BCAP-1 Biomass Conversion Facility Overview (part of AD-1047)

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

(See Page 6 for Privacy Act and Public Burden Statements.)

BCAP-1 U.S. DEPARTMENT OF AGRICULTURE Attachment 1 (proposal 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 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-1 (proposal 15) Page 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 (proposal 15) Page 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:
Direct-Firing
Incineration	Combined Fluidized Beds (CFB)			Other (Specify):
Cofiring
Natural Gas		Oil
Coal		Other (Specify): _______________

BCAP-1 (proposal 15) Page 4 of 8

12. Biomass Conversion Process (Check all that apply) (Continuation):
B. Non-Combustion:
Biochemical
Transesterfication		Hydrolysis		Fermentation		Other (Specify):
Thermochemical
Gasification		Pyrolysis		Torrefaction		Other (Specify):
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 (proposal 15) Page 5 of 8

14. Annual Production Capacity (Must enter all fields for each product selected in Item 13) (Continuation):
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 (proposal 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.), and the Food, Conservation, and Energy Act of 2008 (Pub. L. 110-246).  The information will be used by CCC to determine qualified Biomass Conversion Facility status and to evaluate Biomass Conversion Facility overview information for the Biomass Crop Assistance Program project proposal.  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 determine qualified Biomass Conversion Facility status and to evaluate Biomass Conversion Facility overview information for the Biomass Crop Assistance Program project proposal. 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 (proposal 15) Page 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. Feed Grains (Non-Title I) Please specify crops listed in Project Area 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 (proposal 15) Page 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