ILLINOIS ENVIRONMENTAL PROTECTION AGENCY
1021 NORTH GRAND AVENUE EAST, P.O. Box 19276, SPRINGFIELD, ILLINOIS 62794-9276 · (217) 782-3397
JB PRlnKER, GOVERNOR

JOHN J. KIM, DIRECTOR

217/785-0561
February 14, 2023
CERTIFIED MAIL# 702127200000 2345 0908
RETURN RECEIPT REQUESTED
Shawnee Correctional Center
C/O Darren Galloway
Shawnee Correctional Center
6665 State Route l 46e
Vienna, IL 62995
Re:

Violation Notice: SHAWNEE CORRECTIONAL CENTER
Facility No.: IL0870010
Violation Notice No.: W-2023-00019

Dear Mr. Galloway:
This constitutes a Violation Notice pursuant to Section 3 l(a){l) of the Illinois Environmental
Protection Act {"Act"), 415 ILCS 5/31 (a)(l ), 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 t_o 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 this letter.
If a meeting is requested, it shall be held within 60 days of receipt 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 3 l(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. First Street. Champaign, ll 61820 (217) 278-5800
1101 Eastport Plaza Dr., Suite 100, Collinsville, IL 62234 (618) 346-5120
9511 Harrison Street, Des Plaines, IL 60016 (847) 294-4000
595 S. State Street, Elgin, IL 60123 (847) 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, IL 61103 (81S) 987-7760

PLEASE PAINT ON RECYCLED PAPER

Page 2 of 2
IL0870010 SHAWNEE CORRECTIONAL CENTER
VN W-2023-00019
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 tenns 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: ADAM NUTT, CAS #19
P.O. BOX 19276
Springfield, IL 62794-9276

All communications must include reference to this Violation Notice number, W-2023-00019.
Questions regarding this Violation Notice should be directed to Adam J. Nutt at 217/785-0561.
Sincerely,

~~-~

Manager, Compliance Assurance Section
Division of Public Water Supplies
Bureau of Water
Attachments

cc:

Mike Shumake
Rodney Thacker
Jared Brunk

BOW ID: W08785 I 0003

PAGE NO. 1 OF 5
ATTACHMENT A
SHAWNEE CORRECTIONAL CENTER, IL0870010 VIOLATION NOTICE NO. W-2023-00019:

Questions regarding the violations identified in this attachment should be
referred to Adam J. Nutt 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 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 Illinois EPA by the 10 th of the
month following the monitoring period. Compliance with these monitoring and
reporting requirements is expected to be achieved within the next monitoring
period by submitting sample results for each monitoring program in accordance
with your supply's sample site plans.
Violation
Date
8/17/2022
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).

8/17/2022

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).

Rule/Reg.

8/17/2022
Rule/Reg.

8/17/2022
Rule/Reg.

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).

PAGE NO. 2 OF 5
ATTACHMENT A
SHAWNEE CORRECTIONAL CENTER, IL0870010 VIOLATION NOTICE NO. W-2023-00019:
Drinking Wa t er Monitoring Site Plan Requirements
All public water supplies (PWSs) must achieve and maintain c ompliance with
the monitoring and reporting requirements of the Environmental Protection
Act.
Your supply did not submit required wr i tten sample site plans. This
written plan must be representative of the water throughout the distribution
system and be approved by special exceptio n permit. Compliance with this is
expected to be achieved within 30 days by submitting the required written
sample site plans to the Illinois EPA.
Violation
Date
8/17/2022

Rule/Reg.

8/17/2022

Rule/Reg.

8/17/2022
Rule/Reg.

Violation
Description
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)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
611.1053 (a) (1).

Failure to submit, for Agency approval, a written sample siting
p l an for lead and copper that identifies sampling sites
representative of water throughout the distribution system. (ongo ing violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
611.356(a).
Failure to submit, for Agency approval, a written sample siting
plan for disinfection by-product samples. (on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm.
Code 611. 972 (a).

Drinking Water Monthly Operating Reports
All public water supplies are required to submit reports summarizing daily
operational activities to the Regional Illinois EPA office each month.
Compliance with this is expected within 30 days by submission of the required
reports.
Violation
Date
08/17/2022

Rule/Reg.

Violation
Description
Failure to submit Monthly Operating Reports within 30 days of
the last day of each month. These reports must be prepared on
an operating report form approved by the Agency, must be signed
by the Responsible Operator in Charge, and submitted with i n 30
days of the end of the month.
A copy of the operating report
records must be maintained by the official custodian of the
public water supply.
Sections 18(a) and 19 of the Act, 415 ILCS 5/18 and 5/19, and
35 Ill. Adm. Code 601.l0l(a) and 604.165(a), (c), and (d ).

PAGE NO. 3 OF 5
ATTACHMENT A
SHAWNEE CORRECTIONAL CENTER, IL0870010 VIOLATION NOTICE NO. W-2023-00019:
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
08/17/2022

Rule/Reg.

Violation
Description
Failure to have a comprehensive cross-connection control
program. (on-going violation)
Section 18 of the Act, 415 It,CS 5/18, and 35 Ill. Adm. Code
601.lOl(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
08/17/2022

Violation
Description
Failure to maintain records of
require annual testing.

Rule/Reg.

Section 18 of the Act, 415 ILCS 5/ 1 8,
601.101 (a) and 604 .1505 (b} (5} .

all backflow preventers that

and 35 Ill. Adm. Code

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
8/17/2022

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. 4 OF 5
ATTACHMENT A
SHAWNEE CORRECTIONAL CENTER, IL0870010 VIOLATION NOTICE NO. W-2023-00019:
Water Treatment Plant/Distribution System Maintenance
There are structure/maintenance problems that threaten the quality of the
drinking water provided to customers.
Violation
Date
8/17/2022

Violation
Description
Failure to develop and maintain a systematic flushing program.
(on-going violation)

Rule/Reg.

Section 18 of the Act, 415 ILCS 5/18,
601.lOl(a) and 604.1425(c).

and 35 Ill.

Adm. Code

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
08/17/2022

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,
601.lOl(a) and 604.140.

415 ILCS 5/18,

and 35 Ill. Adm. Code

PAGE NO. 5 OF 5
ATTACHMENT A
SHAWNEE CORRECTIONAL CENTER, IL0870010 VIOLATION NOTICE NO. W-2023-00019:
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 "Notification of Ownership
and Responsible Operational Personnel" form.
Violation
Date
08/17/2022

Violation
Descript:j.on
Operations of a Class D Water system without a properly
certified drinking water operator.
An operator with a valid
Class D Certification or higher is required.

Rule/Reg

Section 18(a) of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.l0l(a), 603.l0l(d), 603.103(a) 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
08/17/2022

Rule/Reg

Violation
Description
Lack of "Notification of Responsible Operational Person n el" f orm
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).

lllinoi'

11tuvh:01i,11e o ta l P(otcc:ti.<l1\ l\gc. 11.<;y
Notification of Responsible Operational Personnel
Please use this form to make community water supply CCWS) contact changes.

Number:

CWS Name:

IL
---------

REASON FOR CHANGE (check all aoolicable 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 only

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 private corporation, or regularly organized body, identify the entity exercising direct supervision over the
CWS in accordance with 35111. 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 (OC) box.

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

Business Address

_____
__ _____

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

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

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

( Siqnalure 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 municipality, member of the board, or an officer of the organization that runs the supply (mayor, president,
chairman. etc. l.

Name:
Title
Cell#
Home#
E-Mail:

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

Signature:_______________________

Business Address

Date:____________

( Sianature of Official Custodian!

AOMINISTRATIVE 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 Notice, Notice of Intent to Pursue
Leaal Action. and notices of reaulatorv reauirements and oermittina transactions.

Name: (print)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Title:
Cell#: (_ _)_ _ _ _ __ Work#: (
l
Home#: (_ _ )_ _ _ _ __
Fax#:<~--~)_ _ _ _ __
E-Mail:
Signature:______________________

Business Address

Date:____________

(Signature of AC)

Signature of the Owner or Official Custodian is required 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)

tl 532-0987/0164 (revised 01-14)

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

tlUnol,

Et\YiXOt\lll©Utni Jlrote;c(,ton J-\gfllf'l'
RESPONSIBLE OPERATOR IN CHARGE (ROINC}

Identify the certified operator(s) designated pursuant to 35111. 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 nP.rson.
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 wlth PWS effective
I Current ROINC on file is still worl<.ina with PWS but will no lonMr servina as ROINC .

{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
Cell#: ( _ )
Work#: (
)
Home#: ( _ )
Fax#: (
)
E-Mail:
Signature:
Date:
~ Sionature of RO/NC 1J

N_
E WROINC2 Please Check One:
Name: (print)
Circle Certificate Class: A B C
)
Cell#: (
)
Home#: (
E-Mail:
Signature:

__
__

Full Time Employee 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 of the public water supply facilities by the operator(s) listed above as
being in responsible charge.

Signature:

Date:
(Sianature of Owner/Official Custodian or Admini strative 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:-,----,,----- -- - - - - - - - - - - ~ - (Samp/e Collector's Signature)

Bottle Malling Address
No ~O~x 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 des'gnated as being in responsible charge pursuant to 35111. Adm.
Code 603.101(d). Please be advised that ii 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 Tille 35: Environmental Protection, SubUtle F: Pubric Water Supplies. Chapter I: Pollution Controt Board, Part
603, Sections 603.101, 603.102, and 603.103.

Be sure to retain copies of this document for your files. Shoold you need additional forms. please call (217)785-0561 or download at
httg·/lwww~epa.state.il.us/water/operator•cert/drinkinq-water/forms{notlfic.ation-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}. Di sd osure 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 felo.ny. A second or subsequent offense after conviction is a Class 3 felOny. (415
ILCS 5/44(h))
1L 532·098710164 (revised Ol-14)

I

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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 daily water treatment and distributmn operations. A
CWS must select only one designated ROl NC for treatment and one designated ROINC for distrlbution. The treatment ROINC and distribution
ROINC mav be the same oerson.
Current ROINC on File:
Please check box that best describes status of c urrent R OINC on File
I Current ROINC on file wm no lonQer be emt,loved or under contract with PWS effective
I Current ROINC on file Is still working with PWS but wiN no lonaer servinn as ROiNC.

NEWROINC 1 Please Check One:
Name:
(print)_
Circle Certificate Class :

A
B
Circle One: Treatmet1t & Distrfbut;on

Full Time Emplovee or

Home#:
E-Mail:

Contract Ooerator (include coav of contract)

'

Business Address
C

D
Treatment On ly

__

(_
(

Cell#:

(print name)

)
)

Work# : (
Fax#: (

Distribution Only

_

)
)

Signature:

Date:
I Slllnature of RO/NC 1)

NEWROINC 2 Please Check One:
(print)
Name:

__

Circle Certificate Class :

(

Cell#:
Home#:

A

8

C

Full Time Emolovee or

Contract Operator (include coDv of contract)
Business Address

D

Circle One:

)

Work#: (

(~ _)

Fax#: (

Distribution Only

)
)

E -Mail:
_ign atur~:

Date:
(Signature of RO/NC 2)

Signature of Owner1 Official Custodian1 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 of the public water supply facilities by the operator(s) listed above as
b~ing m 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-Marl :

__
__)

(
(

)

Signature:_
(Sample Co/lee/or's Signature)

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

Bottle Mailing Address
No P.O.Box Numbers Allowed

) _ _ _ _ __

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

Completion of this form shall indicate acceptance of the duties and respons ibilities for the proper operation and maintenance of the pubhc 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 offce within 15 days of any changes in responsible personnel. Completion and submittal or this form wi I 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
bJJ2:llwww eba.Slate.il.us/water/oper!ltor -cert/drinkmg-walerlforms/no@ca lion-of-OWQtrship.pdf. Return this completed form to;
Illinois Environmental Protection Agency, Bureau of Water #19, 1021 North Grand Ave East, P.O. Box 19276, Sp ringfield, ll 62794-9276
This Agency ,s authorized to require this ·ntormation under 415 ILCS 5/4(b)(2012). Disclosure of this information is required. Failure to do
so may result in a civil penalty up lo $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 offen se after conviction 1s a Class 3 felony. {415
ILCS 5J44(h))
IL 532-0987/0164 (revised 0 1-14\