RECE

WED

CLERK’S OFFICE

State

of Illinois

POLLUTION

CONTROL BOARD

JUN

17

2005

JAMES

R.

THOMPSON CENTER

100W.

RANDOLPH

STREET, SUITE

11-500

STATE OF ILLINOIS

CHICAGO, ILLINOIS

60601

Pollution Control

Boarci

BEFORE THE

ILLINOIS POLLUTION CONTROL BOARD

W~N1NE

ELI~&

__________________________________________________________________

)

__________________________________________________________________

)

_______________________________________________________________________

)

(Insert

your

name(s)

on

lines

)

above),

)

)

Complainant(s),

)

v.

)

PCB

t/-~

)

(For Board

use)

_______________________________________________________________________

)

)

_______________________________________________________________________

)

(Insert

name(s)

of

alleged polluter(s)

)

on

lines above),

)

)

Respondent(s).

)

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.

---

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1.

Your name, street address,

county, state:

2.

Place where you can be

contacted during normal

business hours (if different

from above):

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3.

Name and address ofrespondent

(alleged polluter):

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(if known)

4.

Describe the type ofbusiness or activity that you allege is causing or allowing pollution

(e.g.,

manufacturing company, home repair shop)

and give the address ofthe pollution

source if different than the address above:

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5.

List specific sections ofthe Environmental Protection Act,

Board regulations,

Board

order, orpermit that you allege have been or are being violated:

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Describe the type ofpollution that you allege

(e.g.,

air, odor, noise, water, sewer back-

ups, hazardous waste) and the location ofthe alleged pollution.

Be as specific as you

reasonably can in describing the alleged pollution:

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Describe the duration and

frequency ofthe 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 ofthe 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 oflife or property,

or on any lawful business or activity:

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9.

Describe the reliefthat 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, orpay 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 herselfas an

individual or (b) his or her unincorporated sole proprietorship, though the individual may

prefer having attorney representation.):

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12.

(Comp~fafnant’

s signature)

CERTIFICATION (optional but encouraged)

I,

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,

on

oath or

affirmation,

state

that I have read the foregoing and

that it is accurate to

the best ofmy

knowledge.

(Complainai~t’

s signature)

Subscribed to and sworn before me

this

~

day

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of

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“OFFICIAL SEAL”

NANCYJ. LONG

NOTARY PUBLIC, STATE OF ILLL~OI~

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MY CQMM~SSIONEXPIRES

5.30.07

Notary ~

My

commission

expires:

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---

RECE

fl/ED

CLERK’S OFFICE

JUN

172005

CERTIFICATE

OF SERVICE

STATE OF ILLINOIS

Pollution

Control Board

I, the undersigned, on oath or affirmation, state that on (month, day, year)

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2—00

5

,

I served the attached formal complaint and notice on the

respondent by:

(check appropriate line)

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certified mail (attach copy of receipt if available, otherwise

you must file

receipt later with Clerk)

______

registered mail (attach copy ofreceipt if available,

otherwise

you must file receipt later with Clerk)

_____

messenger service (attach copy ofreceipt if available, otherwise

you must

file receipt later with Clerk)

______

personal service (attach affidavit if available, otherwise you

must

file affidavit later with Clerk)

at the address below:

RESPONDENT’S ADDRESS:

Name

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signature

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Subscribed to and sworn before me

this

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City, state, zip code

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(list each respondent’s

name and addIess if multiple respondents)

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“OFFICIAL SEAL”

•

NANCYJ. LONG

•

NOTARY PUBLIC, STATE OF ILLINOIS

MY

COMMJSSION

EXPIRES 5.30.07

My commission expires:

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SENDER:

COMPLETE THIS SECTION

•~Complete items 1, 2,

and 3. Also complete

item 4

if Restricted

Delivery

Is desired.

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Print your name and address on the reverse

so that we can

return the card to you.

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Attach this

card to the

back of the mailpiece,

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or on

the front if space permits.

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•(I’ransfer from

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PS Form

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February 2004

•

Domestic Return

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U.S~Postal Service

CERTIFIED MAIL RECEIPT

(Domestic Mail Only; No InsuranceCoverage Provided)

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Total Postage

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