bcap0001-150526v01.pdf

This form is available electronically. Form Approved – OMB No. 0560-0082 (See Page 6 for Privacy Act and Paperwork Reduction Act Statements.)

BCAP 1- U.S. DEPARTMENT OF AGRICULTURE Attachment 1 (05-26-15) Commodity Credit Corporation

Biomass Conversion Facility Overview

Purpose: This application is used to determine an applicant’s qualified Biomass Conversion Facility Status and provide Biomass Conversion Facility overview information for the BCAP project proposal.

1. Name of Biomass Conversion Facility National Office Use Only

2A. Facility ID Number

2B. Date ID Assigned

(MM-DD-YYYY)

3A. Street Address 3B. City 3C. State 3D. Zip Code 3E. Mailing Address (Include Zip Code)

4. County of Primary Location 5. State and County Code 6. Telephone Number (Include Area Code)

7. Email Address

PART A - Business Overview 8A. Counties of Operation:

State and County Code State and County Code State and County Code State and County Code

8B. Company Structure (Check all that apply):

Individual Indian tribe Unit of State or local government Partnership Corporation Farm Cooperative Farmer cooperative organization

Association of agricultural producers National laboratory Institution of higher education Rural electric cooperative Public power entity Consortium of any of the above entities Other:

8C. North American Industry Classification System (NAICS) Code:

9. Biomass Conversion Production Status:

A. Production Since Expected

B. Date (MM-DD-YYYY)

10. Brief Overview of Facility Business Operations and Biomass Utilization

The U.S. Department of Agriculture (USDA) prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) Persons with disabilities, who wish to file a program complaint, write to the address below or if you require alternative means of communication for program information (e.g., Braille, large print, audiotape, etc.) please contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). Individuals who are deaf, hard of hearing, or have speech disabilities and wish to file either an EEO or program complaint, please contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (in Spanish).

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter by mail to U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250- 9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

USDA is an equal opportunity provider and employer.

anita.crowell

BCAP-1 (05-26-15) P age 2 of 8 11A. List Material Consumed that is potentially eligible for matching payments program (Check all that apply if participating with matching payments).

For more information on types of material that may be eligible, refer to the rule. (Note: the material should be identified as delivered and only if separated from other materials before arriving at the plant –for example, a delivery of bark would only be considered a delivery of bark itself for purposes of this form if the bark had been separated from the tree prior to delivery and gathered and transported separately by the producer of the bark):

1. Feed Grains (Non-Title I):

Sorghum Other (Specify):

2. Agricultural Commodities (Non-Feed Grain):

Camelina Kenaf Jatropha

Forbs Legumes Grasses

Vines Mosses Other (Specify):

3. Plants and Trees (Non-Agricultural):

Forest thinning materials Forest slash (branches and tops) Post-disaster debris

Wood chips Bark Other (Specify):

4. Crop Residue:

Husks Stover Cobs

Straw Hulls

Other (Specify):

5. Vegetative Waste Materials (Non-Crop):

Roadway Maintenance Cutting

Orchard Waste Vineyard Waste

Sawdust Shavings Other (Specify):

11B. Types of Crops for the Project Area. (Enter all that apply ONLY if participating with BCAP Project Area):

(1) Feed Grains (Non-Title I) Please specify crops listed in Project Area Proposal:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(2) Agricultural Commodities (Non-Feed Grain):

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(3) Plants and Trees (Non-Agricultural):

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

BCAP-1 (05-26-15) P age 3 of 8

11B. Types of Crops for the Project Area. (Enter all that apply ONLY if participating with BCAP Project Area) (Continuation):

(4) Algae:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(5) Crop Residue:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(6) Vegetative Waste Material (Non-Crop):

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(7) Animal Waste and Byproducts:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(8) Food Waste:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

(9) Yard Waste:

(a) (b) (c)

(d) (e) (f)

(g) (h) (i)

12. Biomass Conversion Process (Check all that apply):

A. Combustion:

(1) Direct-Firing

Incineration Combined Fluidized Beds (CFB) Other (Specify):

(2) Cofiring

Natural Gas Oil

Coal Other (Specify): _______________

BCAP-1 (05-26-15) P age 4 of 8

12. Biomass Conversion Process (Check all that apply) (Continuation):

B. Non-Combustion:

(1) Biochemical

Transesterfication Hydrolysis Fermentation Other (Specify):

(2) Thermochemical

Gasification Pyrolysis Torrefaction Other (Specify):

(3) Densification

Pelletization Dehydration Compression Other (Specify):

13. Biomass Conversion Facility Final Product (Check all that apply):

A. Heat:

Steam

B. Power

Electricity

(1) Does this facility sell or allocate electricity to the grid? YES NO

(2) Is this facility a Combined Heat and Power (CHP) facility? YES NO

C. Advanced Biofuels

(1) Gas

Syngas Hydrogen Methane

Other (Specify): _________________________

(2) Liquid

Biodiesel Ethanol Pyrolysis Oil

Other (Specify): _________________________

(3) Solid

Briquette Pellet

Other (Specify): _________________________

Do any of this facility’s Advanced Biofuels meet or will meet Renewable Fuel Standards? YES NO

D. Biobased Products (Please contact State FSA office for assistance) Description:

14. Annual Production Capacity (Must enter all fields for each product selected in Item 13):

A. Product B. Unit C. Amount

(1) Heat MBTU/yr

(2) Power MkWh/yr

(3) Biobased Product /yr

(4) Advance Biofuel –Gas kc/yr

MBTU/yr

BCAP-1 (05-26-15) P age 5 of 8

1 4. An nu a l Pr odu ction C apacit y (m ust ent er all f ields for each product selected in Item 13) (Cont inuat ion):

A. Product B. Unit C. Amount

(5) Advance Biofuel –Liquid Gallons/yr

MBTU/yr

(6) Advance Biofuel - Solid Dry Tons/yr

MBTU/yr

PART B - Facility Description

15. On-Site Material Storage Capacity (Please check one of the following):

Amount Unit

Dry Tons Acres

16. Off-Site Feedstock(s) and Material Storage Capacity (Please check one of the following):

Amount Unit

Dry Tons Acres

17. Permits & Licenses Obtained

A. U.S. Environmental Protection Agency:

(1) License/Permit Number (2) Expiration Date

B. U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms and Explosives:

(1) License/Permit Number (2) Expiration Date

C. Other Federal:

(1) License/Permit Number (2) Expiration Date

D. State:

(1) License/Permit Number (2) Expiration Date (1) License/Permit Number (2) Expiration Date

BCAP-1 (05-26-15) Page 6 of 8 PART B - Facility Description (Continuation) E. Local:

(1) License/Permit Number (2) Expiration Date (1) License/Permit Number (2) Expiration Date

F. ASTM Standard

(1) ASTM # (4) ASTM #

(2) ASTM # (5) ASTM #

(3) ASTM # (6) ASTM #

18. Have all the necessary permits been obtained for this facility? Please check one of the following

Yes No

19. Please check all that apply and provide copies of applicable documents:

Form AD-1047(1/92), Certification Regarding Debarment, Suspension, and other Responsibility Matters – Primary Covered Transactions

For ethanol facilities, copies of Alcohol Producers Permit (ATF F 5110.74)

For ethanol facilities, copies of Registration of Distilled Spirits Plant (ATF F5110.41) and Operating Permit (ATF F 5110.23)

Copies of all required Federal, State and local permits attached.

PART C - Certification of Overview Information I certify that I am authorized to represent the Biomass Conversion Facility listed in Item 1.

I certify that the information included is true and correct to the best of my knowledge and belief. I certify that the annual production estimates are realistic estimates and the most accurate that can be made at this date and time.

This is not an application for payment. Payment will only be made pursuant to proper authorities and upon proper occurrence of the conditions for payment to the satisfaction of the CCC.

I understand that false or improper statements may be actionable under program provisions and that this liability may be in addition to liability which may be incurred under various criminal and civil fraud statutes, including, but not necessarily limited to, 18 U.S.C. 1001 and 15 U.S.C. 714m.

My signature and endorsement are as follows:

20A. Print Name of Representative 20B. Title

20C. Signature 20D. Date (MM-DD-YYYY)

PART D - Primary Contact 21A. Name 21B. Street Address (Including Zip Code)

21C. Telephone Number (Including Area Code) 21D. Email Address

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended). The authority for requesting the information identified on this form is 7 CFR Part 1450, the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.), the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246), and the Agricultural Act of 2014 (Pub. L. 113- 79). The information will be used to determine eligibility to participate in and receive benefits under the Biomass Crop Assistance Program (BCAP). The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated). Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to participate in and receive benefits under the Biomass Crop Assistance Program

(BCAP).

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0560-0082. The time required to complete this information collection is estimated to average 120 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO YOUR

COUNTY FSA OFFICE.

BCAP-1 (05-26-15) P age 7 of 8

CONTINUATION OF ITEM 11B

11B. Types of Crops for the Project Area. (Enter all that apply ONLY if participating with BCAP Project Area):

1. F eed Gr ains (N on-T itle I) P lease spec ify crops list ed in Project Ar ea Proposal:

(a) (b) (c)

(d) (e) (f)

2. Agricultural Commodities (Non-Feed Grain):

(a) (b) (c)

(d) (e) (f)

3. Plants and Trees (Non-Agricultural):

(a) (b) (c)

(d) (e) (f)

4. Algae:

(a) (b) (c)

(d) (e) (f)

5. Crop Residue:

(a) (b) (c)

(d) (e) (f)

6. Vegetative Waste Material (Non-Crop):

(a) (b) (c)

(d) (e) (f)

7. Animal Waste and Byproducts:

(a) (b) (c)

(d) (e) (f)

8. Food Waste:

(a) (b) (c)

(d) (e) (f)

9. Yard Waste:

(a) (b) (c)

(d) (e) (f)

BCAP-1 (05-26-15) P age 8 of 8

CONTINUATION OF ITEM 14

14. Annual Production Capacity (Must enter all fields for each product selected in Item 13):

A. Product B. Unit C. Amount

(1) Heat MBTU/yr

(2) Power MkWh/yr

(3) Biobased Product /yr

(4) Advance Biofuel –Gas kc/yr

MBTU/yr

(5) Advance Biofuel –Liquid Gallons/yr

MBTU/yr

(6) Advance Biofuel - Solid Dry Tons/yr

MBTU/yr