Figure: 30 TAC §37.9220

CERTIFICATE OF INSURANCE

Name and Address of Insurer (herein called the "insurer"): ______________________________________
___________________________________________________________________________________.

Name and Physical and Mailing Addresses of Insured (herein called the "insured"): ____________________
___________________________________________________________________________________.

Quarries covered: (list for each quarry: The permit number, name, physical and mailing addresses, and the amount of insurance for reclamation or restoration (these amounts for all quarries covered must total the face amount shown below).)__________________________________.

Face Amount: _____________________________________________________

Policy Number: ____________________________________________________

Effective Date: _____________________________________________________

          The insurer hereby certifies that it has issued to the Insured the policy of insurance identified above to provide financial assurance for reclamation at the quarry(ies) or restoration related to the quarry(ies), identified above. The Insurer further warrants that such policy conforms in all respects with the requirements of 30 Texas Administrative Code §37.9215 (relating to Insurance Requirements), as applicable and as such regulations were constituted on the date shown immediately below. It is agreed that any provision of the policy inconsistent with such regulations is hereby amended to eliminate such inconsistency.

          Whenever requested by the executive director of the Texas Commission on Environmental Quality, the Insurer agrees to furnish to the executive director a duplicate original of the policy listed above, including all endorsements thereon.

          I hereby certify that the wording of this certificate is identical to the wording specified in 30 Texas Administrative Code §37.9220 as such regulations were constituted on the date shown immediately below.

(Authorized signature of Insurer) ____________________________________

(Name of person signing) __________________________________________

(Title of person signing) ___________________________________________

(Signature of witness or notary:) _____________________________________

(Date) ________________