CLERK’S
OFFICE
POLLUTION
State
CONTROL
of Illinois
BOARD
AV
062
JAMES
R.
THOMPSON CENTER
STATE
OF
ILLINOIS
100
W.
RANDOLPH
STREET, SUITE 11-500
Pollutron
Control
Board
CHICAGO, ILLINOIS 60601
FORMAL COMPLAINT
BEFORE THE
ILLINOIS POLLUTION CONTROL BOARD
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(Insert your name(s) on lines
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Complainant(s),
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(For Board use)
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(Insert name(s) of alleged polluter(s)
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Respondent(s).
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Note:
If you do not use this formal complaint form
and instead draft and type your own, it
must contain
all
of the
information
requested by this form. All items must be completed.
If
there is insufficient space to complete any item,
you may attach additional sheets, specifying
the number
of the
item you
are
completing. Once completed, you must file the original
and
nine copies of
the
formal complaint, notice to respondent,
and
certificate of service with
the
Clerk of the Board at the above address.
1.
Your name,
Street address,
county, state:
2.
Place where you can
be
contacted
during normal
business hours (if different
from
above):
3.
Name and address of
respondent
(alleged
polluter):
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(if known)
4.
Describe the
type of business or activity
that
you
allege
is
causing or
allowing
pollution
(e.g., manufacturing
company, home repair
shop) and give the
address
of
the
pollution
source if different than
the address above:
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5.
List specific
sections
of the
Environmental
Protection
Act, Board regulations, Board
order,
or
permit that you allege have been or are being violated:
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6.
Describe the type of pollution that
you
allege
(e.g., air, odor,
noise,
water, sewer
back-ups, hazardous
waste) and the location of the alleged pollution. Be as specific
as you
reasonably can in describing the alleged pollution:
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7.
Describe the duration and frequency of the alleged pollution. Be as specific as you
reasonably can about when you first noticed the alleged pollution, how frequently
it
occurs, and
whether it is still continuing (include
seasons of the year, dates, and times
of day if known):
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8.
Describe
any
bad
effects that you believe the alleged pollution has
or has had on
human health, on plant or animal life,
on the environment, on the enjoyment of life
or
property, or on any lawful business or activity:
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9.
Describe the relief that you seek from the Board
(e.g., an order that the respondent
stop
polluting,
take pollution abatement measures, perform a cleanup, reimburse
cleanup costs, change its operation, or
pay a
civil
penalty (note that the Board cannot
order the respondent
to pay your attorney fees or any out-of-pocket expenses that
you
incur by pursuing an enforcement action)):
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10.
Identify any identical
or
substantially similar
case you know of that is already
pending
before the Board or in another forum against this respondent for the
same
alleged pollution
(note that you
need not
include
any complaints made
to the Illinois
Environmental
Protection
Agency or any unit of local government):
11.
State whether you are representing
(a)
yourself
as
an individual
or (b) your
unincorporated sole proprietorship. Also, state whether
you
are
an
attorney and, if
so,
whether
you
are licensed
and registered to practice law in Illinois. (Under Illinois
law,
an association, citizens group, unit of
local
government,
or corporation must be
represented before the Board by an attorney. Also, an individual who is not
an
attorney
cannot represent
another
individual
or other individuals before the Board.
However, an individual who is not an attorney is allowed
to represent (a) himself or
herself as an
individual
or (b) his or her unincorporated sole proprietorship, though
the
individual may prefer having attorney representation.):
“1
-
—-
IC
, on
oath
or
affirmation,
state that I
have
read the
foregoing
and
that it is
accurate
to the
best
of
my
knowledge.
OFFCLAL
SEAL
MARiLYN
0
ROJO
NOTARY
PUBLIC
- STATE
OF
ILLINOIS
MY
COMMISSION
EXPIRES04/25/12
12.
(Co
inant’s signkirf
CERTIFICATION (optional
but encouraged)
Subscribed
to
and sworn
before
me
this
day
of
, 2O7
Notary
Publi
0
My commission expires:
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