State

of

Illinois

POLLUTION CONTROL BOARD

JAMES R. THOMPSON

CENTER

100

W.

RANDOLPH STREET, SUITE

11-500

CHICAGO, ILLINOIS 60601

RECEIVED

CLERK’S OFFICE

MAY 20

2004

STATE

OF

ILLINOIS

Pollution

Control

Board

BEFORE

THE

ILLINOIS

POLLUTION

CONTROL

BOARD

____________________________

)

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)

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)

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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.

Ifthere

is

insufficient

space

to

complete

any

item,

you

may

attach additional sheets, specifying the number

ofthe item you are completing.

Once completed,

you

must

filethe original and

nine

copies

of

the formal

complaint,

notice

to

respondent,

and

certificate

of service

with the Clerk ofthe Board

at the above address.

FORMAL COMPLAINT

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(Insert your name(s) on lines

above),

Complainant(s),

v.

DAVE

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PCB

(ForBoard use)

(Insert name(s)

of

alleged polluter(s)

on lines above),

Respondent(s).

---

Your

name, street address,

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county, state:

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Phone(~34)

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2.

Place where you can be

_________________________

contacted during normal

business hours (if different

__________________________

from above):

Phone: ____________________

3.

Name and address ofrespondent

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(alleged polluter):

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Phone: _________________________

(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, or permit that you allege have been or are being violated:

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6.

Describe the type ofpollution that you allege

(e.g.,

air,

odor, noise, water, sewer back-

ups, hazardous waste) and the location ofthe allegedpollution.

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 itis 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 orhas had on human

health,

on plant or animal life, on the environment, on the enjoyment oflife orproperty,

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, 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 incurby

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):

---

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 herselfas an

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

prefer having attorney representation.):

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12..

(Complainant’~

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.

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(Complainalit’s signature)

Subscribed to and sworn before me

this

//

da

Notary Public

My commission expires:

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DORIS M ERBAUGH

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---

CERTIFICATE

OF SERVICE

I, ~

unde~signed,

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

t”i~A

Y

17,

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,

I served the attached formal complaint and notice on the

respondent’by:

(che.ck appropriate line)

X

certified mail (attach copy ofreceipt if available,

otherwise you must file

receipt later with Clerk)

______

registered mail (attach copy of receipt if available,

otherwise

you must file receipt later with Clerk)

______

messenger service (attach copy ofreceipt if available,

atherwise 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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Street

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City, state, zip code

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

Complainant”s signature

Street

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City, state, zip code

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Tt.

Subscribed to and sworn before me

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day

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Notary Public

~

My commission expires:

_____________________________

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