<p> INFORMATION SHEET FOR PAYMENT AGREEMENT WITH NMFS</p><p>Visit our web site for further information:http://galveston.ssp.nmfs.gov/platforms/index.html 1. Please send a copy of the permit application for explosives (which you sent to BOEM) which describes the charges to be used and the structures to be removed. 2. Please complete this form and send to: [email protected] , [email protected] or FAX 409-766-3543. Items in bold are required fields. Multiple structures can be included on this list, but a separate payment agreement will be prepared for each structure. Please include the latitude and longitude in degrees, minutes and seconds and verify accuracy. Contact BOEM if you need help with the Complex ID. Other questions? Call Gregg at 409-766-3513 or Megan at 409-766-3505.</p><p>Name of Signatory on Agreement Official Company Name Physical Address City, State Zip Code Phone FAX e-mail Tax Identification No.</p><p>Mailing Address for Reimb. (if different from above): Mailing Address City, State Zip Code </p><p>Logistics Contact/s (if different from signatory): Name Company (if different from above) Physical address City, State Zip Code Office Phone FAX Cell Phone e-mail</p><p>Planned Removal Date : Salvage Vessel (if known):</p><p>List Information below For Each Structure to Be Removed With Explosives: BOEMRE Water Complex Structure Depth No. of No. of ID # Area Block ID Latitude Longitude (ft) Piles Conductors</p>