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 # 7011 1150 000 I 0857 1811
RETURN RECEIPT REQUESTED
Robinson Correctional Center
c/o Rachel Dodd
13423 E. 1150 W Ave
Robinson, IL 62454
Re:

Violation Notice: ROBINSON CORRECTIONAL CENTER
Facility No.: IL0330010
Violation Notice No.: W-2023-00007

· Dear Ms. Dodd:
This constitutes a Violation Notice pursuant to Section 3 l(a)(l) of the Illinois Environmental
Protection Act ("Act"), 415 ILCS 5/31 (a)( I), 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 ofreceipt 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 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, Collinsville, ll 62234 (618) 346-5120
9511 Harrison Street, Des Plaines, ll 60016 (8471294-4000
595 S. State Street, Elgin, IL 60123 (8471608-3131

2309 W. Main Street, Suite 116, Marion, IL 62959 (618) 993-7200
412 SW Washington Street, Suite 0, Peoria, ll 61602 (3091671-3022
4302 N. Main Street, Rockford, IL 61103 (8151987-7760

PLEASE PRINT ON RECYCLED PAPER

Page 2 of2
IL0330010 ROBINSON CORRECTIONAL CENTER
VN W-2023-00007
The Illinois EPA will review the proposed tenns 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 lllinois EPA sends a proposed CCA, the facility must respond in writing by
either agreeing to and signing the proposed CCA or by notifying the lllinois 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-2023-00007.
Questions regarding this Violation Notice should be directed to Tatum DeMay at 217/785-0561.
Sincerely,

;);~
Joey Logan-Pugh
Manager, Compliance Assurance Section
Division of Public Water Supplies
Bureau of Water
Attachments
cc: Michael Woodward
Jared Brunk
Rodney Thacker

BOW ID: W0338080001

PAGE NO. 1 OF 5
ATTACHMENT A
ROBINSON CORRECTIONAL CENTER, IL0330010 VIOLATION NOTICE NO. W-2023-00007:

Questions regarding the violations identified in this attachment shoul d b e
referred to Tatum DeMay at (217) 785-0561.
A review of information available to the Illinois EPA indicates the following

violations of statutes, r e gulations, or permits. Included with each type of
violation is an explanatio n of the activities that the Illinois EPA believes
may resolve the violation i ncluding an estimated time period for resolution .

Drinking Water Construction Permit
Public Water Supplies (PWSs) are required to obtain a construction permi t
from Illinois EPA for all construction.
To meet compliance, the supply i s
expected to submit as-built plans and specifications pursuant to 35 I ll .
Adm. Code 602.116 within 120 days for approval by Illinois EPA .
Violation
Date
8/11/2022

Rule/Reg.

Violation
Description
Failure to obtain a construction permit for the installation of
multiple water softeners 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 602.101 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 each month.
Compliance with this is expected within 30 days by submission of the required
reports.
Violation
Date
8/11/2022

Rule/Reg.

Violation
Description
(on-going
submit
monthly
operating
reports .
Failure
to
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 5
ATTACHMENT A
ROBINSON CORRECTIONAL CENTER, IL0330010 VIOLATION NOTICE NO. W-2023-00007:
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
8/11/2022

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.l0l(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
8/11/2022

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.lS0S(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
8/11/2022

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.l0l(a) and 604.1510(a).

PAGE NO. 3 OF 5
ATTACHMENT A
ROBINSON CORRECTIONAL CENTER, IL0330010 VIOLATION NOTICE NO. W-2023-00007:
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
8/11/2022

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
8/11/2022

Rule/Reg.

8/11/2022

Rule/Reg.

8/11/2022
Rule/Reg.

Violation
Description
The overflow for the elevated storage tank must open downward
and be screened with a 4 mesh non-corrodible screen or
mechanical device. When a flapper or duckbill valve is used, a
screen must be provided inside the pipe. (on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.101 (a) and 604 . 1305 (e) .

Lack of automatic control equipment to prevent pressure on the
suction side of the pump station from dropping below 20 psi
measured at ground surface. (on-going violation)
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
601.l0l(a) and 604.1215(c).
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.lOl(a) and 604 . 1425(c) .

PAGE NO. 4 OF 5
ATTACHMENT A
ROBINSON CORRECTIONAL CENTER, IL0330010 VIOLATION NOTICE NO. W-2023-00007:
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 opera tor.
Compliance with this is expected within 15 days by
obtaining a
certified operator and submitting the appropriate form
(enclosed) .
Violation
Date
8/11/2022

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. 101 (a), 603 .101 (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
8/11/2022

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).

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
8/11/2022

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)

PAGE NO. 5 OF 5
ATTACHMENT A
ROBINSON CORRECTIONAL CENTER, IL0330010 VIOLATION NOTICE NO. W-2023-00007:

Ru le/Reg.

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

8/11/2022

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 I l l Adm. Code
611.356(a}.

Rule/Reg.

8/11/2022
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 violation)
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 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 resu l ts for each monitoring program in accordance
with your supply's sample site plans.
Violation
Date
8/11/2022
Rule/Reg.

Violation
Description
Failure to collect samp l es and submit coliform sample results.
Sections 18 and 19 o f the Ac t, 4 15 ILCS 5/18 and 5/19, and 35
Ill. Adm. Code 611.1053 (a} (2) and ( 3 ).

8/11/2022

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.

8/11/2022
Rule/Reg.

8/11/2022
Rule/Reg.

Failure to collect samp l es and submit lead and copper sample
results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and 5/ 1 9, and 35
Ill. Adm. Code 611.350(h) and 611.356(c).
Failure to collect samp l es and submit disinfectants and
disinfection by-products (DBPs) s amp l e results.
Sections 18 and 19 o f the Act, 415 ILCS 5/18 and 5/ 1 9, and 35
Ill. Adm. Code 611.971(a).

lUlq{i i~

iji1viro11n1entijl Protc-('tt(l~l Agr,nc 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 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 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 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 # 1 and Address (no signature required) and then complete
OFFICIAL CUSTODIAN (QC) 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 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.).
Name:
Title
Cell#
Home#
E-Mail:

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

Signature:______________________

Business Address

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

( Sianature 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 reaulatorv reauirements and oermittina transactions.

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

Business Address

Date:____________

(Signature of AC)

Signature ofthe Owner or Official Custodian is required before Illinois EPA will add or change an AC contact:
I hereby duly authorize._ _ _ _ _ _ _ _ _ _ _ _ _ _ __ __ _ __ _{prinl) 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 532-096710164 (revised 01-1 4)

Date:_ _ __ _ _ _ _ _ __

llllnol,

tit\Yi.t;o111i1et,\tnl t}rotcc~t101\ 4"\Sf PCM
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 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 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 lonoer servina 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 Employee or

(print name)"

Contract Operator (Include co,w of contract)
Business Address

D
Treatment Only
Work#: (
Fax#: (

Distribution Only

)
)
Date:

{Sionature of RO/NC 11

NEWROINC 2 Please Check One:
Name: (print)

__

Circle Certificate Class:
)
Cell#: (
Home#:
E-Mail:
Signature:

(_

A

B

)

C

Full Time Emolovee or

Contract Operator (Include coov of contract)
Business Address

D

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

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:
f 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)

Bottle Mailing Address

No P.O.Box Numbers Allo w e d

( _ _ )_ _ _ _ _ _ Work#:'- - -~ >- - - - - ( _ _)
Fax#: . __ _)._ _ _ _ __

Signature:_ __ _____ _ _ _~ - - - - - - - - - - - (Sample Collector's Signature)

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 responsibte charge pursuant to 35 IIL Adm.
Code 603.101(d). Please be advised that it is the responsibi!ity of the owner. official custodian and the certified operator(s) 1n responsible charge to
notiry this office within 15 days of any changes in responsible personnel. Completion and submittal of thls form will satisfy the notification of
responsible personnel requirements of Title 35: Environmental Protection, Subtitle F: Pubr c 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 addltional forms, please call (217}785-0561 or download at
!ltlp;ltwv.w.epa.state.il.us/water/o.perator-cert/drinking-water/forms/notification-o[:ownershio.Qdf. 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 tLCS 5/4tb}(2012). o ·sclosure 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 fe'ony. A second or subsequent offense after conviction is a Class 3 felony. (415
ILCS 5/44(h))
IL 532-0987/0164 (revised 01 -14)

lHln

t~n

ti

·iJ <H1 rn<

1 , .. ,1

,~rot =>1t fi •n
1

RESPONSIBLE OPERATOR IN CHARGE {ROINC) Identify the certified operalor(s) designated pursuant to 35 Ill. Adm.
Code 603.103 in responsible charge of lhe CWS operations. The ROINC runs and oversees dally water trealment and dislribution operations. A
CWS must select only one designated ROINC for treatment and one designated ROINC for distribution. The treatment ROINC and distrlbulion
ROINC mav be the same oerson.
Current ROINC on File:
Please check box that best describes status of current RO/NC on File
J Current ROINC on file will no lonQer be emoioved or under contract with PWS effective
l Current ROINC on file is still working with PWS but will no lonoer serving as ROINC.

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

__
__

Full Time Emclovee or

(prmt name)

Contract Operator (include coov of contractJ
Business Address

D
Treatment Only

Work#: (
Fax#: (

Distribution Only

)
)

Date:

CSionature of RO/NC 1J

NEW ROINC 2 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 Ooerator {include coav of contract)
Business Address

Distribution Only

Date:

(Signature of RO/NC 2)

Signature of Owner1 Official Custodlan 1 or Administrative Contact is reguired before Illinois EPA will add or
change a ROINC contact{s}.

~

As Owner/Official Custodian or Administrative Conlact, 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:
(Siona/ure of Owner/Official Custodian or Administrative Contact)

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

Bottle Mailing Address
Name:
Cell#:
Home#:
E-Mail:

. , - - - - - - - - - - -- - -- - - - - - - ( p r i n t )
(_ _)_ __ _ _ _ Work#:( _ _ _ )_ _ _ _ __
(_ _)
Fax#:
)_ _ _ _ __

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

No P.O.Box Numbers Allowed

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

(Sample Collector's Signature)

Complelion 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 advlsed that it is the responsibility of the owner, official custodian and the certified operator(s) in responsible charge lo
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. Secti ons 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~llwww,epa,cStale.ilu~wal~r/gp1!fator-qfl/drinking-·« aterlforms/notificatii911-of-gwnershio.oof. 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 required. Failure to do
:.o 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 lllino;s EPA commits a Class 4 felony. A second or subsequent offense after convicUon is a Class 3 felony. (415
ILCS 5/44(h))
IL 532-0987 f0164 (revised 01 -14)