ASC farm certification please make a list with location below:

Name of unit Location

3. How long the farm have been in operation? In case that is less than 18 months, mention if the farm have been completed at least one harvest cycle.

4. Is the farm located in a protected area? If YES, please identified the PA and the IUCN category following the website: http://www.protectedplanet.net/ Please enclose relevant documents concerning the designation of permission for concessional areas (Environmental license, declarations, etc.)

5. Does the farm use antibiotics? If YES, please identified all the ponds, farms that use antibiotics. Describe the type of antibiotics.

Attach extra sheets if needed 2/4 ASCAPPL.F01 (04.2) Control Union Peru SAC Av. Petit Thouars 4653, Piso 6 – Miraflores • Lima • Perú Tel.: + 511-7190400 Fax: +511-7190410 www.cuperu.com [email protected] 6. Post-harvest operations Please describe below the post-harvest operations taken place while the certified products stays in your ownership. This operation includes owned or subcontracted post-harvest handling or processing, transhipments, etc. The post- harvest operations must apply for the ASC products MSC chain of custody certification if the products will enter to further certified chains of custody.

Name of unit Location Owned or Not ASC ASC Chain of Changed, added or (Address) subcontracted by products are custody certified? withdrawn the applicant handled? Yes/no Yes/no, certificate (if applicable) number

7. Please describe the access to each of all units mentioned, e.g. travel time between the different units, and time from nearest airport, etc. Travel time between units, if applicable estimated time needed for travelling from nearest airport etc.

8. Has the project ever been registered, inspected or certified before by a Compliance Assessment Body (CAB) for ASC farm certification? For any other quality management system certification? If YES, please mention: the name of the CAB, year of application, the previous registration number, reason of changing CAB, copy of expired, terminated or valid certificate. Please enclose relevant documents concerning the previous inspection(s) / certification(s) (inspection report, certificate etc.). Also detail if is the first or second transfer between the validity period established by the first CAB.

9. Stakeholders Please make a list of all your potential stakeholders. CU office will invited them to participate in the initial audit. (NGO, neighbour, governmental authorities, veterinary authority, environmental authority, etc)

Type of stakeholder Name/ Contact Address Email Phone person number Neighbour Governmental authorities Veterinary authority Environmental authority NGO Others (add extra rows):

10. Social Information

Attach extra sheets if needed 3/4 ASCAPPL.F01 (04.2) Control Union Peru SAC Av. Petit Thouars 4653, Piso 6 – Miraflores • Lima • Perú Tel.: + 511-7190400 Fax: +511-7190410 www.cuperu.com [email protected] Country information Official Language: Local Language of the farm´s city: Employee information Total number of workers: Total number of workers Living on site: N° subcontracted workers: N° Permanent workers: N° Temporary Workers: N° Local workers: Native Languages of local workers: N° of foreign workers: Nationalities and languages of foreign workers:

NAME COMPANY

LEGAL REPRESENTATIVE (The person of the company, accepted by the Chamber of Commerce registration as assignment authorized)

DATE & SIGNATURE

Based on the above information, Control Union Peru will draw up a no-obligation offer for a contract.

Attach extra sheets if needed 4/4 ASCAPPL.F01 (04.2) Control Union Peru SAC Av. Petit Thouars 4653, Piso 6 – Miraflores • Lima • Perú Tel.: + 511-7190400 Fax: +511-7190410 www.cuperu.com [email protected]