Coal Mine Methane Project Submittal Form

							                                                                       Coal Mine Methane Project Submittal
                                                                                           August 5, 2011




                  Coal Mine Methane Project Submittal Form
Instructions: Please complete all fields as thoroughly as possible. If the project in question is still in the
planning/ development phase, all fields must be completed using best available data and estimates based
on the proposed system design. This is an interactive Word form. Upon completion, please save this
form as a PDF prior to uploading it to the Reserve. This will lock your answers and protect the document
from any further changes. All fields must be completed, even if the answer is also provided elsewhere; if
a field is not applicable insert N/A in the space provided.

Reserve project ID (numerical, as it appears in the Reserve software): CAR

Project crediting period (select only one):

        First Crediting Period                       Second Crediting Period

Section 1: Project Contact Information

Project name (as it appears in the Reserve software):

Account holder (as it appears in the Reserve software):

Is the account holder authorized to sign the “Attestation of Title” form?            Yes         No

Methane destruction system owner:

Technical consultants:

Other parties with a material interest:

Date of form completion:

Form completed by (name, organization):



Section 2: Project Site Information

1. Name of mine:

2. Mine owner (name of entity) and parent company (if different from owner):

3. Mine MSHA ID #:

4. Mine site address (including county and country):

5. Mine basin:



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                                              Climate Action Reserve – Coal Mine Methane Project Submittal
                                                                                           August 5, 2011

6. Mining method:

7. Average annual mineral production (please specify tons or tonnes):

8. Year of initial production:

9. Estimated year of closure:



Section 3: Project Eligibility and Monitoring

10. What version of the Coal Mine Methane Project Protocol is the project being submitted
    under?

11. Type of project:             Drainage project                    Ventilation air methane (VAM) project

12. Project diagram: diagram of mine that illustrates how the project is defined and includes the
    location, quantity and type of boreholes, ventilation shafts, eligible destruction devices and
    non-qualifying devices within the project’s GHG Assessment Boundary (upload as a
    separate PDF titled “Project Diagram”).

13. Project definition/description (provide one to two paragraphs in addition to project diagram):


14. Project start date (MM/DD/YYYY):

15. First reporting period (MM/DD/YYYY):                        to

16. Have any GHG reductions from the project ever been registered with or claimed by another
    registry or program prior to registering with the Reserve?

    If the answer is yes, you must complete and return a "Project Transfer" form.

17. Have any GHG reductions from the project ever been sold directly to a third party (i.e., sold
    without being registered with or claimed by another registry or program) prior to registering
    with the Reserve?

    If yes, please describe:

18. Description and citation of all local and state air and water quality, safety, or other
    regulations pertinent to the project:

19. Is this project being implemented and maintained as the result of any law, statute,
    regulation, court order, or other preexisting legally binding mandate?    Yes       No

    If yes, please explain:

20. Has a detailed monitoring plan been developed for this project? If not, by what date will a
    monitoring plan be in place?

21. Are there currently any other coal mine methane offset projects at this mine?                Yes         No


Please make sure you are using the latest version of this document                                            2
                                              Climate Action Reserve – Coal Mine Methane Project Submittal
                                                                                           August 5, 2011

    If yes, please list the registry where the offset project is registered, the project name, and
    start date:



Section 4: Non-Qualifying Device Information

22. Was there any destruction of coal mine methane at the mine prior to implementation of this
    project?     Yes        No

    If yes:

    a. Is/are the non-qualifying device(s) assigned to this project?                   Yes       No

         If no, please list the project name that the non-qualifying device(s) is/are assigned to:


         If yes:

         i)   Please describe (source of methane, number and type of destruction devices, etc.):


         ii) What date was the non-qualifying device operational? (MM/DD/YYYY):

         iii) If no longer operating, on what date was the device shut off? (MM/DD/YYYY):



Section 5: Gas Destruction Information for Project Activity

23. Gas destruction description (one to two paragraphs on how the coal mine methane will be
    utilized, including number and type of destruction devices, as well as metering and data
    collection systems):

24. If a VAM project, is supplemental coal mine methane used?                Yes       No        N/A

25. Provide a summary and citation of the permits obtained to build and operate the coal mine
    methane gas destruction system:

26. Additional information (if any):
                                                         End of form




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