Biomass Conversion Facility Eligiblity Certificate Form

Attachment 1

1. Name of Primary Contact: ______________________________________________________

_____________________________________________________________________________

2. Address of Primary Location (facility physical location): ______________________________

3. City_____________________________________           4. State______    5. Zip___________

6. County of Primary Location _____________________________

Business Overview:

Element	Description
7.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: ___________________________
8.Biomass Conversion Production Status:	Production (□ to begin or □ since) Date:
9. Brief Overview of Facility Business Operations and Biomass Utilization:

Facility Overview:

Element	Description
10. Energy\Fuel Produced:   Check all that apply	□  Biodiesel □  Ethanol □  Bioethanol □  Butanol, methanol or other alcohols □  Electricity □  Syngas □  Pellets/Briquettes □  Other(s): _______________________________
11. Conversion Process   Check all that apply	Combustion □  Woodchip boilers □  Incineration □  Natural Gas Boiler □  Oil Fueled Boilers □  Other: ________________________________ Non-Combustion □  Gasification □  Pyrolysis □  Hydrolysis □  Anaerobic digestion □  Other: ________________________________
12.Biomass Material(s) Used:    Check all that apply	Plant species: □  Trees □  Shrubs □  Forbs □  Legumes □  Hays □  Grasses □  Other ___________________________________ Non-Title 1 Agricultural residues and wastes: □  Straw □  Hulls □  Stover □  Bagasse □  Nursery inventory waste □  Other agricultural plant residues & agricultural plant wastes □  Other ___________________________________ Forestry and logging materials: □  Forest thinnings □  Tree branches □  Otherwise unmerchantable species □  Forest slash (branches, tops, insect and disease debris and wildfire/disaster debris) □  Hardwood chips □  Softwood chips □  Cutoffs □  Roots □  Bark □  Other wood/tree pieces □  Other ___________________________________ Other/Factory/Industrial Sources □  Non-edible food processing waste □  Sawdust □  Roadway maintenance cuttings □  Other ___________________________________
13. Permits Obtained	US EPA:___________________________________ US ATF:___________________________________ Other Federal:______________________________ State: ____________________________________ Local: ____________________________________
14. Have all the necessary permits been obtained for this facility or group of facilities?   Please check one of the following	□  Yes    □  No

Facility Description:

Item	Amount	Unit
15. Annual Production (Current or Planned) Please enter all that apply		British Thermal Unit per year (BTU/yr) or equivalent Kilowatt-Hour per year (kWh/yr.)
		Tons of fuel per year
		Gallons of biofuel per year
16. On-Site Material Storage Capacity Please check one of the following 17. Off-Site Feedstock(s) and Material Storage Capacity Please check one of the following		□  Tons                   □  Acres □  Tons                   □  Acres

18. Please check off 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.

Certification of Overview Information

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. 

My signature and endorsement are as follows:

1. Biomass Conversion Facility

A. _________________________________________________________________________

(COMPANY NAME)

B. By: ______________________________________________________________________

(Officer, Member, Partner, Proprietor)

C.  Title: ____________________________________________________________________

D.  Date: ____________________________________________________________________

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