bcap0022-150804v01.pdf

This form is available electronically. Form Approved – OMB No. 0560-0082

BCAP-22 U.S. DEPARTMENT OF AGRICULTURE

(08-04-15) Commodity Credit Corporation

BIOMASS CROP ASSISTANCE PROGRAM (BCAP)

PROJECT AREA ENVIRONMENTAL SCREENING WORKSHEET

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.), 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 through documentation of environmental screening information concerning the project sponsor’s proposed project area. 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. .

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 15 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 WITH

YOUR PROJECT ARE PROPOSAL.

1. Name of Proposed Project Area

PART A - SPONSOR’S CONTACT INFORMATION

2A. Name of BCAP Project Sponsor 2B. Street Address (Number and Name) 2C. City 2D. State 2E. Zip Code

2F. Telephone Number (Include Area Code) 2G. Mailing Address (Include Zip Code)

PART B - PROJECT AREA OVERVIEW

3. County of Primary Location 4. State/County Code 5. Telephone Number

(Include Area Code)

6. Email Address

7. Counties to be included in Proposed BCAP Project Area: (See Page 5 for Continuation Sheet for Item 7.)

A. County Name B. State and County Code

PART C - BIOMASS FACILITY OVERVIEW

8. Name of Biomass Facility(ies):

A. County Name B. State and County Code

9. North American Industry Classification System (NAICS) Code:

10. Biomass Conversion Production Status:

A. Production

Since Expected B. Date (MM/DD/YYYY)

11. 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.

BCAP-22 (08-04-15) Page 2 of 5

PART D - FACILITY OVERVIEW

12. Energy\Fuel Produced (Check all that apply):

Biodiesel Butanol, methanol or other alcohols Pellets/Briquettes

Electricity Steam

Bioethanol Syngas Other(s):

13. Biomass Material(s) Used (Check all that apply):

A. Plant species:

Trees Shrubs Forbs Legumes

Grasses Other (non-algae) plants:

B. Agricultural residues and wastes:

Straw Hulls Stover

Cobs Nursery inventory waste Other:

Please check if Title 1 crop residue is used

C. Forestry and logging materials:

Forest thinnings material Sawdust Hardwood chips

Softwood chips Bark Other wood/tree pieces

Forest slash (branches, tops, and disaster debris)

Other:

D. Other/Factory/Industrial Sources:

Non-edible food processing waste Wood mill waste and scraps

Roadway maintenance cuttings Non-edible plant processing waste and scraps

Nonedible fats, oils and greases derived from eligible plant species

Other:

14. Types of Potentially Eligible Crops (Enter all that apply ONLY if participating with BCAP Project Area):

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

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

B. Agricultural Commodities (Non-Feed Grain):

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

Ethanol

BCAP-22 (08-04-15) Page 3 of 5

14. Types of Potentially Eligible Crops (Continuation):

C. Plants and Trees (Non-Agricultural):

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

D. Algae:

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

E. Crop Residue:

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

F. Vegetative Waste Material (Non-Crop):

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

G. Animal Waste and Byproducts:

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

H. Food Waste:

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

I. Yard Waste:

(1) (2) (3)

(4) (5) (6)

(7) (8) (9)

BCAP-22 (08-04-15) Page 4 of 5

15. Have all the necessary permits been obtained for this facility? Please check one of the following. YES NO

If “NO”, explain why.

Harvesting

16. When (timing/frequency) will the material be harvested?

PART E - PROTECTED RESOURCES TO BE CONSIDERED (Completed by FSA Offices) Threatened and Endangered Species

17. Are there threatened and/or endangered species or critical habitat within the proposed project area? YES NO

Cultural Resources

18. Will tree planting/harvesting be part of this proposed BCAP project area? YES NO

Wetlands

19. Are there known wetlands in or adjacent to the proposed BCAP project area? YES NO

NOTE: If either Items 17, 18, or 19 are answered “YES”, then appropriate agency consultation (U.S. Fish and Wildlife Service, Section 106, U.S. Army Corps of Engineers) may be required during the site specific environmental evaluation.

PART F - CERTIFICATION OF OVERVIEW INFORMATION

I certify that I am authorized to represent the Project Sponsor listed in Item 2A.

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

I also acknowledge and understand that any false representations or fraudulent claims or misinformation contained on this form will be subject to remedies under program authorities and may be in addition to any liability which may be incurred under various criminal and civil fraud statutes, including, but not limited to those provided for by 18 U.S.C. 1001 and 15 U.S.C. 714m.

My signature and endorsement are as follows:

20A. Print Name Representative 20B. Title

20C. Signature 20D. Date

PART H - PRIMARY CONTACT

21A. Name 21B. Street Address (Including Zip Code)

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

BCAP-22 (08-04-15) Page 5 of 5

CONTINUATION PAGE FOR ITEM 7A AND 7B

7. Counties to be included in Proposed BCAP Project Area:

A. County Name B. State and County Code

BCAP0022 was BCAP0006_10xxxxV01 prop11 usda 9.0.0.2.20120627.2.874785 This form is available electronically.

Form Approved – OMB No. 0560-0082

BCAP

U.S. DEPARTMENT OF AGRICULTURE

(08-04-15) Commodity Credit Corporation

BIOMASS CROP ASSISTANCE PROGRAM (BCAP)

PROJECT AREA ENVIRONMENTAL SCREENING WORKSHEET

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.), 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 through documentation of environmental screening information concerning the project sponsor’s proposed project area. 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. .

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 15 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 WITH YOUR PROJECT ARE PROPOSAL 1.

Name of Proposed Project Area

PART A

SPONSOR’S CONTACT INFORMATION

2A. Name of BCAP Project Sponsor 2B.

Street Address (Number and Name) C . City D . State E . Zip Code F . Telephone Number ( Include Area Code) G . Mailing Address (Include Zip Code)

PART B - PROJECT AREA OVERVIEW

. County of Primary Location . State/County Code . Telephone Number Include Area Code) . Email Address . Counties to be included in Proposed BCAP Project Area (See Page 5 for Continuation Sheet for Item A.

County Name B.

State and County Code

PART C - BIOMASS FACILITY OVERVIEW

Name of Biomass Facility(ies):

A.

County Name B.

State and County C ode . North American Industry Classification System

(NAICS)

Code:

. Biomass Conversion Production Status:

A.

Production Sin ce Expected B.

Date

(MM/DD/YYYY)

. 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.

BCAP-22

(08-04-15) Page 2 of 5

PART D - FACILITY OVERVIEW

Energy Fuel Produced ( Check all that apply) Biodiesel Butanol, methanol or other alcohols Pellets/Briquettes Electricity Steam Bioethanol Syngas Other(s):

Biomass Material (s) Used ( Check all that apply) A.

Plant species:

Trees Shrubs Forbs Legumes Grasses Other (non algae) plants:

B.

Agricultural residues and wastes:

Straw Hulls Stover Cobs Nursery inventory waste Other:

Please check if Title 1 crop residue is used C.

Forestry and logging materials:

Forest thinnings material Sawdust Hardwood chips Softwood chips Bark Other wood/tree pieces Forest slash (branches, tops, and disaster debris) Other:

D. Other/Factory/Industrial Sources:

Non-edible food processing waste Wood mill waste and scraps Roadway maintenance cuttings Non-edible plant processing waste and scraps Nonedible fats, oils and greases derived from eligible plant species Other:

14. Types of Potentially Eligible Crops (Enter all that apply

ONLY

if participating with BCAP Project Area) A . Feed Grains (Non Title I) Please specify eligible crops listed in Project Area Proposal B . Agricultural Commodities (Non Feed Grain):

Ethanol

BCAP-22

(08-04-15) Page 3 of 5

14. Types of Potentially Eligible Crops (Continuation) C . Plants and Trees (Non Agricultural):

(4 D . Algae:

E . Crop Residue:

F . Vegetative Waste Material (Non Crop):

G . Animal Waste and Byproducts:

H . Food Waste:

I . Yard Waste:

(7

BCAP-22

(08-04-15) Page 4 of 5

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

YES

NO

If “NO”, explain why.

Harvesting . When (timing/frequency) will the material be harvested?

PART E - PROTECTED RESOURCES TO BE CONSIDERED

(Completed by FSA Offices) Threatened and Endangered Species

17. Are there threatened and/or endangered species or critical habitat within the proposed project area?

YES

NO

Cultural Resources

18. Will tree planting/harvesting be part of this proposed BCAP project area?

YES

NO

Wetlands

19. Are there known wetlands in or adjacent to the proposed BCAP project area?

YES

NO

NOTE:

If either Items 17, 18, or 19 are answered “YES”, then appropriate agency consultation (U.S. Fish and Wildlife Service, Section 106, U.S. Army Corps of Engineers) may be required during the site specific environmental evaluation.

PAR

T F

CERTIFICATION OF OVERVIEW INFORMATION

I certify that I am authorized to represent the Project Sponsor listed in Item 2A I certify that the information included is true and complete to the best of my knowledge and includes the most accurate annual production estimates that can be made at this date and time.

I also acknowledge and understand that any false representations or fraudulent claims or misinformation contained on this form will be subject to remedies under program authorities and may be in addition to any liability which may be incurred under various criminal and civil fraud statutes, including, but not limited to those provided for by 18 U.S.C. 1001 and 15 U.S.C. 714m.

My signature and endorsement are as follows:

A. Print Name Representative B. Title C. Signature D. Date

PART H - PRIMARY CONTACT

A. Name B. Street Address (Including Zip Code) C. Telephone Number (Including Area Code) D . Email Address

BCAP

CONTINUATION PAGE FOR ITEM 7A AND 7B

7. Counties to be included in Proposed BCAP Project Area:

A. County Name B. State and County Code