APPENDIX J Sample Agri Environmental Support Plan PAA Situation

APPENDIX J Sample Agri-Environmental Support Plan (PAA) Situation scenario A dairy farmer with facilities located at two separate sites that are more than 200 m apart owns 75 ha of land (15 ha of grain corn, 15 ha of silage corn, 15 ha of oats, 20 ha of hay and 10 ha of pasture). All raising sites have been in existence since the 1980s. The dairy herd generates 90% of the operator’s income. The operation is in compliance with its Certificate of Authorization issued by MDDEP. In addition, it receives liquid manure from a feeder pig operation. SPECIFICS SITE 1 60 dairy cows (including 10 calves less than 11 days old), complete confinement Circular pit with 365 days capacity containing dairy wastewater Production volume = 2 000 m 3 SITE 2 15 cow yearlings and 25 heifer calves, partial confinement Non-draining platform Production volume = 330 m3 Load produced = 780 kg P2O5 30 ha, sandy (with many large stones) Soil disposal capacity (chart) = 2 100 kg P2O5 No neighbours No well Ten-hectare sugar bush Hayfields and pastures, no exercise yard Ditches and watercourses Livestock have access to watercourses Load produced = 3 050 kg P2O5 45 ha, sandy Soil disposal capacity (chart) = 3 150 kg P2O5 Neighbours nearby (there have been complaints when hog manure is being spread). Well belonging to the owner, located less than 30 m from the fields. The physical location of the well is not indicated either on the map of the farm or in the field. No woodlot Annual crops Ditches and watercourses Slopes and banks damaged, riparian strips less than 1 m wide All the land is drained (no other excess water disposal system) Use of inorganic fertilizers: Slopes and banks damaged by livestock, riparian strip more than 1 m wide Pastures not drained (no other excess water disposal system) – Corn: before seeding, broadcast (150 kg/ha of a phosphorus-free fertilizer) and applied in strips at seeding (200 kg/ha of a 13-13-13 formulation) – Oats: before seating, 250 kg/ha of a 15-18-15 formulaion (675 kg P2O5) LIQUID HOG MANURE No analysis performed Applied by neighbour by low-level aerial spraying Equipment calibrated Applied in spring on harvested, cornfields, ploughed under within 48 hours Applied on hayfields after last pastures cut, left on the surface Crop protection: – Contract basis exclusively A P P L I C AT I O N O F M A N U R E LIQUID COW MANURE Analyses in 2002 and 2003 Applied by producer by low-level aerial spraying Equipment calibrated Applied in spring on hayfields Applied on hayfields after first cut SOLID CATTLE MANURE No analysis performed Applied by producer with a rear-delivery spreader Equipment not calibrated Applied after the oats are ploughed under after more than 48 hours Applied late in the season on or cornfields – Full-rate spraying with full field coverage on annual crops – No field scouting Other characteristics (according to the PAEF produced annually and the phosphorusreport dated June 15, 2003): – Member of an agri-environmental advisory club – No established crop rotation – No slope to fields – Soil analyses for all fields within the past five years – Signs of wind erosion on site 1 – Lime applied at five-year intervals on fields planted in annual crops – Ploughing both in the fall (15 ha) and in the spring (30 ha) I N F O R M AT I O N F R O M P H O S P H O R U S R E P O R T S F I L E D W I T H M D D E P RAISING SITE 2 75 ha in crops Receives liquid hog manure (435 m3; 1 000 kg P2O5) Receives solid manure from site 2 Surplus of 1 035 kg P2O5 Non-complying by 2010 Disposal capacity/total load ratio = 84% Phosphorus balance in equilibrium by 2010 Disposal capacity/total load ratio = 100% All solid manure exported to site 1 0 ha in crops (all areas compiled on site 1) Note 1 : Site 2 is not required to produce a phosphorus report. However, the agrologist and the producer decided to produce one with a view to transparency REASON FOR PAA: Phosphorus surplus Financial assistance Other 1) IDENTIFICATION OF OPERATION 123456789 NIM 1 P M M or N 2 04-05-18 Date file was opened 10-05-18 Projected End Date of PAA 2 Number of livestock or 3 manure-spreading sites PAA number Legal name XYZ Farm Mr I.M. Lucky 3000 Town Line Qc (123) 456-7891 Z0W 3X9 Principal owner Mailing address for the operation City Fortune (123) 456-7890 luckyim@address.net Province Postal code Phone Fax E-mail 1 2 3 NIM: MAPAQ identification number. Indicate M (member of an agri-environmental advisory club) or N (non-member). Animal production or manure-spreading sites assigned distinct ID numbers by the MDDEP. An agrologist completes the PAA form in collaboration with the farm operator. Keep this document because you may be required to submit it and implement the indicated initiatives for entitlement to certain government financial assistance programs. PAA_0107 PART A – AGRI-ENVIRONMENTAL SCAN 2) TYPES OF LIVESTOCK AND CROPS Indicate each production type and its relative share (%) of farm income. RELATIVE SHARE (%) OF FARM INCOME RELATIVE SHARE (%) OF FARM INCOME LIVESTOCK/CROP SITE NUMBER(S) 4 LIVESTOCK/CROP SITE NUMBER(S) 4 MAPLE SYRUP POULTRY CATTLE GOATS HORSES FIELD CROPS FRUITS VEGETABLES ORNAMENTAL HORTICULTURE DAIRY PRODUCTS SHEEP 90 1, 2 POTATOES APPLES 10 1 HOGS GREENHOUSE CROPS OTHER: 3) AREAS, CROPS AND LIVESTOCK AREAS Total cropland Owned 75 ha Rented 0 ha TYPES OF CROPS AND THEIR AREAS CROP ha CROP ha CROP ha Grain corn Silage corn Oats Meadows Pasture 15 15 15 20 10 LIVESTOCK INVENTORY (NUMBER OF HEAD) ANNUAL PRODUCTION (HEAD, EGGS, L OR kg OF MILK) TYPES OF ANIMALS TYPES OF ANIMALS INVENTORY (NUMBER OF HEAD) ANNUAL PRODUCTION (HEAD, EGGS, L OR kg OF MILK) Dairy cows (700 kg) Calves Cow-heifer Heifers 60 10 15 25 480 000 kg NA NA NA 4 Site number: assign a number to each animal production or spreading site defined by MDDEP (e.g. 1, 2, 3, etc.). PAA_0107 NIM: 123456789 P Year: 2004 2 PART A – AGRI-ENVIRONMENTAL SCAN 4) PHOSPHORUS REPORT Complete this section for each production or spreading site. Number of animal production or spreading site: 1 Description: Dairy cows Lot number, address, geographic reference or production MOST RECENT REPORT SUBMITTED PHOSPHORUS REPORT* TO MDDEP INITIAL REPORT FOLLOWING VALIDATION 5 OF LOAD OR ANNUAL UPDATE (REFERENCE REPORT) Total load minus total disposal capacity (kg of P2O5) Ratio of total disposal capacity to total P2O5 load (%) 7 NOTE : Ratio < 50% ⇒ corrective action must be taken by April 1, 2005; ratio ≥ 50% and < 75% ⇒ corrective action must be taken by April 1, 2008; ratio ≥ 75% and < 100% ⇒ corrective action must be taken by April 1, 2010. 6 1 035 1 035 Reference date of phosphorus report Method used to determine load produced by the herd (characterization of livestock waste, referential values set by CRAAQ, dietary levels, etc.) 84 June 2003 Characterization of livestock waste 84 June 2003 Characterization of livestock waste * Where requested by MAPAQ, enclose the most recent phosphorus report with the PAA. Number of animal production or spreading site: 2 Description: Replacement animals Lot number, address, geographic reference or production MOST RECENT REPORT SUBMITTED PHOSPHORUS REPORT* TO MDDEP (REFERENCE REPORT) INITIAL REPORT FOLLOWING VALIDATION 5 OF LOAD OR ANNUAL UPDATE Total load minus total disposal capacity (kg of P2O5) Ratio of total disposal capacity to total P2O5 load (%) 7 NOTE : Ratio < 50% ⇒ corrective action must be taken by April 1, 2005; ratio ≥ 50% and < 75% ⇒ corrective action must be taken by April 1, 2008; ratio ≥ 75% and < 100% ⇒ corrective action must be taken by April 1, 2010. 6 0 0 Reference date of phosphorus report Method used to determine load produced by the herd (characterization of livestock waste, referential values set by CRAAQ, dietary levels, etc.) 100 June 2003 Transitional values set by CRAAQ 100 June 2003 Transitional values set by CRAAQ * Where requested by MAPAQ, enclose the most recent phosphorus report with the PAA. Number of animal production or spreading site: Description: Lot number, address, geographic reference or production MOST RECENT REPORT SUBMITTED PHOSPHORUS REPORT* TO MDDEP INITIAL REPORT FOLLOWING VALIDATION 5 OF LOAD OR ANNUAL UPDATE (REFERENCE REPORT) Total load minus total disposal capacity (kg of P2O5) Ratio of total disposal capacity to total P2O5 load (%) 7 NOTE : Ratio < 50% ⇒ corrective action must be taken by April 1, 2005; ratio ≥ 50% and < 75% ⇒ corrective action must be taken by April 1, 2008; ratio ≥ 75% and < 100% ⇒ corrective action must be taken by April 1, 2010. 6 Reference date of phosphorus report Method used to determine load produced by the herd (characterization of livestock waste, referential values set by CRAAQ, dietary levels, etc.) * Where requested by MAPAQ, enclose the most recent phosphorus report with the PAA. NOTE: ADD AN EXTRA SHEET IF YOU HAVE MORE THAN THREE SITES. 5 6 7 Where the site has a phosphorus surplus or the phosphorus balance needs to be monitored, we highly recommend recalculating the phosphorus load produced by the herd using another method. Disposal capacity/total P2O5 load: site with P surplus ⇒ < 100%; site whose P balance needs to be monitored ⇒ ≥ 100 and ≤ 125%; site without P problem ⇒ > 125%. A farm operation that has increased its herd or that does not use animal waste on its cropland is not entitled to use regulatory deadlines and must immediately comply with the obligation concerning phosphorus load and disposal capacity balance (ratio of 100%). PAA_0107 NIM: 123456789 P Year: 2004 3 PART A – AGRI-ENVIRONMENTAL SCAN 5) PRIORITY AGRI-ENVIRONMENTAL PRACTICES Complete this section for each production or spreading site. ANIMAL PRODUCTION OR SPREADING SITE SITE NUMBER Answer by: Y = Yes N = No NA = Not Applicable 5.1 5.2 5.3 8 No. 1 Y Y Y Y Y Y N N NA NA N NA NA Y No. 2 Y Y N Y N NA NA Y Y N Y N Y N No. Did the production site exist on June 15, 2002? Do you have an Agro-Environmental Fertilization Plan (PAEF) for the last crop season? Do you have a recent (less than 1 year) analysis of the animal waste produced by your operation? Do you have a recent (fewer than 5 years) soil analysis for all your cropland? Do you manage liquid animal waste (not including liquid manure)? If so, a) b) Is it stored in a watertight storage facility? Is it spread using a boom? 9 5.4 5.5 5.6 Do you manage solid animal waste? If so, a) b) Is it stored in a watertight facility? Do you stockpile manure in your fields? 5.7 Are the animals allowed outside the livestock buildings? If so, a) b) Do they have access to an exercise yard? Can they drink freely from a watercourse? 5.8 Do you manage dairy wastewater? If so, how do you do it? Check off the applicable situation(s). a) b) c) d) Storage in a watertight storage facility Discharged into a septic tank with a separator, filter or lagoon Discharged into the municipal sewer system Other NOTE: FOR SECTION 5, ADD AN EXTRA SHEET IF YOU HAVE MORE THAN THREE SITES. 6) ASSESSMENT OF RESOURCES SIGNS OF SOIL DEGRADATION Compaction, deterioration of soil structure or drainage 6.1 6.2 6.3 6.4 YES NO NA Are there ruts caused by farm machinery in certain fields? In certain fields, are there water puddles that never dry up and areas where the soil is always wet? Are any fields flooded when the water level rises? Do any of the following occur in certain fields, areas or crops: a) slow growth? b) c) d) uneven maturation? reduced yield? yellowing? 6.5 6.6 Do ploughs have more trouble penetrating the soil in certain fields? Does tillage equipment require extra draw bar power? Wind or water erosion 6.7 6.8 6.9 Does blowing dust occur in certain fields? Does sediment tend to accumulate at the base of slopes? Is there gullying or rilling caused by water erosion in the fields? 8 9 In this form, NOT APPLICABLE can be used as an answer only when the subject or the resources needed for carrying out the intervention in question do not exist (e.g. cropland, livestock or watercourses). Include owned and rented cropland. PAA_0107 NIM: 123456789 P Year: 2004 4 PART A – AGRI-ENVIRONMENTAL SCAN 6) ASSESSMENT OF RESOURCES (continued) SIGNS OF DITCH, WATERCOURSE AND WATER QUALITY DEGRADATION YES NO NA 6.10 6.11 6.12 6.13 6.14 Is there faulting, gullying or rilling at the edge of certain ditches or watercourses? Is there sediment transport and deposition in certain watercourses? Is there occasional blockage of culverts? Are there perceptible signs of pollution in certain watercourses or bodies of water? 10 To your knowledge, have there ever been nitrates, pesticides or fecal coliforms in the drinking water wells of the farm operation? IF THERE IS DEGRADATION, WHAT IS IT CAUSED BY? 6.15 YES NO PARTLY NA a) b) c) d) e) f) g) the crop itself tillage surface drainage width of buffer strips the slope surface landscaping other: BIODIVERSITY 6.16 6.17 6.18 6.19 YES NO NA Have you ever been part of a project for conserving, managing or restoring wildlife habitats? Have you ever been part of a project for protecting threatened plant or animal species? In the past 10 years, has biodiversity decreased on your property (e.g. loss of fish or bird species)? In the past 5 years, has there been work (dredging, straightening or clearance) done on the municipal watercourses on your property? Does your property include at least 30 hectares of woodland? Does your farm operation regularly sustain economic damage (loss of crops or livestock) due to wildlife? 6.20 6.21 AIR, DUST AND NOISE 6.22 YES NO NA Have your neighbours ever complained about: a) odours from livestock buildings or manure storage facilities? b) c) d) manure spreading odours? dust? noise? If so, have you done anything to rectify the situation? 7) LIVESTOCK, FERTILIZER AND AMENDMENT MANAGEMENT YES NO PARTLY NA LIVESTOCK AND PRODUCTION FACILITY MANAGEMENT 7.1 7.2 7.3 7.4 7.5 Does your animal feed contain phytase? 11 Is a multiphase feeding system used (more than two different feed rations)? Are wet feeders used? Are water cups used? Are there man-made single or double-row windbreaks or shelterbelts/natural windbreaks or shelterbelts near production facilities (livestock buildings, manure storage facilities)? Are storage facilities for animal waste covered? 7.6 FERTILIZER AND AMENDMENT MANAGEMENT (PRODUCED AND IMPORTED) 7.7 7.8 % of total volume NA What proportion of animal waste do you spread yourself? 12 84 78 22 What proportion of animal waste is spread: a) in spring or on growing crops (including green manure)? b) after the fall harvest? 10 11 12 Perceptible signs of pollution: green algae growth during heatwaves, brownish water, bad smell or abnormal quantities of dead fish on streambanks. See the feed mill’s animal nutrition consultant, representative or advisor and Appendix C of the Development Guide. Without the services of another farm operator, specialized contractor or any similar resource. PAA_0107 NIM: 123456789 P Year: 2004 5 PART A – AGRI-ENVIRONMENTAL SCAN 7) LIVESTOCK, FERTILIZER AND AMENDMENT MANAGEMENT (continued) FERTILIZER AND AMENDMENT MANAGEMENT (PRODUCED AND IMPORTED) % of total volume NA 7.9 What proportion of spread animal waste: a) is incorporated or ploughed under while spreading? b) c) is incorporated or ploughed under in fewer than 48 hours after spreading? is left as is for more than 48 hours? 0 30 70 YES NO PARTLY NA 7.10 7.11 7.12 7.13 7.14 Is spreading equipment properly calibrated? Do you have a later spreading season because the farm’s manure storage capacity is inadequate? Is crop residue composted? Do you use Fertilizing Residual Materials (FRMs)? Do you lime the fields that require it? kg of N 7.15 kg of P2O5 kg of K2O What was the total amount of inorganic fertilizer bought within the past year? 3 410 1 450 1 340 8) SOIL CONSERVATION AND WATERCOURSE PROTECTION 13 PRIMARY TILLAGE 8.1 8.2 8.3 FALL (ha) SPRING (ha) NA Total area tilled 14 15 Annual area under reduced tillage Annual area directly seeded (including ridge crops) 16 15 0 0 30 0 0 HECTARES NA GREEN MANURE AND INTERCROPS 8.4 8.5 8.6 Areas seeded with green manure ploughed under in the fall Areas seeded with green manure (winter cover crops) ploughed under in the spring Areas seeded with green manure under reduced tillage, 17 zero tillage, or seeded directly 0 0 0 % NA FIELD-RELATED DEVELOPMENTS 8.7 8.8 What proportion of cropland has subsurface drainage? What proportion of cropland is irrigated using systems that reduce water loss (e.g. drip irrigation)? What proportion of cropland is protected by shelterbelts (trees or shrubs) or woodland? 87 8.9 0 YES NO NA 8.10 8.11 8.12 Do you have irrigated areas? Are there drinking sites other than watercourses for the animals allowed outside livestock buildings? Do any of your fields have the following surface configurations: a) b) c) crowned seedbed (cross-slopes are uneven from centre to side)? seedbed with one or two slopes (cross-slopes are even and gentle)? levelling (terrain tailored to the natural slope)? DITCH, WATERCOURSE AND WATER-RELATED DEVELOPMENTS 8.13 % 18 NA What proportion of watercourses (excluding forest streams) is protected by buffer strips? 50 13 14 15 16 17 18 Primary tillage: first tillage method used to re-seed or transplant a crop. Include owned and rented cropland. Reduced tillage: use of a chisel plough, harrow or other primary tillage instrument for soil conservation. Minimum crop residue after seeding must be 30%. Intercrops: crops sown under the main crop for better use of growing space and constant soil cover. Areas treated using more than one conservation practice (e.g. chisel plough and green manure) must be indicated here. Buffer strips with permanent green cover or rock filling at least three metres wide starting at the high-water mark and including at least one metre on the top slope, bordering a watercourse (defined as a body that drains more than two lots of the original cadastre). PAA_0107 NIM: 123456789 P Year: 2004 6 PART A – AGRI-ENVIRONMENTAL SCAN 8) SOIL CONSERVATION AND WATERCOURSE PROTECTION (continued) DITCH, WATERCOURSE AND WATER-RELATED DEVELOPMENTS (CONTINUED) YES NO PARTLY NA 8.14 8.15 8.16 8.17 8.18 8.19 8.20 8.21 8.22 Are there drop inlets or filter trenches on the farm? Are there sediment basins on the farm? Does your farm have grassed waterways? Are ditch and watercourse junctions protected? Are drain outflows protected? Is subsurface water used for irrigation purposes? 19 Do you visually inspect your storage facilities every year? Do you recycle or treat the water used to wash fruits and vegetables? Are the water wells for human consumption, located near production and spreading sites (fewer than 30 m from cropland), clearly identified? Are unused wells permanently off limits so as to prevent contamination? Are used wells adequately protected from surface contamination (e.g. fence, proper runoff slope)? 8.23 8.24 9) CROP PROTECTION HECTARES NA 9.1 9.2 What is the total area of cropland for which phytosanitary measures are used? 20 45 0 45 0 0 0 0 0 0 0 0 SPRAYER(S) What is the area of cropland for which the following phytosanitary measures are used? a) b) c) d) e) f) g) h) crops grown without herbicides broadcast application of chemical pesticides band or directed application of pesticides chemical herbicide treatment using reduced rates mechanical weeding biological pesticide control treatments or biopesticide use physical removal (e.g. burning) combined methods 21 9.3 How much cropland is scouted before a phytosanitary measure is chosen: a) b) for fields used for crops other than hay and pasture crops? for fields used for hay and pasture crops? NA 9.4 9.5 How many sprayers do you own or co-own (e.g.: CUMA/machinery cooperative)? How often are the sprayers calibrated? More than once a year Once a year Every two years or less frequently 0 YES 9.6 9.7 9.8 NO PARTLY NA Do you keep an updated record of the phytosanitary measures used on your farm? Do you use information from RAP (plant protection warning bulletins), whether you subscribe or not? Who carries out pest scouting on your farm? (more than one choice possible) You or an employee Your input supplier A technical support club or an agri-environmental advisory club 22 9.9 9.10 What area of cropland is under integrated pest management? 50 ha % What is the estimated percentage of pesticide-treated crops harvested in compliance with the prescribed waiting time ("do not harvest until…")? 19 20 21 22 Include owned and rented cropland. Phytosanitary measures: means for protecting crops against weeds, insects or disease (e.g. mechanical weeding, pesticides, predators). Combined methods: areas where more than one mean for protecting crops is used. Area under integrated pest management: Within the meaning of Québec’s pesticide reduction strategy (Stratégie phytosanitaire), integrated pest management involves the following six steps: identification of pests; scouting; use of intervention thresholds; ecosystem adaptation; combined pest management methods; and evaluation of consequences and of intervention effectiveness. PAA_0107 NIM: 123456789 P Year: 2004 7 PART B – ACTION PLAN CARRIED OUT NO. YEAR-MONTH ACTION NUMBER YEAR-MONTH SITE NO. INDICATOR AND UNIT PLANNED COMMENTS AND DETAILS ON THE COURSE OF ACTION NUMBER 1 Eliminate animal access to watercourse, install fences, and construct watering area 2004-05 Sample solid animal waste. 2 - - 2004-05 Use fences to delineate pastures with access to watercourse; construct watering area. 2 Have animal waste analysed 2 % of volume of animal waste analysed 100 3 Use a low-ramp equipment to spread liquid bovine waste 1 - - 2007-04 Purchase low level applicator. 4 Reduce proportion of phosphate-based mineral fertilizers 1 reduction in number of kg of P205 1 035 2010-04 Test phosphorus-free corn starter fertilizer, in order to reduce mineral phosphorus by 2010 in accordance with the regulations. Reduce proportion of mineral phosphorus used in growing oats. 5 Calibrate spreading equipment 1, 2 % of equipment calibrated 100 2004-05 - 6 Introduce green manure 1 Areas seeded with green manure (ha) 15 2008-09 Seed areas with green manure after oat harvest, in order to protect soil and optimize animal waste applications following oat harvest. 7 Scout fields 1 Areas scouted (ha) 45 2006-09 Scout fields used for annual crops in order to optimize herbicide use (for example, choose herbicides depending on weeds, apply herbicide locally). I declare that I was involved in producing this Action Plan. Signature of principal owner or that person’s representative Date PAA_0107 NIM: 123456789 P Year: 2004 8 PART C – DECLARATION BY AGROLOGIST I hereby declare that this Agri-Environmental Support Plan (PAA) was produced according to standard practice. I also declare that a copy was given to the main owner or that person’s representative. Consultant, Bob FAMILY NAME AND GIVEN NAME OF AGROLOGIST (IN BLOCK LETTERS) SIGNATURE OF AGROLOGIST 9999 ORDRE DES AGRONOMES DU QUÉBEC (OAQ) MEMBERSHIP NUMBER 04-05-18 DATE EverGreen Consulting NAME OF AGROLOGIST’S EMPLOYER 200 Main BUSINESS MAILING ADDRESS: CIVIC NUMBER AND STREET Fortune MUNICIPALITY Z0W 3X9 POSTAL CODE (123)456-7899 PHONE NUMBER (OFFICE) (123) 456-7898 FAX NUMBER ( ) ( ) OTHER NUMBER OTHER NUMBER evergreen@address.net E-MAIL PART D – FARM OWNER’S OR REPRESENTATIVE’S CONSENT FOR TRANSFER OF INFORMATION The ministère de l’Agriculture, des Pêcheries et de l’Alimentation du Québec (MAPAQ) wishes to obtain the voluntary consent of farm operators to use the information contained in this support plan to form a secure information bank for producing compilation reports in which no nominative information may be released without the consent of the operators concerned. Only aggregate data and impersonal data may be made public. This information bank is required for MAPAQ to fulfill its responsibilities in the area of agri-environmental support, notably in order to establish priority initiatives and to plan funding assistance. There will be no consequences for you or your farm operation should you refuse to grant consent. The information gathered will be safely collated, kept and managed by MAPAQ according to strict confidentiality and personal information protection criteria prescribed under the Act respecting access to documents held by public bodies and the protection of personal information (R.S.Q., c. A-2.1). Pursuant to the Act respecting access to documents held by public bodies and the protection of personal information, I hereby give my consent for the use of the information contained in this Agri-Environmental Support Plan for the above purposes. Lucky, I.M. Family name and given name of principal owner or that person’s representative Signature 300 Town Line, Fortune Business address May 18, 2004 Date PAA_0107 NIM: 123456789 P Year: 2004 9