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)

)

(Insert your name(s) on lines

)

)

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above),

Complainant(s),

V .

(Insert name(s) of alleged polluter(s)

on lines above),

Respondent(s) .

State of Illinois

POLLUTION CONTROL BOARD

JAMES R . TnomPSON CENTER

100 W. RANDOLPII STREET, SUITE 11-500

CHICAGO, ILLINOIS 60601

FORMAL COMPLAINT

BEFORE THE

ILLINOIS POLLUTION CONTROL BOARD

PCB

01 -

11

(For Board use)

RECEIVED

SEP 1 8 2006

Pollution

STATE OF

Control

ILLINOIS

Board

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:

3 .

Name and address of respondent

(alleged polluter) :

Phone :5 9 /~S

2 .

Place where you can be

contacted during normal

IV?? A/-~

business hours (if different

from above):

Phone :

Phone :

(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,

S'~

or

C

permit

ToA)

that you

&

allege

y OF

have

7y~

been or are

~C-

being violated

%G/i~

:

IL C,S

799(2ocQ

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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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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C'74'/2,/9/4'/

---

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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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)):

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)

:

vs,

i'G-D

-/6y

---

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 .) :

12.

plainant's signature)

CERTIFICATION (optional but encouraged)

on oath or

affirmation, state that I have read the foregoing and that it is accurate to the best of my

knowledge .

/ -

,

"j ""y~ -

ainant's signature)

Subscribed to and sworn before me

this day

of Srsptom,,g~2 , 20al,

Notary Public

My commission expires

: ') -/3-

0 1

OFFICIAL SEAL

PATRICK J . BLASI

Notary Public. State of Illinois

My Commission Expires 9/13/09

---

CERTIFICATE OF SERVICE

/s

06

1, the

:7d1

d,

th oation, state that on (m&ith, day, year)

~~ I served the attached formal complaint and notice on the

spondent by : (check appropriate line)

certified mail (attach copy of receipt 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 of receipt 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 7

7/q~~

~ 7i

AcAez-

Street

liv

City, state, zip code TLG" Z

~v/yam?,

(list each respondent's name and adds if multiple respond nts

Complain ant's signature

City,

Streetstate,

~~-zip

code•~

TIGET~~o~

/w/o

TLL'y

Subscribed to and sworn before me

this /c/-

.I-

day

of

5LpJ(A,

f/.'2

,200(0

Notary Public

My commission expires: 5 - (S-u

6

OFFICIAL SEAL

PATRICK J

. BLASI

Notary Public, State of Illinois

My Commission

Expires 9/13/09