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

JOHN J. KIM, DIRECTOR

217/785-0561
February 6, 2023
CERTIFIED MAIL# 7021 2720 0000 2345 0878
RETURN RECEIPT REQUESTED
Pontiac Correctional Center
c/o Mindi Nurse
700 West Lincoln St.
Pontiac, IL 61764

Re:

Violation Notice: PONTIAC CORRECTIONAL CENTER
Facility No.: IL1055500
Violation Notice No.: W-2023-00008

Dear Mindi Nurse:
This constitutes a Violation Notice pursuant to Section 31 (a)(]) 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 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
(4'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. First Street, Champaign, IL 61820 (217) 278-5800
1101 Eastport Plaza Dr., Suite 100, Colhnsv1lle, ll 62234 (618) 346-5120
9S11 Harrison Street, Des Plaines, IL 60016 (847) 294 4000
S95 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, IL 61602 (309) 671-3022
4302 N. Main Street, Rockford, IL 61103 (815) 987-7760

PLEASE PRINT ON RECYCLED PAPER

Page 2 of2
IL 1055500 PONTIAC CORRECTIONAL CENTER
VN W-2023-00008
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: Adam J. Nutt, CAS #19
P.0. BOX 19276
Springfield, IL 62794-9276

All communications must include reference to this Violation Notice number, W-2023-00008.
Questions regarding this Violation Notice should be directed to Adam J. Nutt at 217/785-0561.
Sincerely,

vbg.~~

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

Attachments
cc:

Richard B. Gramley
Jared Brunk
Rodney Thacker

BOW ID: Wl050600002

PAGE NO. 1 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, IL1055500 VIOLATION NOTICE NO. W-2023-00008:

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.

Water Trea tment Plant/Distribution Sy stem Maintenance
There are structure/maintenance problems that threaten the quality of the
drinking water provided to customers.
Violation
Date
08/09/2022

Violation
Description
Failure to Remove all chemical storage for the retired sodium
silicate / sodium hypochlorite system and ensure that the
remaining injection port is adequately sealed to ensure the
sanitary integrity of the finished water line.

Rule/Reg.

Section 18 of the Act, 415 ILCS 5/18,
601.lOl(a) and 604.135(a).

Violation
Date
8/09/2022

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,
601.101 (a) and 604 .1425 (c).

Violation
Date
08/09/2022

Violation
Description
Inadequate booster pump capacity. Each booster pumping station
must contain no fewer than two pumps with capacities such that
maximum demand can be satisfied with the largest pump out of
service.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.lOl(a) and 604.1215(a).

Rule/Reg.

and 35 Ill.

and 35 Ill.

Adm.

Adm.

Code

Code

PAGE NO. 2 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, IL1055500 VIOLATION NOTICE NO. W-2023-00008:
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
08/09/2022

Violation
Description
Failure t o 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 within 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.

Rule/Reg.

Section 18(a) and 19 of the Act, 415 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 601.101 (a) and 604 .165 (a), (c), and (d) .

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 i n
Bare exceeded.
d.
Be maintained on site and made available to the Agency upon request.

Violation
Date
08/09/2022

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

Rule/Reg.

Sec tion 18 of the Act,
60 1 .l0l(a) and 604.140.

415 ILCS 5/18,

and 35 Ill. Adm.

Code

PAGE NO. 3 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, IL1055500 VIOLATION NOTICE NO. W-2023-00008:
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
08/09/2022

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
08/09/2022

Violation
Description
Failure to maintain records of all backflow preventers
require annual testing.

Rule/Reg.

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

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
08/09/2022

Violation
Description
Failure to perform annual testing of all backflow prevention
devices in the system.
(on-going violation)

Rule/Reg.

Section 18 of the Act, 415 ILCS 5/ 18 ,
601.101 (a) and 604 .1510 (a).

and 35 Ill. Adm.

Code

PAGE NO. 4 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, IL1055500 VIOLATION NOTICE NO. W-2023-00008:
Emergency Operation Plan
Each community water supply must develop an EOP for the provision of water
during emergency circumstances including earthquakes, floods, tornados, and
other disasters. The EOP must include a review of methods and means by which
alternative supplies of drinking water could be provided in the event of
destruction, impairment, or contamination of the community water supply. The
community water supply must review its emergency operations plan at least
every three years and revise the plan as necessary. The plan must be
maintained on site and made available to the Agency, upon request .
Violation
Date
08/09/2022

Violation
Description
At the time of inspection, there was no Emergency Operations
Plan (EOP) available for review.

Rule/Reg.

Section 18 of the Act,
604 .135 (d) .

415 ILCS 5/18,

and 35 Ill. Adm.

Code

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 days by submitting the required written
sample site plans to the Illinois EPA.
Violation
Date
8/09/2022

Rule/Reg .

8/09/2022

Rule/Reg.

8/09/2022
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
plan for lead and copper that identifies sampling sites
representative of water throughout the distribution system. (ongoing 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).

PAGE NO. 5 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, IL1055500 VIOLATION NOTICE NO. W-2023-00008:
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 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
8/09/2022
Rule/Reg.

Violation
Descripti on
Fai lure to col lect samples and submit coliform sample results .
Se ctions 18 a nd 19 of the Act, 4 15 ILCS 5/18 and 5/19 , and 35
Ill. Adm . Code 611.1053 (a) (2) and (3) .

8/09/2022

Fa ilure to collect samples and . s ubmit disinfectant residual
sample res ults.
Sec tions 1 8 and 19 of the Act, 415 ILCS 5/18 and 5/19 , and 35
Ill . Adm . Code 611.382( a ) and (c).

Rule/Reg.

8/09/2022
Rule/Reg.

8/09/2022
Rule/Reg.

Failure t o collect samp les and s ubmit lead and copper sample
results.
Sections 18 and 19 of the Act, 41 5 I LCS 5/18 and 5/19 , and 35
Ill. Adm. Code 611. 350(h) and 611. 356(c) .
Failure to collect s amples and subm i t disinfectants
and disinfection by-products (DBPs) sample results .
Sections 18 and 19 o f the Ac t, 41 5 ILCS 5/18 and 5/19 , and 35
Ill. Adm. Code 611. 97 1 (a) .

Notification of Ownership or Responsible Operational Personnel
Every community public water supply (PWS) is requ ired to submit a statement
of ownership to the Illinois EPA identifying a n 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
08/09/2022

Ru l e /Reg

Violation
Description
Lack of "Notification of Responsible Operational Personneln 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. 6 OF 6
ATTACHMENT A
PONTIAC CORRECTIONAL CENTER, ILl0SSSO0 VIOLATION NOTICE NO. W-2023-00008 :
Responsible/Certified Operator
Every community public water supply (PWS) is r e quired to employ on its
operational staff at least one person certified as competent as a water
supply operator.
Compliance with this is expe cted within 15 days by
obtaining a certified operator and submitting the "Notifi cation of Ownership
and Responsible Operational Personnel" form.
Violation
Date
08/09/2022

Violation
Description
Op erations of a Class B Water system without a properly
ce rtified drinking water operator. ' An operator with a valid
Class B Certification or higher is requ~red.

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) •

tlHnui\

~nvir91\n1e nt9 1- 1>1·ot<"cti<>~l Agency
Notification of Responsible Operational Personnel
Please use this form to make community water supply tCWS) contact changes.

CWS Name:

Number:

.:.: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 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 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, 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#: (
)_ _ _ _ _ __

__
_______
__ _____

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

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

( Sicmature of lndividua/J

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 Address

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

Signature:, _______________________

Date:. ____________

(Sionature of Official Custodian)

ADMINISTRATIVE CONTACT (AC) An owner or official custodian may designate an administrative contact lo 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 reoulatorv reouirements and oermiltino transactions.
Name: (print)._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Title:
Cell#: (_ _),_ _ _ __
Work#:(, _ __,)_____ __
Fax#: (_ __,l,_ _ _ _ __
Home#: (_ _)._ _ _ _ __
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)
IL 532-0987/0164 (revised 01-14)

Date:_ _ __ __ _ _ _ _ __

tttlnol~

En,viro~\1l1COW.t rtotcrticn1 f\gr-ncy
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 nerson.

'
Current ROINC on FIie:
Please check box that best describes status of current RO/NC on File
I Current ROINC on file will no lonMr be emoloved or under contract with PWS effective
I Current ROINC on file is still workina with PW$ but will no lonner servinQ as ROINC.

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

Full Time Emp loyee or

(print name)'

I

Contract Operator (Include coov of contractJ
Business Address

D
Treatment Only
Work#: (

(_)

Fax#: (

Distribution Only

)
)
Date:

( Sionature of RO/NC 1J

NEWROINC2 Please Check One:
Name: (print)
Circle Certificate Class: A B C
Cell#: ( _ )
Home#: ( _ )

Full Time Employee or
D

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

Contract Operator {Include CORY of contract>
Buslness Address
Distribution Only

E-Mail:
Signature:

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:
(Sionature of Owner/Official Custodian or Administrative ContactJ

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: _ _ _ _ _ _ _ _~ --

Completion of this form shall indicate acceptance of the duties and responsibilllies 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 \II. 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 Title 35: Environmental Protection. Subtitle F: Pub'ic Water Supplies, Chapter I: Pollution Control Board. Part
603, Sections 603.101, 603.102, and 603.103.
Be sure lo retain copies of this document for your files. Should you need additional forms, please call (217)785-0561 or download al
http://www.eoa.stateJ LuslwaterLopera~or•cert/dfinking•water/forms/notificalion-of-ownership.pdf. Return this completed form to:
Illinois Environmental Protection Agency, Bureau of Waler #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 5144(h))
IL 532,0987/0164 (revised 01-14)

11'l,

•t·

r n -;y < ► n nH 1-n t;lf

flrrtt< cli<)n

1

~e nc ,

RESPONSIBLE OPERATOR IN CHARGE {ROINC} Identify lhe certified operator(s) designated pursuant to 35111. 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
ROINC mav be the same oerson.
Current ROlNC on File:
Please cheek box that best describes status of current RO/NC on File
I Curren! ROINC on file will no lancer be emoloved or under contract with PWS effective
I Current ROINC on file is still workino with PWS but will no lancer Servino as ROINC.

NEWROINC 1 Please Check One:
Name: (print}
Circle Certificate Class: A B C
Circle One Treatment & Distribution
}
Cell#: (
)
Home#: (
E-Ma il:
Signature:

__
__

Full Time Emolovee or

(print name)

Contract Ooerator (Include coav of contract,
Business Address

D
Treatment Only

Work#: (
Fax#: (

D1str1bution Only

_

)
}
Date:

( Sionature of RO/NC 1J

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

__

Full Time Employee or

D

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

Contract o~rator {include conv of contractJ
Business Address

Distribution Only

Date:

(Signature of RO/NC 2)

Signature of Owner1 Official Custodlan 1 or Administrative Contact is reguired lbefore 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.

Sjgo.atu.re:

---

Date:
fSiQnature of Owner/Official Custodian or Administrative ContactJ

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.0.Box Numbers Allowed

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

(Sample Co//ector·s Signature)

Complelion of this form shall indicate acceptance or the duties and respons bilities for the proper operation and maintenance of the public water
supply facilities by both the owner or official custodian and the certilied 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 custodran and the certified operator(s) in responsible charge to
notify th,s office with"n 15 days of any changes in responsible personnel. Complefon and submittal of this form will satisfy the notilication of
responsible personnel requirements of Title 35: Environmental Protection. Subtitle F: Public Water Supplies. Chapter I: Pollution Control Board, Part
603, Seel ans 603.101, 603.102, and 603.103.
Be sure to retain copies of this document for your files. Should you need additional farms please call (217)785-0561 or download at
hUp:llwww.epa.state il,~lerloperalor-t e,Wrinking-wateyffarmslnQ!!li&;alion-of-ownership p(lf. 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 author"zed 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 lo $1,000.00. Any person who knowingly makes a false fictitious. or fraudulent material statement.
orally or 1n writing. to the lninois EPA commits a Class 4 fe·ony. A second or subsequent offense after conviction is a Class 3 felony. (415
ILCS 5/44(hJ)
IL 532.0V87/0164 (revised 01-141

I