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 21, 2023
CERTIFIED MAIL #7011 1150 0001 0857 1378
RETURN RECEIPT REQUESTED
Taylorville Correctional Center
Melinda Eddy, Warden
1144 IL-29
Taylorville, IL 62568

Re:

Violation Notice: TAYLORVILLE CORRECTIONAL CENTER
Facility No.: IL0210010
Violation Notice No.: W-2023-00012

Dear Ms. Eddy:
This constitutes a Violation Notice pursuant to Section 31 (a)( 1) 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 of receipt of this letter.
If a meeting is requested, it shall be held within 60 days ofreceipt of this notice. The response must
include information in rebuttal, explanation, or justification of each alleged violation and a statement
indicating whether or not the facility wishes to enter into a Compliance Commitment Agreement
("CCA") pursuant to Section 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-S120
9511 Harrison Street, Des Plaines, IL 60016 {8471294-4000
595 S. State Street, Elgin, IL 601231847) 608-3131

2309 W. Main Street, Suite 116, Marion, IL 62959I618) 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 PAINT ON RECYCLED PAPER

Page 2 of2
IL0210010 TAYLORVILLE CORRECTIONAL CENTER
VN W-2023-00012
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: Mandy Trader, CAS #19
P.0. BOX 19276
Springfield, IL 62794-9276

All communications must include reference to this Violation Notice number, W-2023-00012.
Questions regarding this Violation Notice should be directed to Mandy Trader at 217/785-056 I.
Sincerely,

Or~~

Joey Logan-Pugh
Manager, Compliance Assurance Section
Division of Public Water Supplies
Bureau of Water
Attachments
cc: Geoffrey Burris
Jared Brunk
Rodney Thacker
BOW ID: W0218160012

PAGE NO. 1 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL CENTER, IL0210010 VIOLATION NOTICE NO. W-202300012:
Questions regarding the violations identified in this attach~ent should be
referred to Mandy Trader 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 construction perrni ts
from Illinois EPA for all construction.
Before any deviations from plans
and specifications approved by the Agency are made, the public water supply
must make a written request for a permit.
To meet compliance the supply is
expected to submit as-built plans and specifications pursuant to 35 Ill.
Adm. Code 602.116.
Violation
Date
10/20/2022

Rule/Reg.

Violation
Description
Failure to obtain a construction permit for the installation of
a water softener and brine storage tank used to treat water that
may be used for consumption.
Sections 15 (a) and 18 (a) (3) of the Act, 415 ILCS 5/15 and 5/18,
and 35 Ill. Adm. Code 602.l0l(a) and (b), 602.116 and
602. 200 (a} and (b) .

Emergency Operations Plan
All public water supplies must have an active Emergency Operations Plan (EOP)
in place. Compliance with this is expected to be achieved within 90 days by
developing and maintaining an EOP for the water supply.
This EOP must be
available to the Agency, upon request.
Violation
Date
10/20/2022
Rule/Reg.

Violation
Description
Failure to have an emergency operations plan for review. (ongoing violation)
Section 18 of the Act, 415 ILCS 5/18, 35 Ill. Adm. Code 601.l0l(a)
and 604 .135 (d).

PAGE NO. 2 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL CENTER, IL0210010 VIOLATION NOTICE NO. W-202300012:

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
10/20/2022
Rule/Reg.

Violation
Description
Failure to submit Monthly Operating Reports within 30 days of
the last day of each month.
Section 18 of the Act, 415 ILCS 5/18, and 35 Ill. Adm. Code
604.165(a), (c), and (d).

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 contro l devices and their
annual inspection.
Violation
Date
10/20/2022
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. Cqde
601.l0l(a) and 604.1505(a) and (b).

PAGE NO . 3 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL CENTER, IL0210010 VIOLATION NOTICE NO. W-202300012:

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
10/20/2022

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.lSlO(a).

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
10/20/2022

Rule/Reg.

Violation
Description
Failure to maintain records of all backflow preventers that
require annual testing. Testing must be conducted annually by a
person approved by the Agency and in accordance with the
manufacturer's instructions
Section 18 of the Act 415, ILCS 5/18, 35 Ill. Adm. Code 601.101,
and 604.1505(b) (5).

Water Treatment Plant Laboratory
The laboratory equipment or filed testing equipment are inadequate.
Compliance with this is expected within 30 days by obtaining or repairing of
equipment.

Violation
Date
10/20/2022

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, 35 Ill . Adm. Code
604 .130 (c) .

PAGE NO. 4 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL CENTER, IL0210010 VIOLATION NOTICE NO.
w-2023-00012:

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
10/20/2022

Rule/Reg

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

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
10/20/2022

Rule/Reg

Violation
Description
Operations of a Class B Water system without a
properly certified drinking water operator.
An
operator with a valid Class B Certification or higher
is required.
Section 18(a) of the Act, 415 ILCS 5/18, 35 Ill. Adm.
Code 601.101, 603.l0l(d), 603.103(a) and (b), and
681. 215 (a) and (b} .

PAGE NO. 5 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL .CENTER, IL0210010 VIOLATION NOTICE NO.
W-2023-00012:
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
Violation
Date
Description
10/20/2022
Failure to submit, for Agency approval, a written
sample siting plan for coliform that identifies
sampling sites representative of water throughout the
distribution system. (on-going violation)

Rule/Reg.

Sections 18 of the Act, 415 ILCS 5/18,
Adm. Code 611.1053 (a) (1).

10/20/2022

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. (on - going violation)
Sections 18 of the Act, 415 ILCS 5/18, and 35 Ill
Adm. Code 611.356(a).

Rule/Reg.

10/20/2022

Rule/Reg.

and 35 Ill.

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 I l l 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 results for each monitoring program in
accordance with your supply's sample site plans.

PAGE NO. 6 OF 6
ATTACHMENT A
TAYLORVILLE CORRECTIONAL CENTER, IL0210010 VIOLATION NOTICE NO.
W-2023-00012:
Violation
Date
10/20/2022

Rule/Reg.

10/20/2022
Rule/Reg.

10/20/2022
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, 35 Ill. Adm. Code 611.1053 (a) (2) and (3).

Failure to collect samples and submit lead and copper
sample results.
Sections 18 and 19 of the Act, 415 ILCS 5/18 and
5/19,35 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,
35 Ill. Adm. Code 611.971(a).
.

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
10/20/2022

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, 35 Ill. Adm.
Code 601 .101 (a) and 604 .1425 (c) .

UHnoic..

~nyiJ·.on1nr ota t f>rote-cti<lU Ag€
,.... nt;;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
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 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 publical!y owned or owned by private corporation, or regularly organized body, identify the entity exercising direct supervision over the
CWS in accordance with 35 UL 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 (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:____________

( Signature of Individual)

OFFICIAL CUSTODIAN (OC) lfthe 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. t

Name:
Title
Cell#
Home#
E-Mail:

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

Signature: ___ ____________ _________

1

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 CW$. 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
LAnal AcUon. and notices of reaulatorv rAnuirements and oermittina transactions.

Name: (print) _ _ __ _ __ _ _ _ _ __ _ _ _ _ _ _ __
Titre:
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)

IL 532-0M7/0Hl 4 Hevised 01-14)

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

llUnol.~

Envb"~u1110u.tat Ptotoc·tiou. ,\gen9y
RESPONSIBLE OPERATOR IN CHARGE {ROINC} Identify the certified operator(s) designated pursuant to 35 111. 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 FIie:

(print name)°

Please check box that best describes status of current RO/NC on File
I Current ROINC on file will no lonaer be emoloved or under contract with PWS effective
I Current ROINC on file is still worldna with PWS but will no lonoer servino as ROINC.

Full Time Employee or

NEWROINC 1 Please Check One:
Name: (print)
Circle Certificate Class: A
B
C
Circle One: Treatment & Distribution
Cell#: ( _ )
)
Home#: (
E-Mail:
Signature:
(Sionature of RO/NC 1)
NEWROlNC2 Please Check One:

__

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

\
I

Contract O perator (Include coov of contract}
Business Address

D
Treatment Only
Work#: (
Fax#: (

Distribution Only

)
)
Date:

Full Time Employ ee or

Contract Ov erator (Include coav of contract)
Business Address

A

B

C

D

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

Distribution Only

Signature:

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
being jn responsible charge.
S ignature:
Date:
fSianature 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 :

__
__ _____
_______

_

(
(

Bottle Mailing Address

_ _ _ _ _ _ _ _ _ __ __

)
)

Work#:( _

_

_ _ _ __

_

(print)

No P.O.Box Numbers Allowed

_ ,._ _ _ _ __

Fax#: ' -- -- ·- - - - - - - -

S ignature:_ __ __ __ _ _ _ _ _ _ _ _ _ _ _ __ __

Date:___ _ __ _ _ __ _ __

(Sample Collector's Signature)

Completion of this form shall indicate acceptance of the duties and responsibilities for the proper operation and maintenance of the public water
supply facilities by both the owner or official custodian and the certified operators designated as being in responsible charge pursuant to 35 Ill. Adm.
Code 603,101(d), Please be advised that it is the responsibility of the owner, official custodian and the certified operator(s) in responsible charge to
notify this office within 15 days of any changes in responsible personnel. Completion and submittal of this form will satisfy the notification of
responsible personnel requirements of Title 35: Environmental Protection, Subtitle F: Pub'ic 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 yourfiles. Should you need addaional forms, please call (217)785-0561 or download al
hllp;(lwMv.e:pa,stale:.fl.UiSlw-lllerlooorator-cert/drinkin9.•water/forms/notification-of-ownership.pdl. 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). Disdosure 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, lo the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction l s a Class 3 felony. (415
tlCS 5/44(h))
IL 532-0987/0164 (revised 01-14)

ttllnul~

~:,n ·it o nn1• ntal p·, t ►1

:-.

"'tf, n l\ffv nc ,
m.

RESPONSIBLE OPERATOR IN CHARGE {ROINC} Identify the certified operator(s) designated pursuant to 35 Adm .
Code 603.103 in responsible charge of the CWS operations. The ROINC runs and oversees dally water treatment and distribution operahons. A
CWS must select only one designated ROINC for treatment and one designated ROINC for distribution. The treatment ROINC and distributton
ROINC may be lhe same cerson.
Current ROINC on File:
Please check box that best describes status of current RO/NC on File
I Current ROINC on file will no lor'l;:ier be emploved or under contract with PWS effective
f Current ROINC on file is still working 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:
Sign~:

Full Time Emolovee or

__
__

'

Contract Ooerator (Include copy of contract)
Business Address

D
Treatment Only

Work#: (
Fax#: (

D1str1bulion Only

)

)

Date:

(Signature of RO/NC 1J

NEWROINC2 Please Check One:
Name: (print)
Circle Certificate Class: A B C
)
Cell#: (
)
Home#: (
E-Mail:
$jgnature:

(print name)

Full Time Employee or

D

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

Contract Operator (include coovof contractJ
Business Address

Distribution Only

-Date:
-

( Signature of RO/NC 2)

Signature of Owner1 Official Custodlan 1 or Administrative Contact is regulred before Illinois EPA will add or
change a ROINC contact{s}.
As Owner/Official Custodian or Administrative Contact, I
(print name). accept and
assign the duties and respons,bilities for the proper operation and maintenance of the public water supply facilities by the operator(s) listed above as
beln~ 'in res~onsible charge.

Signature.

Date:
J _SiS}nature 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#:

- , - - - - - - - - - - - ---,---,--- - - - , - - -- - - <Print)
( _ _ )_ _ _ __ _ Work#:( _ _ _ )_ _ _ _ __

Hi~:!; (__)

Fax#: (

Bottle Mailing Address
No P.O.Box Numbers Allowed

)_ _ _ _ __

gnature:-=---,--=--::--,.....,.....,,., - - ~ -- - - - -- - - - - - -

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

(Sample Collector's Signature)

Completion of this form shall indicate acceptance of the duties and responsibilities for the -proper operation and maintenance of the public water
supply facilities by both the owner or official custodian and the certified operators designated as being in responsible charge pursuant to 35 tit. Adm.
Code 603.101(d). Please be advised that it is the responsibility of the owner. off,cial custodian and the certified operator(s) in responsible charge to
notify this office withfn 15 days of any changes in responsible personnel. Completion and submittal of this form will satisfy the notification of
responsible personnel requirements of Title 35: Environmental Protection. Subtitle F: Public Water Supplies. Chapter I: Pollution Control Board. Part
603, Sections 603.1 O1. 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
btlcrllwww eoa.sla!e.il.uslwaterlooerator-certldrinking-wa1er/forms/notific:atiqn-of:9W(!ersh1p.p<lf. 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 1s authorized to require th·s Information under 415 ILCS 514(b)(2012). Disclosure of th,s information is required. Failure to do
result in a civil penalty up to $1 .000.00. Any person who knowmgly 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))

so may

It. S32-0987/0164 (revised 0 1 141