FORMAL COMPLAINT

State of Illinois

CLERK’S O~rr-~

POLLUTION CONTROL BOARD

JAMES R. THorvIPsoN CENTER

6 2003

100 W. RANDOLPH STREET, SUITE 11-500

CHICAGO, ILLINOIS 60601

STATE OF ILLINOIS

Pollution ControJ Board

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) ofalleged polluter(s)

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Respondent(s).

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Note: Ifyou do not use this formal complaint f~rmand instead draft and type your own, it must

contain all ofthe information requested by this form. All items must be completed. Ifthere 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.

Your name, street address,

county, state:

Place where you can be

contacted during normal

business hours (if different

from above):

Name and address ofrespondent

(alleged polluter):

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Phone:

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Phone:

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Phone:

(if known)

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:

List specific sections ofthe Environmental Protection Act, Board regulations, Board

order, or permit 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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Describe any bad effects that you believe the alleged pollution has orhas 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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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 cjvil 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 ofthat 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 oflocal government):

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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 oflocal 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 orher unincorporated sole proprietorship, though the individual may

prefer having attorney representation.):

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(Complainant s signature)

CERTIFICATION (optional but encouraged)

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affirmation, state that I have read th~foregoing and that it is accurate to the West ofmy

knowledge.

(Complainant’s signature)

Subscribed to and sworn before me

this

4•t~~~day

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Public, State

of II

CommIssion

Expires

Notary Public

12.

My commission expires:

CERTIFICATE OF SERVICE

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

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I served the attached formal complaint and notice on the

re~pondent’by:(check appropriate line)

~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_____________________

Street

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City, state, zip code/J~e~.~i

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(list each respondent’s name and address if multiple respondents)

Subscribed to and sworn before me

this

11+t.

day.

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City, state, zip code

Complainant’s signature

Notary Public

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BETH

LUBBERT

~ Notary

Public, State of Illinois

My commission expires:

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