RECEIVEDCLERK'S

OFFICE

STATE OF ILLINOIS

RUN,,

I 1 2007

POLLUTION CONTROL

BOARD

100 W.

RANDOLPH STREET, SUITE 11-500

STATE OF ILLINOIS

Pollution Control Board

CHICAGO,

ILLINOIS 60601

NOTE: All items must be completed

. If there is insufficient space to complete any item,

additional sheets may be attached, specifying the number of the item you are completing

.

Once completed, you must file the original and nine copies with the Board

.

FORMAL COMPLAINT

BEFORE THE

ILLINOIS

POLLUTION CONTROL BOARD

GroRGe I?, ST2uNk

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)

(Insert your name(s) on lines

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above),

)

Complainant,

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_

PCB

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(For use by the Board)

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Respondent .

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1 . Your Name, Address and Phone

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2 . Place where you can be

contacted during normal

business hours (if different

from above) :

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. Name and Address of Respondent

(Alleged Polluter)

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. Describe the type of business or activity which you allege (believe) is causing

. pollution (for

example, manufacturing company, grain elevator, home repair shop)

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. List specific Sections of the Environmental Protection Act and/or Board regulations which you

allege (believe) are being

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6. Describe the type of alleged pollution (for example air, odor, noise, water, drinking water, sewer

back-ups) and the location of the alleged pollution . Be as specific as possible in describing the

pollution discharge or emission . *(PAST

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you first noticed the alleged pollution, how frequently it occurs, and whether it is still continuing

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include dates and/or times of day if available.

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8. Describe any bad effects which you believe the alleged pollution has on human health, plant or

animal life, or the environment

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. Describe the relief you wish the Board to grant (for example, an order that the Respondent stop

polluting, perform a specific action, make a specific changee in its operation, and/or pay a money

penalty

; the Board cannot order Respondent to pay you money damages, attorney's fees or any out-

of-pocket expenses which you incur by filing this complaint

.

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whether

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you knoww if there

is any court or other forum in which you are or anyone else is

suing or complaining against this Respondent for the same alleged pollution discharge or emission

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. CERTIFICATION (Optional but encouraged)

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having read the above do hereby swear and attest that I have read the

forgoing and I have filled out the above form accurately and to the best of my knowledge

.

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Subscribed to and Sworn

before me this day

of . 19

My Commission Expires

9- ~a-

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OFFICIAL SEAL

MELISSA A

. TANNER

NOTARY PUBLIC, STATE OF LLXIOIS

MY COMMISSION

EXPIRES 412

.2007