Figure: 30 TAC §37.341

CERTIFICATE OF INSURANCE

Name and Address of Insurer (herein called the "insurer"): ______________________________
___________________________________________________________________________.

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

Facilities covered: (list for each facility: The permit number, name, physical and mailing addresses, and the amount of insurance for closure, post closure, or corrective action (these amounts for all facilities 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 closure, post closure, or corrective action for the facilities identified above. The Insurer further warrants that such policy conforms in all respects with the requirements of 30 Texas Administrative Code §37.241 (relating to Insurance), 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 §37.341 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) ________________