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RECEIVEDCLERK'S
OFFICE
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JUN
2 2 2006
ILLINOIS
Control Board
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File room use only
Site #
031 -CCDD
Log CCDD
ROD R. BLAGOJEVICH, GOVERNOR
Application for Interim Authorization for Clean Construction or Demolition Debris Fill Operations
~"
(LPC-PA24)
This form must be used to
apply for interim authorization for clean
construction or demolition debris fill
operations pursuant to
Section 22.51
of the Illinois Environmental
Protection Act . Interim authorization
is required only for sites where clean
construction or demolition debris is being
used as fill in a current or former quarry,
mine, or other excavation . This application is
not required for clean construction or demolition debris recycling sites, active mining operations,
or permitted landfills unless
clean construction or demolition debris
is being used as fill at the site in a current
or former quarry, mine, or other excavation
.
One original and two (2) photocopies of all
forms must be submitted to :
Illinois EPA Mail Code #33
1021 N. Grand Ave. East, P .O
. Box 19276
Springfield, IL, 62794-9276
which
Forms
Please
that
may
type
result
do
or print
not
In
have
legibly
the
the
denial
.
necessary
Required
of interim
fields
information
authorization
are indicated
In the
.
required
with • .
fields will be considered incomplete and will be rejected,
I.
SITE IDENTIFICATION
(Describe the location of the excavation
site being filled . You may attach a site
map to further identify the fill operation .)
Facility name
: °
VA'1-56NEXCA
V fh*/ n~
Office phone #, if available : 1 t
a.S-~03aS
CityPhysical
: Site
Location (Street, Road)
nner9
: *
'
A9
y
~O
P rd.rl5)1n
State1
:
.t)L
Road
Zip Code :
•
c0
a
9 3 3
County: •
I I ~ ILAM'S
Township:'
Latitude and Longitude of approximate center of site to five decimal places (e.g ., 90.12345N 40 .678
IEPA
R.
Site
LatitudeLongitude#s
(if assigned)
:
: N
W
:
3
BOWBOLBOA
nf?
:
7
:
:
ir
-7
.
7S
9
c19344R
6
~S
A95 t)
)
3
OWNER/OPERATOR INFORMATION
(Site owner is the owner of the property on which the clean construction or demolition debris fill operation is located, site
operator is the owner of the clean construction or demolitiop
:debris fill operation . If the site owner or site operator is not
a sole proprietorship, or government entity, please complete and return form LPC-PA24A as part of this application.)
1~
SITE OWNER
NameAddress
: •
: °
. )PEtt
. O,,qvx
W1t7
S-i
-
9
50-
-
105' P_sn1'/nm)
/ penc.
e--
city : *
mn
ot-zj
%
_ /: _-zip
:
4&2.133
Contact Name: *
'-F/p v ~
Last Name
First Na e
Phone#Email
:
: *
1,18'-9a c- r.3a .r
SITE OPERATOR
NameAddress
!oc
: °
: •
¶
Psirdinlal
~Y,rt2J2
O ,I
y
bDK
1 A/A-7
LI9nt-
S ?
-S
7
0 Al
City :
*
State :
Sf
Zip: •G ~93,3
Contact Name: IA/(J'S/.A1
Last Name
First Nam
Phone
Email: #
:
III .
TYPES OF CLEAN CONSTRUCTION OR DEMOLITION DEBRIS
ACCEPTED FOR FILL
(* Mark all types that are accepted for fill
. At least one field must be checked
.)
Uncontaminated concrete without protruding rebar
0
Stone
® Brick
LRI
Reclaimed
s
asphalt pavement
® Rock
EEC
Uncontaminated soil
Q Other
: (Specify)
TV.
AMOUNT OF CLEAN CONSTRUCTION OR DEMOLITION DEBRIS ACCEPTED
* Estimated annual fill (yd'/year)
: Check only one :
12 Less than 10,000 Q
10,000 to 50,000 Q50,000 to 100,000
0100,000 to 150,000
F1 Greater than 150,000
Estimated average daily volume (yd/day) :
*
I
D/1) X
Approximate bulk density of material (tons/yd') :*.c,¶f~ye ,
CommentsV
.
:
CONFLICT OF INTEREST DISCLOSURE *
Pursuant to Section 22
.52 of the Illinois Environmental Protection Act, certain individuals are prohibited from having a direct
financial interest in or receiving a personal financial benefit from (1) any
waste disposal operation or any clean construction or
demolition debris fill operation that requires a permit or interim authorization
tinder the Illinois Environmental Protection Act, or
(2) any corporate entity related to any such waste-disposal operation
or clean construction or demolition debris fill operation .
This
prohibition does not apply to the ownership of publicly traded stock.
On or after August 18, 2005, other than the ownership of publicly traded stock,
will any of the persons listed below have a direct
financial interest in or receive a personal financial benefit from (I) the clean
construction or demolition debris fill operation for
which interim authorization is sought, including but not limited to a direct financial
interest in or a personal financial benefit from
the site owner or site operator, or (2) any corporate entity related to the clean
construction or demolition debris fill operation,
including but not limited to any corporate entity related to the site owner or site operator?
the Governor of the State of Illinois;
the Attorney General of the State of Illinois
;
the Director of the Illinois Environmental Protection Agency ;
the Chairman of the Illinois Pollution Control Board ;
a Member of the Illinois Pollution Control Board ;
the staff of any person listed in items (a) through (e) who makes a regulatory
or licensing decision that directly
applies to any waste-disposal operation or any clean construction or demolition debris fill operation
;
the relative' of any person listed in items (a) through (1)
(a)
(b)
(c)
(d)
(e)
(f)
(g)
[:]Yes
r;71 No
If the answer to the above question is "yes," please complete and submit form
LPC-PA24B as a part of this application .
'
For purposes of this application, the term "relative" means father, mother,
son, daughter, brother, sister, uncle, aunt, husband,
wife, father-in-law, mother-in-law, brother-in-law, or sister-in-law.
2
VI.
COMPLIANCE WITH SECTION 39(i-5) OF THE ACT
Pursuant to Section 39(i-5) of the Environmental
Protection Act, for any clean construction or demolition
debris fill operation in
which any ownership interest was transferred
between January 1, 2005 and July 19, 2005, the
Illinois EPA must conduct an
evaluation of the operation if any previous activities
at the site or facility may have cause or allowed
contamination at the site . The
Illinois EPA may deny an interim authorization
if previous activities at the site
may have caused or allowed contamination at the
site, unless such contamination is authorized
under a permit issued by the Agency
.
Was any ownership interest in the clean construction
or demolition debris fill operation, including but not limited to any ownership
interest in a current or former owner or operator,
transferred between January I, 2005 and July
19, 2005?
Yes
&No
If the answer to the above question is "yes," please
complete and submit form LPC-PA24C as a part of this application .
VII . SIGNATURES"
(Original signatures required .
Signature stamps or applications transmitted
electronically or facsimile are not acceptable.)
All applications must be signed by the site owner
and site operator or duly authorized representatives of the site owner and site
operator
. The following persons are considered
duly authorized representatives of the following
site owners or site operators :
I .
For a corporation - A principal executive officer of at least the level of vice-president ;
2 .
For a partnership - A general partner
;
3 .
For a sole proprietorship - The sole proprietor
;
4 .
For a government entity - Either a principal executive officer or a ranking
elected official ; or
5 .
Another person authorized by one of the persons
listed in items I through 4 above to sign this application on
behalf of the site owner or site operator . Written proof of such authorization must be submitted with this
application .
CERTIFICATION STATEMENT
To the best of my knowledge and belief, since July 1, 1970, or the date on which the current owners
first acquired their ownership
interest of the site, whichever occurs later,
no waste or construction or demolition debris other than clean construction or
demolition debris has been disposed of or used
as fill material at the site for which this application is submitted . Further, no waste
or construction or demolition debris other than clean construction or demolition debris will be disposed of or used as fill material
at the site for which this application is submitted .
I certify under penalty of law that the information
submitted, including but not limited to all attachments and other information, is,
to the best of my knowledge and belief, true, accurate, and complete . I am aware that there
are significant penalties for submitting
false information, including the possibility of fine and imprisonment for knowing violations .
Furthermore, I certify that I am either
the site owner or site operator or a duly authorized
representative of the site owner or site operator and am authorized to sign this
form
.
Site Owner Signature :
~LIL//L
First Name:
-Fe
L .(-"'Name : W 1R-TS ON
Title :
0I
?/J2_
(this line may be typed)
Notary : Subscribed and sworn be f-re me this i 9 da of ;7a/'t° _.?o
Ct ,b
Notary Signature : s .
My commission expires on
: A
4/a
3
Date :
C~
/ / ~~
-OFFICIAL SEAL"
LINDA K
. JOHNSON
Notary Public, State of Illtnols
My Co/nmtssb Expires 02/04/08
Site Operator Signature :
First Name:
9! ._
4V
A Last
-r
Notary: Subscribed and sworn be or me this (`!
da of ,
-7-;LA) P 'Z00 (o
Notary Signature
:
La
:
,a
ANA
Notary Seal :
My commission expires on :A/4/D
x
Date :
e
:JN~9Trp/J
Title : ,( IA1,4IER
4
(this line may be typed)
"OFFICIAL SEAL"
LINDA K
. JOHNSON
Notary Public, State of Illinois
My Commission E$ ires 02/04/08
All information submitted as part of the Application is available to the public except when specifically designated by the Applicant
to be treated confidentially as a trade secret or secret process in accordance with
Section 7(a) of the Illinois Environmental
Protection Act, applicable Rules and Regulations of the Illinois Pollution
Control Board and applicable Illinois EPA rules and
guidelines .
