BCAP-6 Environmental Screening Worksheet

BCAP-6

U.S. DEPARTMENT OF AGRICULTURE
Commodity Credit Corporation

(proposal 7)

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
1404 and the Commodity Credit Corporation Charter Act (15 U.S.C. 714). The information will be used to allow the producer to authorize CCC to make a program payment to an assignee.
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 that a payment to the assignee cannot be made.
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-XXXX. The time required to complete this information collection is estimated to average 4 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. RETURN THIS COMPLETED FORM TOYOUR COUNTY FSA OFFICE.

1. Name of BCAP Project Sponsor
SPONSOR’
S CONTACT INFORMATION
2A. Street Address (Number and Name)

2B. City

2E. Telephone Number (Include Area Code)

PROJECT AREA OVERVIEW
3. County of Primary Location

4. State/County FIPS
Code

2C. State

2D. Zip Code

2F. Mailing Address (Include Zip Code)

5. Telephone Number
(Include Area Code)

6. Email Address

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

B. State and County FIPS Code

BIOMASS FACILITY OVERVIEW
8. Name of Biomass Facility(ies):
A. County Name

B. State and County FIPS Code

9. North American Industry Classification System (NAICS) Code:
10. Biomass Conversion Production Status:
A. Production
B. Date (MM/DD/YYYY)
Since
Expected
11. Brief Overview of Facility Business Operations and Biomass Utilization

The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status,
familial status, parental status, religion, sexual orientation, political beliefs, genetic information, reprisal, or because all or part of an individual’
s income is derived from any public assistance program. (Not
all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’
s
TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400
Independence Avenue, S.W., Stop 9410, Washington, DC 20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136
(Spanish Federal-relay). USDA is an equal opportunity provider and employer.

BCAP-6 (proposal 7)
FACILITY OVERVIEW
12. Energy\Fuel Produced (Check all that apply):
Biodiesel
Butanol, methanol or other alcohols
Pellets/Briquettes

Page 2 of 3

Ethanol
Electricity
Other(s):

Bioethanol
Syngas
Steam

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

B.

Plant species:
Trees

Shrubs

Grasses

Other (non-algae) plants:

Forbs

Legumes

Agricultural residues and wastes:
Straw
Cobs
Other:

Hulls
Bagasse

Stover
Nursery inventory waste

Please check if Title 1 crop residue is used
C. Forestry and logging materials:
Forest thinnings material

Sawdust

Hardwood chips

Softwood chips

Cutoffs

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. Have all the necessary permits been obtained for this facility? Please check one of the following.
If “
NO”
, explain why.

YES

NO

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

PROTECTED RESOURCES TO BE CONSIDERED (Completed by FSA Offices)
Threatened and Endangered Species
16. Are there threatened and/or endangered species or critical habitat within the proposed project area?

YES

NO

YES

NO

Cultural Resources
17. Will tree planting/harvesting be part of this proposed BCAP project area?

BCAP-6 (proposal 7)

Page 3 of 3

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

YES

NO

NOTE: If either Items 16, 17, or 18 are answered “YES”, then appropriate agency consultation (U.S. Fish and Wildlife Service,
Section 106, Army Corp) may be required during the site specific environmental evaluation.
CERTIFICATION OF OVERVIEW INFORMATION

I certify that I am authorized to represent the Project Sponsor 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.
I also acknowledge and understand that any false representations or fraudulent claims I have made on this form will
subject me to civil and criminal penalties, including but not limited to those provided for by 18 U.S.C. 1001.
My signature and endorsement are as follows:
19A. Print Name

19B. Title

19C. Signature

19D. Date

PRIMARY CONTACT
20A. Name

20B. Street Address (Including Zip Code)

20C. Telephone Number (Including Area Code)

20D. Email Address