BCAP-22 Environmental Screening Worksheet

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

BCAP-22 U.S. DEPARTMENT OF AGRICULTURE (proposal 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 Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used by CCC to perform environmental screening of the project sponsor’s proposed project area for designation of a geographic project area under the Biomass Crop Assistance Program.  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 an inability on the part of CCC to perform environmental screening of the project sponsor’s proposed project area for designation of a geographic project area 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 TO YOUR COUNTY FSA OFFICE.
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 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-22 (proposal 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			Ethanol Electricity Steam			Bioethanol Syngas Other(s):      
13. Biomass Material(s) Used (Check all that apply):
Plant species:
Trees	Shrubs				Forbs			Legumes
Grasses	Other (non-algae) plants:      
Agricultural residues and wastes:
Straw	Hulls				Stover
Cobs	Nursery inventory waste
Other:       Please check if Title 1 crop residue is used
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)

BCAP-22 (proposal 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 (proposal 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 (proposal 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