ILLINOIS ENVIRONMENTAL PROTECTION AGENCY
1021 NORTH GRANO AVENUE EAST, P.O. Box 19276, SPRINGFIELD, ILllNOIS 62794-9276 · (217} 782-3397
JB PRITIKER, GOVERNOR

JOHN J. KIM, DIRECTOR

217/785-0561
February 27, 2023
CERTIFIED MAIL# 7011 1150 0001 0857 1842
RETURN RECEIPT REQUESTED
Western IL Correctional Center
c/o Brittany Greene
2500 IL-99
Mt. Sterling, IL 62353

Re:

Violation Notice: WESTERN IL CORRECTIONAL CENTER
Facility No.: IL0090010
Violation Notice No.: W-2023-00018

Dear Ms. Greene:
This constitutes a Violation Notice pursuant to Section 31 (a)(l) of the Illinois 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 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, IL61820 (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 (84 7) 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 (8151987-7760

PLEASE PRINT ON RECYCLED PAPER

Page 2 of 2
IL0090010 WESTERN IL CORRECTIONAL CENTER
VN W,-2023-00018
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: TATUM DEMAY, CAS #19
P.O. BOX 19276
Springfield, IL 62794-9276

All communications must include reference to this Violation Notice number, W-2023-00018.
Questions regarding this Violation Notice should be directed to Tatum DeMay at 217/785-0561 .
Sincerely,

{:1:l;f~~
Manager, Compliance Assurance Section
Division of Public Water Supplies
Bureau of Water
Attachments
cc: James Robinson
Jared Brunk
Rodney Thacker
BOW ID: W 1178990003

PAGE NO. 1 OF 6
ATTACHMENT A
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:

Questions regarding the violations identified in this attachment should be
referred to Tatum DeMay 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
10/19/2022

Rule/Reg.

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

Drinking Water Monthly Operating Reports
All public water supplies are required to submit reports summarizing dai l y
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
10/19/2022

Rule/Reg.

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

(on-going
Adm. Code.

PAGE NO. 2 OF 6
ATTACHMENT A
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:
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
10/19/2022

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
10/19/2022

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.lOl(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
10/19/2022

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
601.101 (a) and 604 .1510 (a) .

PAGE NO. 3 OF 6
ATTACHMENT A
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:
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
10/19/2022

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.l0l(a) 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
10/19/2022

Rule/Reg.

Violation
Description
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).

water Treatment Plant Laboratory
The laboratory equipment or field testing equipment is inadequate.
Compliance with this is expected within 30 days by obtaining or repairing
equipment.
Violation
Date
10/19/2022

Rule/Reg.

Violation
Description
Lack of proper test equipment for measuring chlorine residuals
in the distribution system. DPD test equipment or other means
approved in "Standard Methods for the Examination of Water and
Wastewater" must be used.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
604.130(c).

PAGE NO. 4 OF 6

ATTACHMENT A
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:

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
10/19/2022

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.lOl(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
10/19/2022

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
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:
Drinking Water Monitoring Site Plan Requirements
All public water supplies (PWSs) must achieve and maintain compliance with
the monitoring and reporting requirements of the Environmenta l Protec tion
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 days by submitting the required written
sample site plans to the Illinois EPA.
Violation
Date
10/19/2022

Rule/Reg.

10/19/2022

Rule/Reg.

10/19/2022
Rule/Reg.

Violation
Description
Failure to submit, for Agency approval, a written sample s i ting
plan for coliform that identifies sampling sites representat i ve
of
water
throughout
the
distribution
system.
(on-goi ng
violation)
Sections 18 of the Act, 415 ILCS 5/ 18, and 35 Il l . Adm. Code
611.1053 (a) (1).

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 I l l Adm. Code
611.356 (a).
Failure to submit, for Agency approval, a written sample s i ting
plan for disinfection by-product samples. (on-going v i olation)
Sections 18 of the Act, 415 ILCS 5/18, and 35 Ill Adm. Code
611.972(a) .

PAGE NO. 6 OF 6
ATTACHMENT A
WESTERN IL CORRECTIONAL CENTER, IL0090010 VIOLATION NOTICE NO. W-202300018:
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
10/19/2022
Rule/Reg.

Violation
Description
Failure to collect samples and submit coliform sampl e 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).

10/19/2022

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.

10/19/2022
Rule/Reg.

10/19/2022
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).

tUtrtUi'-

Bl\¥it:()llt}lent&l J>r<.ltOctioQ Agency
Notification of Responsible Operational Personnel
Please use this form to make community water supply (CWS) 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
Charge 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 lhe 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 35 Ill. Adm. Code 603.101 (e.g., Municipality, Water District, Waler 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#: (.__ __,)________

(
(

__
__ ____
______

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

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

(Sianature of fndividuafJ

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:
Tille
Cell#
Home#
E-Mail:

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

S1gnature:___________- , - - , - - - - - - - - - - - - -

Business Address

Date:_ __ _ _ _ _ _ _ __

' Sianature 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 !he 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
L~al Action, and notices of reaulatorv reauirements and oermlllina transactions.

Name: (print)_ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ __
Title:
Cell#: (_ _)_ _ _ _ _ _ Work#:( _ _ _)_ _ _ _ __
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)

ll 532·0987/0164 (revised 01-14)

Date:_ _ __ _ _ _ _ _ __

llHn.q l~

E11.virQt1tnenta I Protortio1\ .,\~t?Df)'
RESPONSIBLE OPERATOR IN CHARGE {ROINC}

Identify the certified operator(s) designated pursuant to 35 Ill. Ad"1.
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 ROlNC for distribution. The treatment ROINC and distribution
ROINC mav be the same person.
Current ROINC on FIie:
Please check box that best describes status of current ROINC on File
l Current ROINC on file will no lonaer be emoloved or under contract with PWS effective
I Current ROINC on file is still working with PWS but will no longer serving as ROINC.

NEW ROINC 1 Please Check One:
Name: (print)
Circte Certificate Class: A B C
Circle One: Treatment & Distribution
Cell#: ( _ )
)
Home#: (
E-Mail:
Signature:

Full Time Employee or

Work#: (
Fax#: (

--

C

Distribution Only
}

)
Date:

l Sianature of RO/NC 1 )
NEWROINC2 Please Check One:

B

Contract Operator (Include CODY of contractJ
Business Address

D
Treatment Only

__

Name: (print)
Circle Certificate Class: A
Cell#: ( _ )
Home#: ( _ )
E-Mail:
Signature:

(print name)

Full Time Employee or
D

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

Contract Operator (Include coov of contract}
Business Address

Distribution Only

Date:.

(Signature of ROINC 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 Administrative Contactl

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

Bottle Mailing Address
No P.O.Box Number~ 8 llowed

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

Date:

Completion of this form shall indicate acceptance of the duties and responsibilities for the proper operation and maintenance of the publi c 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 responsibitity 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, Subtitle F: Public Water Supplies. Chapter I: Po'lution Control Board. Part
603. Sections 603.101, 603.102. and 603.103.
Be sure to retain copies of this document for your files. Shou d you need additional forms , please call (217)785•0561 or download at
http~llwww eoa,stait1.il.us/water/operator-cert/drinkin9:water/forms/n0Ufication:9f:9wnership 1odf. Return this completed form to:

Illinois Environmental Protection Agency, Bureau of Water #19, 1021 North Grand Ave East, P.0. Box 19276, Springfield, IL 62794•9276
This Agency is authorized to require this information under 415 ILCS 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 01-141

l Uit1n t~

r~n 'iJ OUP lf J trll ,"),. oh: , tion
RESPONSIBLE OPERATOR IN CHARGE (ROINC} Identify lhe certified operator{s) designated pursuant lo 35 1n. Adm,
Code 603.103·in responsible charge of the CWS o·peralions. 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 Flle:
Please check box that best describes status of current RO/NC on File
I Current ROINC on file will no lona:er be emoloved or under contract with PWS effective
I Current ROINC on file is still working with PWS but wilt no lonoer servino as ROINC.

NEW ROINC 1 Please Check One:
Name: (print)

Full Time Emolovee or

Contract Ooerator (include coov of contract}
Business Address

Circle Certificate Class: A
B
C
Circle One: Treatment & Distribution
Cell#:
Home#:
E-Mail:

(print name)·

__

(
)
(_)

D
Treatment Only
Work#: (
Fax#: (

Dtstrtbution Only

)
)

Sign~tur~:

Date:
l Siana/ure of RO/NC 1'

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

__

C

Full Time Emolovee or

Contract Ooerator (include CODY of contract}
Buslness Address

D

Circle One
Work#: (
)
Fax#: (

Distribution Only

- --

)

-Date:

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 respons1biht1es for the proper opera! on and maintenance of the public water supply facilities by the operator(s) listed above as
being in responsible charge .
Sjgnature:
Date:
(Sia.nature of Owner/ Official Custodian or Administrative Contacli

l

-

Sample Collector/Bottle Recipient Identify the person employed by the cws that will collect samples and complete the

paperwork associated with sampling.
Bottle Mailing Address
Name:
Cell#:
Home#:
E-Mail:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (print)
{ _ _ )_ _ __ _ _
( _ _ )_ _ _

No P.O.Box Numbers Allowed

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

Signature:_ _ _ _ _----:----=----------------(Samp/e Collector's Signature)

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

'-----~--CompIeIIon of this form shall indicate acceptance of the duties and responsibilities for the proper operation and maintenance of the pubhc water
supply facilities by both the owner or olfic,al custodian and the certified operators des·gnated 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 custod an and the certified operator(s) in responsible cha rge 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 Protecron, Subtitle F: Public Water Supplies, Chapter I: Pollution Control Board. Part
60J, 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,epa.sta!e.iLuslwater(:ope1ator-ceft(drinking-water/form_s/n-0lificaUon -of-own~rship 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 information is requi red. Failure to do
so may result in a cwil penalty up to $1 ,000 00. Any person who knowmgly makes a false. fictitious, or fraudulent material statement.
orally or m writing , to the Illinois EPA commits a Class 4 fe ony. A second or subsequent offense after conviction is a Class 3 felony. (415
ILCS 5/44(h))
IL 532·098 710164 (rell"Sed 0 1- 14)