Primary Road Certification

1PRIMARY ROAD CONSTRUCTION/RECONSTRUCTION CERTIFICATION

I do hereby certify that the primary road(s) designated or described as in Permit No. for Surface Coal Mining and Reclamation Operations submitted by for Mine, has (have) been constructed (reconstructed):

Check appropriate box:

 In the designated location and according to the design approved in said permit.

 According to the approved design, with the exception of the following minor changes.

Discuss in detail any changes in route, embankments, drainage structures, surfacing, etc. Also discuss reasons for changes and justification of new design if applicable. Include any required maps, drawings, etc. (Please use additional pages as necessary.)

INDIVIDUAL P.E. CERTIFICATION

______Name Illinois Registration Number (Seal)

______Firm

______

______Address Signature

______Phone Number Date

PROFESSIONAL DESIGN FIRM CERTIFICATION

Complete if applicable. If not, respond N/A.

______As an employee of a Professional Design Firm as defined by the Illinois Department of Financial and Professional Regulation, I certify that the professional design firm is registered and in good standing with the Illinois Department of Financial and Professional Regulation.

______

1 | P a g e C r e a t e d : S e p t e m b e r 1 5 , 2 0 1 7 ______Professional Design Firm Name Professional Design Firm Number

2 | P a g e C r e a t e d : S e p t e m b e r 1 5 , 2 0 1 7