ILLINOIS ENVIRONMENTAL PROTECTION AGENCY
1021 NORTH GRAND AVENUE EAST, P.O. Box 19276, SPRINGFIELD, llllNOIS 62794-9276 · (217) 782-3397
JOHN J. KIM, DIRECTOR

JB PRlnKER, GOVERNOR

21 71785-0561
February 21, 2023
CERTIFIED MAIL# 7021 2720 0000 2345 0397
RETURN RECEIPT REQUESTED
Graham Correctional Center
c/o Glen Austin
12078 IL Rte 185
Hillsboro, IL 62995
Re:

Violation Notice: GRAHAM CORRECTIONAL CENTER
Facility No.: IL01355100
Violation Notice No.: W-2023-00020

Dear Mr. Austin:
This constitutes a Violation Notice pursuant to Section 31 (a)(l) of the lllinois Environmental
Protection Act ("Act"), 415 ILCS 5/31 (a)( 1), and is based upon a review of available information and
an investigation by representatives of the Illinois Environmental Protection Agency ("Illinois EPA").
The Illinois EPA hereby provides notice of alleged violations of environmental laws, regulations, or
permits as set forth in Attachment A to this notice. Attachment A includes an explanation of the
activities that the Illinois EPA believes may resolve the specified alleged violations, including an
estimate of a reasonable time period to complete the necessary activities. Due to the nature and
seriousness of the alleged violations, please be advised that resolution of the violations may also
require the involvement of a prosecutorial authority for purposes that may include, among others, the
imposition of statutory penalties.
,,
A written response, which may include a request for a meeting with representatives of the Illinois
EPA, must be submitted via certified mail to the Illinois EPA within 45 days of receipt of thi s letter.
If a meeting is requested, it shall be held within 60 days ofreceipt of this notice. The response must
include information in rebuttal, explanation, or justification of each alleged violation and a statement
indicating whether or not the facility wishes to enter into a Compliance Commitment Agreement
("CCA") pursuant to Section 31(a) of the Act. If the facility wishes to enter into a CCA, the written
response must also include proposed terms for the CCA that includes dates for achieving each
commitment and may include a statement that compliance has been achieved for some or all of the
alleged violations. The proposed terms of the CCA should contain sufficient detail and must include
steps to be taken to achieve compliance and the necessary dates by which compliance will be
achieved.

2125 S. Fi11t Street, Champaign, ll 61820 (217) 278-5800
1101 Eastport Plaza Dr., Suite 100, Collinsville, IL 62234 (618) 346-5120
9511 Harrison Street, Oes Plaines, IL 60016 (847) 294-4000
595 S. State Street, El~ n, IL 60123 1847) 608-3131

2309 W. Main Street, Suite 116, Marion, IL 62959 (618) 993-7200
412 SW Washington Street, Suite D, Peoria, ll 61602 (309) 671-3022
4302 N. Main Street. Rockford, ll 61103 (815) 987-7760

PLEASE PAINT ON RECYCLED PAPER

Page 2 of2
IL08755 IO GRAHAM CORRECTIONAL CENTER
VN W-2023-00020
The Illinois EPA will review the proposed terms for a CCA provided by the facility and, within 30
days of receipt, will respond with either a proposed CCA or a notice that no CCA will be issued by
the Illinois EPA. If the Illinois EPA sends a proposed CCA, the facility must respond in writing by
either agreeing to and signing the proposed CCA or by notifying the Illinois EPA that the facility
rejects the terms of the proposed CCA.
If a timely written response to this Violation Notice is not provided, it shall be considered a waiver
of the opportunity to respond and meet, and the Illinois EPA may proceed with referral to a
prosecutorial authority.
Written communications should be directed to:
Illinois EPA - Division of Public Water Supplies
Attn: Kathy Andring, CAS # 19
P.0. BOX I 9276
Springfield, IL 62794-9276

· All communications must include reference to this Violation Notice number, W-2023-00020.
Questions regarding this Violation Notice should be directed to Kathy Andring at 2 l 7/785-0561 .
Sincerely,

Jo~
P~~
Manager, Compliance Assurance Section
Division of Public Water Supplies
Bureau of Water
Attachments
cc:

Jared Brunk
Rodney Thacker

BOW ID: Wl358070007

PAGE NO. 1 OF 6
ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL13355100 VIOLATION NOTICE NO. W-2023-00020:

Questions regarding the violations identified in this attachment should be
referred to Kathy Andring at (217) 785-0561.
A review of information available to the Illinois EPA indicates the following
violations of statutes, regulations, or permits. Included with each type of
violation is an explanation of the activities that the Illinois EPA believes
may resolve the violation including an estimated time period for resolution.
Drinking Water Construction Permit
Public Water Supplies (PWSs} are required to obtain a construction permit
from Illinois EPA for all construction.
To meet compliance, the supply is
expected to submit as-built plans and specifications pursuant to 35 Ill.
Adm. Code 602.116 within 120 days for approval by Illinois EPA.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure to obtain a construction permit for the installation of
multiple water softeners and the brine storage tank used to
treat water that may be used for consumption.
Sections 15(a) and 18(a) (3) of the Act, 415 ILCS 5/15 and 5/18,
and 35 Ill. Adm. Code 602.l0l(a) and (b) and 602.200(a) and (b).

Drinking Water Monthly Operating Reports
All public water supplies are required to submit reports summarizing daily
operational activities to the Regional Illinois EPA office eac h month.
Compliance with this is expected within 30 days by submission of the required
reports.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure
to
submit
monthly
operating
reports.
(on-going
violation)
Section 18(a) and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm . Code. 604.165(a), (c), and (d) .

PAGE NO. 2 OF 6
ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL1355100 VIOLATION NOTICE NO. W-2023-00020:
Drinking Water Cross-Connection Control Program
All public water supplies must have an active cross-connection control
program. It is not possible for the Agency to evaluate whether a water
system's cross-connection control program is comprehensive without the
ability to evaluate an ordinance or service agreement. Compliance is expected
to be achieved by submitting your water supply's cross-connection control
ordinance or water use agreement within 90 days to the Illinois EPA.
Additionally, provide an implementation schedule including when your water
system will conduct its cross-connection survey of the distribution system;
how your water system will evaluate high risk service connections; and how
your water system will track cross connection control devices and their
annual inspection.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure to have a comprehensive cross-connection control
program. (on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.101 (a) and 604 .1505 (a) and (b)

Drinking Water Cross-Connection Program Device Inventory
A community water supply must maintain records of all backflow preventers
that require annual testing.
To achieve compliance, an inventory of all
backflow prevention devices in the system must be created, and documentation
submitted to the Illinois EPA within 90 days.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure to maintain records of all backflow preventers that
require annual testing .
Section 18 of the Act 415 ILCS 5/18, 35 Ill. Adm. Code 601.101 (a)
and 604.1505(b) (5).

Drinking Water Cross-Connection Device Testing
A community water supply must assure all backflow preventers are tested at
least annually. To achieve compliance, each backflow prevention device must
be tested, and documentation submitted to the Illinois EPA within 90 days.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure to perform annual testing of all backflow prevention
devices in the system.
(on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.lOl(a) and 604.1510(a).

PAGE NO. 3 OF 6
ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL1355100 VIOLATION NOTICE NO. W-2023-00020:
Emergency Operation Plan
Each community water supply must develop an Emergency Operations Plan for
the provision of water under emergency circumstances, including earthquakes,
floods, tornados, and other disasters.
The Emergency Operations Plan must
include a review of the methods and means by which alternative supplies of
drinking water could be provided in the event of destruction, impairment, or
contamination of a community water supply. Compliance with this is expected
to be achieved within 90 days by developing and maintaining an Emergency
Operations Plan for the public water supply. This Emergency Operations Plan
must be maintained on-site and available to the Agency, upon request, and
must be reviewed every three years.
Violation
Date
10/25/2022

Rule/Reg.

Violation
Description
Failure to have an Emergency Operations Plan for the provision
of water under emergency circumstances. (on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.101 and 604.135(d).

Water Treatment Plant/Distribution System Maintenance
There are structure/maintenance problems, which threaten the quality of the
drinking water provided to customers.
Compliance with this is expected
within 180 days by obtaining permits and completing the necessary
construction.
Violation
Date
10/25/2022

Rule/Reg.

10/25/2022
Rule/Reg.

10/25/2022
Rule/Reg.

Violation
Description
Verify that the sodium chloride used for regenerating the Ion
Exchange units meets the American National Standards Institute
Standard 60. Evidence of approval must be provided from one of
the
three
certifying
organizations:
National
Sanitation
Foundation, Underwriters Laboratories, Inc. or Water Quality
Association.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
604.105(b) and (g).

Install 4 mesh, non-corrodible screen on the 200,000 gallon
elevated storage tank overflow line to prevent contamination.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.101 (a) and 604 .1305 (e) .
Failure to develop and maintain a systematic flushing program.
(on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.101 (a) and 604 .1425 (c) .

I

PAGE NO. 4 OF 6
ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL1355100 VIOLATION NOTICE NO. W-2023-00020:
Violation
Date
10/25/2022

Rule/Reg.

10/25/2022

Rule/Reg.

Violation
Description
Obtain chlorine residual testing equipment to verify chlorine
residual.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
604.130(c).

Bare metal rust is present on the exterior of the 200,000
elevated storage tank.
A comprehensive inspection of the
200,000 gallon elevated storage tank is recommended every five
years.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.l0l(a) and 604.1330(a).

Responsible/Certified Operator
Every community public water supply (PWS) is required to employ on its
operational staff at least one person certified as competent as a water
supply operator.
Compliance with this is expected within 15 days by
obtaining a certified operator and submitting the appropriate form
(enclosed) .
Violation
Date
10/25/2022

Rule/Reg

Violation
Description
Operations of a Class B Water
certified drinking water operator.
Class B Certification or higher is
Section 18(a) of the Act, 415 ILCS
601.l0l(a), 603.l0l(d), 603.103(a)

system without a properly
An operator with a valid
required.
5/18, and 35 Ill. Adm. Code
and (b), and 681.215(a) and

(b) .

Notification of Ownership or Responsible Operational Personnel
Every community public water supply (PWS) is required to submit a statement
of ownership to the Illinois EPA identifying an Owner, Official Custodian,
Administrative Contact, Responsible Operator in Charge (ROINC), and Sample
Bottle Collector .
Compliance with this is expected within 30 days by
determining the ownership or responsible personnel and submitting the
appropriate form.
Violation
Date
10/25/2022

Rule/Reg

Violation
Description
Lack of "Notification of Responsible Operational Personnel" form
on file with the Illinois EPA identifying a Responsible Operator
in Charge (ROINC).
Section 18(a) of the Act, 415 ILCS 5/18, and 35 Ill. Adm . Code
603.103(e).

PAGE NO. 5 OF 6
.ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL1355100 VIOLATION NOTICE NO. W-2023-00020:
Drinking Water Monitoring Site Plan Requirements
All public water supplies (PWSs) must achieve and maintain compliance with
the monitoring and reporting requirements of the Environmental Protection
Act.
Your supply did not submit required written sample site plans. This
written plan must be representative of the water throughout the distribution
system and be approved by special exception permit. Compliance with this is
expected to be achieved within 30 d9 ys by submitting the required written
sample site plans to the Illinois EPA.
Violation
Violation
Date
Description
10/25/2022
Failure to submit, for Agency approval, a written sample siting
plan for coliform that identifies sampling sites representative
of
water
throughout
the
distribution
system.
(on-going
violation)

Rule/Reg.

Sections 18 of the Act,
611.1053 (a) (1).

10/25/2022

Failure to submit, for Agency approval, a written sample siting
plan for lead and copper that identifies sampling sites
representative of water throughout the distribution system. (ongoing violation)
Sections 18 of the Act, 415 ILCS 5/18, and 35 Ill Adm. Code
611.356(a).

Rule/Reg.

10/25/2022
Rule/Reg.

415 ILCS 5/18, and 35 Ill. Adm. Code

Failure to submit, for Agency approval, a written sample siting
plan for disinfection by-product samples. (on-going viol~tion)
Sections 18 of the Act, 415 ILCS 5/18, and 35 Ill Adm. Code
611. 972 (a).

Drinking Water Monitoring
All Public Water Supplies (PWSs) must achieve and maintain compliance with
the monitoring and reporting requirements of the Environmental Protection
Act.
Your supply did not submit required sample results from a certified
laboratory.
Sample results are due to the Illino is EPA by the 10 t h of the
month following the monitoring period. Compliance with these monitoring and
reporting requirements is expected to be achieved within the next monitori ng
period by submitting sample results for each monitoring program in accordance
with your supply's sample site plans.
Violation
Date
10/25/2022
Rule/Reg.

Violation
Description
Failure to collect samples and submit coliform sample results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 611.1053 (a) (2) and (3).

PAGE NO. 6 OF 6
ATTACHMENT A
GRAHAM CORRECTIONAL CENTER, IL1355100 VIOLATION NOTICE NO. W-2023-00020:
Violation
Date
10/25/2022

Rule/Reg.

10/25/2022
Rule/Reg.

10/25/2022
Rule/Reg.

Violation
Description
Failure to collect samples and submit disinfectant residual
sample results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 611.382(a) and (c).

Failure to collect samples and submit lead and copper sample
results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 611.350(h) and 611.356(c).
Failure to collect samples and submit disinfectants and
disinfection by-products (DBPs) sample results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 611.971(a)

Nitrification Action Plan
Any community water supply distributing water without a free chlorine
residual must create a Nitrification Action Plan (NAP).
The NAP must:
a.
Contain a plan for monitoring total ammonia as nitrogen (N), free
ammonia as N, nitrite as N, nitrate as N, monochloramine residual,
dichloramine residual, and total chlorine residual.
b.
Contain system specific levels of the chemicals in listed in A when
action must be taken.
c.
Contain specific correction actions to be taken if the levels listed in
Bare exceeded.
d.
Be maintained on site and made available to the Agency upon request.

Violation
Date
10/25/2022

Violation
Description
No Nitrification Action Plan has been created for
the
distribution system. A NAP for the distribution system must be
created.

Rule/Reg.

Section 18 of the Act, 415 ILCS 5/18, 35 Ill. Adm. Code 601.101
and 604.140.

UPnul.'i

J?p~it:OlllllC l)ta I @rotc\?ttOJl Ag(~IJC'y
Notification of Responsible Operational Personnel
Please use this form to make community water supply (CWS) contact changes.

CWS Name:

Number:

IL
-----------

REASON FOR CHANGE (check all aoDlicable boxes)
Change in Owner and/or Official
Custodian Information
Change in Responsible Operator in
Charae Information

Change in Administrative Contact
Information
Updating phone, mailing address, and/
or E-Mail information onlv

Change of Sample Collector
Information
This is a NEW CWS

OWNER (OW)

If the CWS is privately owned. identify the individual (and contact information) exercising direct supervision over the CWS
in accordance with 35 Ill. Adm. Code 603.101 (e.g., Mobile Home Park, Apartment Complex. or Private Business, etc.). This individual must sign.
If the CWS is publically owned or owned by pnvate corporation, or regularly organized body, identify the entity exercising direct supervision over the
CW$ in accordance with 35 Ill. Adm. Code 603.101 (e.g., Municipality, Water District, Water Corporation, Water Cooperative, Conservancy District.
Subdivision, or Association), If an entity, only complete Entity Name, Business#, and Address (no signature required) and then complete
OFFICIAL CUSTODIAN
box.

mcl

Name (Individual) 2! Entity Name (Municipality, Water District, Assoc., etc.)
Title:
Cell#:
Home#:
E-Mail:

Business Address

(if applicable)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Business#: (_ _)_ _ _ _ _ __
( _)
(
)
Fax#: (
)

_____

__ ____~-

If Individual, Signature:_ _ _ _ _ _ _ _ __ _ __ __ _ _ __

Date:_ _ _ _ _ _ _ _ _ __

( S,analure of Individual)

OFFICIAL CUSTODIAN (OC) If the owner is an Entity as listed above (Municipality, Water District. Water Corporation, Water
Cooperative, Conservancy District, Subdivision or Association. etc.) identify a person who acts on behalf and is responsible for the supply. This
' person should be an elected official of a municipa~ty. member of the board, or an officer of the organization that runs the supply (mayor, president.
chairman etc.t

Name:
Title
Cell#
Home#
E-Mail:

(print),_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _

Business Address

(if applicable) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(_ _)_ _ _ _ _ _ Business#:(_ _)_ _ _ _ __
(_ _) _ _ _ _ _ _ Fax#: (_ _ _)_ _ _ _ _ __

S1gnature:_.,...._ _ ....,...,..,.._...,..._______________

Date:____________

(Siqnature of Official Custodian)

ADMINISTRATIVE CONTACT (AC) An owner or official custodian may designate an administrative contact to oversee daily
managerial operations of the CWS. Any notice provided by the Agency to the AC shall be considered notice to the owner or official custodian.
These notices may include, but are not limited to Sample Demand Letters, Public Notice Advisories, Violation Notic e, Notice of Intent to Pursue
Leoal Action and notices of rer:iulatorv reouirements and Dermitlin9 transactions.
Name: (print)_ __ __ _ _ _ _ _ _ _ _ _ __ _ __ _
Title:
Cell#: (_ _)_ _ _ _ __ Work#:<.___ _ )_ _ _ _ __
Fax#: (_ _ _,)_ _ _ _ __
Home#: (_ _)
E-Mail:
Signature:___________________ __ _ _

Business Address

Date: ____________

(Signature of AC)

Signature of the Owner or Official Custodian is reguired before Illinois EPA will add or change an AC contact:
I hereby duly authorize._ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ __ _ _ (print) as my Agent. with actual authority to conduct legal
transactions arising from the daily managerial operations of the CWS on my behalf.

Signature:_ _ _ _ _ __ _______________
( Signature of Owner or Official Custodian)

L 532-11967/0164 (revised 01-14)

Date:_ _ _ _ _ _ _ _ _ __

llllnnl,

~nvi~•otu1ic1!Jtil ~ ~~oJ~t:tioi\ ,\gc n,·r
RESPONSIBLE OPERATOR IN CHARGE (ROINC} Identify the certified operator(s) designated pursuant to 35 Ill. Adm.
Code 603.103 in responsible charge of the CWS operations. The ROINC runs and oversees dally water treatment and distribution operations. A
CWS must select only one designated ROINC for treatment and one designated ROINC for distribution. The treatment ROINC and distribution
ROJNC mav be the same oerson.
Current ROINC on File:
Please check box that best describes status of current ROINC on File
I Current ROINC on file will no longer be employed or under contract with PWS effective
I Current ROINC on file is still workina with PWS but will no lonaer servinci as ROl NC.

(print name)°

NEW ROINC 1 Please Check One:
Full Time Employee or
Contract Operator {Include coov of contract)
Name: (print)
Business Address
Circle Certificate Class: A B C D
Circle One: Treatment & Distribution
Treatment Only
Distribution Only
Cetl#: ( _ )
Work#: (
)
)
)
Home#: (
Fax#: (
E-Mail:
Signature:
Date:

__

t Sianature of RO/NC 1>

NEWROINC 2 Please Check One:
Name: (print)
Circle Certificate Class: A B C
)
Cell#: (
Home#: ( _ )
E-Mail:
Signature:

__

Full Time Emolovee or
D

Circle One:
Work#: (
)
)
Fax#: (

Contract Operator (include coov of contract)
Business Address

Distribution Only

Date:

{ Signature of RO/NC 2)

Signature of Owner1 Official Custodian 1 or Administrative Contact is reguired before Illinois EPA will add or
change a ROINC contact(s).
As Owner/Official Custodian or Administrative Contact, I
(print name). accept and
assign the duties and responsibilities for the proper operation and maintenance or the public water supply facilities by the operator(s) listed above as
being in responsible charge.

Signature:

Date:
{Sionature of Owner/Official Custodian or Administrative Contact>

Sample Collector/Bottle Recipient tdenlify the person employed by the cws that will collect samples and complete the
paperwork associated with sampling.

Name:
Cell#:
Home#:
E-Mail:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (print)
(_ _)_ _ _ _ _ _ Work#:( _ _ _)_ _ _ _ __
(_ _)
Fax#:
)_ _ _ _ __

Signature:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Sample Collector's Signature)

Bottle Mailing Address
No P .O.Box Numbers Allowed

Date:

-------------

Completion of this form shall indicate acceptance of the duties and responsibilities for the proper operation and maintenance of the public water
supply facilities by both the owner or official custodian and the certified operators designated as being in responsible charge pursuant to 35 Ill. Adm.
Code 603.101(d). Please be advised that it is the responsibility of the owner. official custodian and the certified operator(s) in responsible charge to
notify this office within 15 days of any changes in responsible personnel. Completion and submittal of this form will satisfy the notification of
responsible personnel requirements of Title 35: Environmental Protection, Subtitle F: Public Water Supplies. Chapter I: Pollution Control Board. Part
603, Sections 603.101, 603.102, and 603.103.
Be sure to retain copies of this document for your files. Should you need additional forms, please call {217)785-0561 or download at
ll1tp:llwww.epa.state.il.us/water/operator-cert/drinking-water/forms(noti[glt9n-of-oJM1ershipJl.SU. Return this completed form to:
Illinois Environmental Protection Agency, Bureau of Water #19, 1021 North Grand Ave East, P.O. Box 19276, Springfield, IL 62794-9276

This Agency is authorized to require this information under 415 tLCS 5/4(b)(2012). Disclosure of this information is required. Failure to do
so may result in a civil penalty up to $1,000.00. Any person who knowingly makes a false, fictitious, or fraudulent material statement,
orally or in writing, to the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony. (415
ILCS 5/44(h})
IL 532-0987/0164 (revised 01-14)

tUh1 ·

f1n\ ironn1,· ntrll Pr ott""( tt,,n r\Ht"ll C¥
RESPONSIBLE OPERATOR IN CHARGE {ROINC} Identify the certi~ed operator(s) qesignated pursuant to 35 UL Adm .
Code 603 103 in responsible charge of the CWS operations. The ROINC runs and oversees daily water treatment and distribution operations. A
CWS must select only one designated ROINC for treatment and one designated ROINC for distribution. The treatment ROINC and distribution
ROINC mav be the same oerson.
Current ROINC on File:
Please check box that best describes status of current RO/NC on File
I Current ROINC on file will no lonaer be employed or under contract with PWS effective
I Current ROINC on file is still working with PWS but will no lonaer servina as ROINC

(print name}

NEW ROINC 1 Please Check One:
Full Time Emolovee or
Contract Ooerator (Include coov of contract}
Name: (print)
Business Address
Circle Certificate Class: A B C D
Circle One: Treatment & Distribution
Treatment Only
Distribution Only
Cell#: ( _ )
Work#: (
)
Home#: ( _ )
Fax#: (
)
E-Mail:
Signature:
Date:
(Sionature of RO/NC 1)

NEW ROINC 2 Please Check One:
Name: (print)
Circle Certificate Class: A B C
)
Cell#: (
Home#: ( _ )
E-Mail:
Signature:

__

Full Time Employee or

D

( Signature of ROINC 2)

Circle One:
Work#: (
)
Fax#: (
)

Contract Operator (include coov of contract)
Business Address

Distribution Only

'

Date:

Signature of.Owner 1 Official Custodian 1 or Administrative Contact is regulred before Illinois EPA will add or
change a ROINC contact(s}.
As Owner/Official Custodian or Administrative Contact. I
(print name}. accept and
assign the duties and responsibilities for the prop~r operation and maintenance of the public water supply facilities by the operator(s) listed above as
beJng in responsible charge.

Signature:

Date:
(Sianature of Owner/Official Custodian or Administrative Contact)

Sample Collector/Bottle Recipient Identify the person employed by the cws that will collect samples and complete the
paperwork associated with sampling.

Name:
Cell#:
Home#:
E-Mail:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ (print)
(
)
Work#:( _ _ _ )_ _ _ _ __
(
)
Fax#: (
)_ _ _ _ __

__ ______
__ _ _ _ _ _

Signature:.--=---,,....,.,----,----=----,-------- - - -- - -

Bottle Mailing Address
No P.O.Box Numbers Allowed

Date:_ _ __ _ _ __ _ _ __

(Samp/e Collector's Signature)

Completion of this form shall indicale acceptance of the dulies and responsibilities for the proper operation and maintenance of the public water
supply facilities by both the owner or official custodian and the certified operators designated as being in responsible charge pursuant to 35 Ill. Adm.
Code 603.101(d}. Please be advised that it is the responsibility of the owner, official custodian and the certified operator(s) in responsible charge to
notify this office within 15 days of any changes in responsible personnel. Completion and submittal of this form will satisfy the notification of
responsible personnel requirements of Title 35: Environmental Protection. Subtitle F: Public Water Supplies, Chapter I: Pollution Control Board Part
603. Sections 603.101, 603.102, and 603.103.
Be sure to retain copies of this document for your files. Should you need additional forms. please call (217)785-0561 or download at
http://www.eoa.slate.il.us/water/ooerator-cert/drinking-watertrorms/notification-of-ownership.pdf. Return this completed form to:
Illinois Environmental Protection Agency, Bureau of Water #19, 1021 North Grand Ave East, P.O. Box 19276, Springfield, IL 62794-9276

This Agency is authorized to require this information under 415 ILCS 5/4(b)(2012). Disclosure of this informaUon is required. Failure to do
so may result in a civil penalty up to $1.000.00. Any person who knowingly makes a false. ficbtious, or fraudulent material statement,
orally or in writing. to the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony. (415
ILCS 5/44(h))
IL 532-098710164 (revised 01-14)