AGRICUL TURAL ENVIRONMENTAL MANAGEMENTTier I

Last Name: k H- A- N First Name: /tD A MAddress: M (if~I.-~ I 0 ~ t; 1/ "J)I M ()'Y7"f"~o~: # ~ ~- - 6' 10 C

rv1 a' '" K 11i"1.- ;...tt-

2~t~~iS'~T I ~ f"- ,/ ..,.Farm NameOperators Name if different:

1. Future Status of the Farm

Do you anticipate a~~~~r modifications on your farm within the next. 5 years?(please circle) ~~O

If yes, please circle the 11 0 tion(s) that best describe the change(s):{Expansion

tirement)(Sale of Farm)(Business structure changes)(Change in type of operation)

2. Basic Farm Information

Please circle one of the following that describes your PRIMARY Farm Type:

Livestock (type): .)( Cash Crop (type)Other (Please list):Total Farm Acres: J ~ ~ 6 :!,otal ~i!l~~l~ _Acres: :;z t} 6:Rented Acres: ~, ~ Rented Tillable Acres: ~ 6 ~

Heifers & Dry

_~L.~';-'-

Lactating-~-9-~

~_x,

Livestock NumbersDairy Cows Underl6 Mos. l~-Beef Under 6 Mos. -~Other ,"- -

Dairy Cows Overl6 Mos.Beef Over 6 MosOther

Please circle Yes or No for the following questions:Do you spread manure? ~I noDo you utilize a manure stacking area or storage? (ffil noIs there a stream or watercourse on or within 50 feet of farm? yes 16i9JDo you store silage on the farm? ~I noDo you store petroleum products on your farm? yes I noIs there a barnyard or feedlot on your farm? 0Do you use fertilizer? 0Do you use pesticides (herbicide, insecticide, fungicide)? 0Is the water supply on your farm from a well or spring? noDo you grow row crops such as Corn, Cash grains, Vegetables, etc.? noDo you utilize pastureland on your farm? noDo you presently or do you plan to harvest any timber, pulp, or fire wood on your farm? no

Note: All answers provided will be confidential

Chapter 4, Reference 4.6, Page

I NOTES

Chapter 4, Reference 4.6, Page 2

TIER II SUMMARY & FIELD EVALUATION

This ranking gives you an idea of how your farmstead management practices as a wholemight be affecting your land resource. These rankings should serve only as a generalguide, not a precise diagnosis. Verify the existence of situations on the farm which mayormay not substantiate the concern. Plans and actions can then be outlined.

Items ofConcern

Level ofConcern

(1-4)

Evaluation and Recommendations-Worksheet Nameand Number

1 Pathogens

2 Man ure ,~

~ k~-~.:t::-

'-,

g~-4trr- top-ev-~ -

3 StreamManagement

3

~~;~---~:to ~ /$ t "'" M.. e.1-, 5 0 ~ A u..r "s:"'-- .

N~ yl,~~.- :'~~.

('J ~ P JAt.-c1.£\>"l~P'tAt'~ "" b~A r, 61? '+~ -:t vJ,' k ~ ~.~-f-

V~; .e-{;6-'£~ rr'" ~ \, D! ~ ~

4 Milk CenterWash Water

5 Silage Storage

6 PetroleumStorage

,

Chapter 4, Reference 4.6, Page 48

Level ofConcern

(1-4)

Items ofConcern

Worksheet Nameand ~~umber

Evaluation and Recommendations

7 FertilizerStorage

8 Pesticide UseStorageMixin g &Loading

::?:(-~:]~-, tJ~ y" "\9 Barnyard ~~~~~! "Y"~' ~ -' ~ v:' 1-11A~ ~ ~

I ..Il.JGA ';\A. t ¥" ~

:>

10 WaterSupplyEvaluation

11 Waste

Disposal

I/:-~~~1 00(' f

12 SoilManagement .3

13 PastureManagement

14 ForestManagement

Chapter 4, Reference 4.6, Page 49

OTHER:Road & skid trail considerations:. Are topo maps used to help plan location of roads, trails and landings?. Is surface water diverted off skid trails and roads using water bars and

broad based dips?. Are culverts used on main haul roads?

Management of stream crossings:. Is there any skidding across streams without utilization of stream crossing

structures?

Post-Harvest Maintenance:. Are livestock allowed access to woodlots?. Are logging roads and skid trails seeded after harvesting?. Has water barrier been installed to break up sloping roads and skid trails~

ADDITIONAL COMMENTS:

Chapter 4, Reference 4.6, Page 47

Linkina Tier I to Tier II

(Charting the relationship between Tier I questions / answers and corresponding Tier 11worksheets)

Farmer Answers: Corresponding Worksheet:Tier I Question #:

Milkhouse Center Wash W at~rFarm type Dairy ./

(n;:';;; Beef. Deer.'\-j;~~ry. Sheep

PathogenFarnl type

\ Manure Management.YesDo you spread manure?

Stream ManagementStream within 50' of farm? Yes

\ Silage StorageYesDo you store silage on thefarm?

Petroleum Product StorageDo you store petroleumproducts on the farm? ./

\ Barnyard Management.YesIs there a barnyard orfeedlot on the farm?

'\ Fertilizer managementYesDo you store fertilizer?

Pesticide Usel Storage/MixinglLoading

YesDo you use pesticides?

Water Well EvaluationYesIs the water supply onyour farm from a well orspring?

Yes" Soil Management

Do you grow row cropssuch as corn, cash grains,vegetables, etc.?

" Pasture MangementDo you utilize pasture landon the farm?

Yes

Yes Forest ManagementDo you presently, or doyou plan to harvesttimber, pulp, or firewood?

Chapter 4, Reference 4.6, Page 3

NRCS-CPA.521.94

us. DEPARTMENT OF AGRK;UL TURENATtJRAL RESOURCES CONSERVATION SERVICE

ENVIRONMENTAL EFFECTSFOR RESOURCE MANAGEMENT PLANS

PURPOSE: This fonT1 summarizes effects of the practices/systems. It also provides summary documentation for environmental evaluation ofthe planned actions.

INSTRUCT10NS: Complete the evaluation of eadl conservation management system (CMS). Short term refers to installation period and longterm refers to the effects during the life span of the practice or systems Effect codes + = beneficial; - = adverse; 0 = none For Quality Criteriacolumns, check yes or no. Effects are to be quantified where possible.

EffectsNotes

Fffeds Quality CriteriaNotes

ResourceConsiderations.

-Short

-Long

SOIL

P7

Erosion -++

+r\7Condition -f-

-f- \I#"-t- v'Deposition

~.~R

"I'Quantity .J- ...,..

17-

.IQuality -+-- +-A~P.

~Quality t--f"

-f-

V'../-+C".ondition

PLANT-+Suitability ~ ~ ~

17Condition ~-f"

-f-Management

AMMAL

JHabitat(Domestic) f- J+ 1-

vi'/Habitat(Wldlife)

~

+~Ii.-t" TManagement

. May be amplified, if appropriate, by subcategories, such as sheet erosion, wind erosion, gully erosion, etc.

See continuation on reverse page

Plan IDNO: 7 -= i;- - CJ [) - ',{?.

I CTU/Fields:

Date: .

County:

FSA Farm Number:

Watershed Number:

ZipC~e:.. '- ./76): ,~ . ftA Ij.J If. ~ M tJ'{ '(" I '.-! V ~ . ~

lb::::~~~ A G RI C UJ

OPERA ~~~~~~~~~~~ yR INFORft-1A TJON: , Fann Name: <; fA fJ rV1oY(,' .

Contact: -.Address: ~~ U,J MolT;<Y'~City: M O...('"'"'W'"14." ~Q; .' State: N ~ - . -

Phone No. "1'S- - "K l{~' 6(0 b Fax: -oj IC;-"" 6flJ- .1",,5"""- e-mail-GENERAL FARM INFORMATION: -

Fann Type: ~Dairy, 0 Livestock 0 Cash Crop, 0 Orchard. 0 Vineyard, 0 Vegetable, .0 Nursery/Greenhous~. ~ Other;

Animal Units: 0 less than 300; ~30I to 1,000; 0 greater than 1,000 (I AU. = 1,000 lbs live weight)

Acres: Cropland: ~r41 ~:z '- Hayland: q ,; } . -Pasture: ~ s3 . Woodland: :1$ ~ II 0

- -RESOURCE MANA GEMENT AND CONSER VA TION ISSUES (id~ntiJy ;n/~resl):

--

AEMWORKSHEET

82,4,5,9

. 2

212

s

10

713

t63

3

10

Agricbemical Management: IA High - 0 Medium - 0 Low - 0 None IAgrialltural Waste Management: ~ High - 0 Medium - 0 Low - 0 None IAgriallwral Waste Storage: CI High - 0 Medium - 0 Low - 0 None. 1

Air Quality Concerns - wind erosion: ~gh - 0 Medium - 0 Low - 0 None IAir Quality Concerns - odors: , ,.., 0 High - a Medium - 0 Low - [) None ICropland Erosion Control: 3High - 0 Medium - 0 Low - 0 None IFarmland Protection: ~High - 0 Medium - 0 Low - 0 None IFish Habitat Improvement: 0 High - 0 Medium - ~ Low - 0 None IFarm Chemical Storage & Handling: , 0 High - Ir Medium - 0 Low - C None IGrasslands Farming: ~High - 0 Medium - 0 Low - 0 None IGround Water Quality: 0 High - II Medium. 0 Low - 0 None IIrrigation Water Management: 0 High - 0 Medium - ~Low - Q None INutrient Management: 8. High - 0 Medium. 0 Low - 0 None IPasnJre Management: KHigh - 0 Medium. 0 Low - 0 None IPathogen Management: ~High . 0 Medium - 0 Low - 0 None IPetroleum Storage & Handling: 0 High - 0 Medium - 0 Low - ~None IRiparian Area M3nagement: ~High - 0 Medium - 0 Low - 0 None ISensitive Area Protection: 0 High - 0 Medium - C Low - .None IStrearnbank Erosion and Stream Management: 0 High - 0 Medium - 0 Low - ~None ISurface Runoff & Water Management: ~High - 0 Medium - 0 Low - [] None ISurface Water Quality: : a High - 0 Medium - 0 Low - 0 None IWellhead .,eProtection: High - 0 Medium - 0 Low - 0 None IWetland Conservation: 0 High - 0 Medium - 0 Low - ~None IWildlife Habitat Improvement: ~ High - 0 Medium - 0 Low - C r,fon~\ IWoodland Management: '... ~gh - 0 Medium - Q Low - 0 None I 14

I AM INTERESTED IN MORE INFORMA TION ON THE FOUOWING:Technical Assistance a Safe Drinkin Water Act

~ rl~~n WArn Act n 1IJV.<: Q ~Vf'lvi"2 J ,..ft J;,lftA

NOTES:Signature

- - - - -- - - - -NYS Agricultural AsSISIan« Pro~ IS a coopera\l\'C program of the local Soil and WDICJ ConseI"\'iltion DlsUtct. NYS Dcparuncnt of A~cuJturc andMarkets, NYS Soil and Water Consm'auon COIJUnittcc. Cornell Cooperative Ex1ension. USDA. Natural Resources Consen..tioo SCfVlce and USDAFarm SerVIces A!tCl1cv Submission oflhls t~ docs nO( @uannlcc pro~m eligibility or availability off\mdmg

Cost effectivenessFinancial condition IMar1<.els available

_C)ient input (mgt., labor)Base acreaQe maintainedSust~inabili~

~s:Public health & safety

SociL\1 valtJes

Client characteri~SOOCII risk - reason~ble

CULTURAL RESOURCES: (If response to the following questions is "No", implementation may proceed when documentation is

completed.)1. Do the planned alternatives include undertakings defined by NRCS GM 420-401? (Practices that may damage cultural resources.)

If "Yes," see below. No [XI Yes D2. Are cultural resources present? If "Yes, " document the resource(s) on the site and detenTline impacts following NRCS GM 420-401

No IXJ Yes D

SPECIAL ENVIRONMENTAL CONCERNS: If answer is yes to any of the following, explain in notes section or on attachment

EffectPresentYes ICONSIDERATION

-NoV

Unknown ~ I-Y-;-;-I UnknownPrime ;=Ind unioue f~rmland.

Threatened or endangered plant or animalVisulilresource-Coastal zone management areaNatural areaWild and scenic riverWetlandRil1ari;on area

~

~~~-

p;=-SI)Scj~1 al'uatic sit~ r-;--

~~

~

-Flood plain management

NOTES: (Attad1 additional comments)

No DNo DNo D

Yes DYes DYes D

404 Permit needed?State, county, local requirements?Mitigation planned or required?

State degree of public interest/potential controversy:

To be in compliance with NEPA, all resource considerations on the front of this foml must be answered "yes" for meeting the planned qualitycriteria; all economic and social concems above must be checked to indicate that they have been considered; and cultural Resources andSpecial Environmental Concems must be checked "no". Checj( one of the following:

,)'" This is not a Federal action that will have significant effect on the quality of the human environment.

This may be a major Federal action that will have significant effect on the quality of human environment. NRCS NEPAregulations must be followed (GM 180 Part 410).