Form Il 532-0987/0164 - Notification Of Ownership And Responsible Operational Personnel - Illinois Environmental Protection Agency
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1
2Notification of Responsible Operational Personnel
Please use this form to make community water supply (CWS) contact changes.
CWS Name:
____________________________________
Number :
IL_____________
REASON FOR CHANGE (check all applicable boxes)
Change in Owner and/or Official
Change in Administrative Contact
Change of Sample Collector
Custodian Information
Information
Information
Change in Responsible Operator in
Updating phone, mailing address, and/
This is a NEW CWS
Charge Information
or E-Mail information only
OWNER (OW)
If the CWS is privately owned, identify the individual (and contact information) exercising direct supervision over the CWS
in accordance with 35 Ill. Adm. Code 603.101 (e.g., Mobile Home Park, Apartment Complex, or Private Business, etc.). This individual must sign.
If the CWS is publically owned or owned by private corporation, or regularly organized body, identify the entity exercising direct supervision over the
CWS in accordance with 35 Ill. Adm. Code 603.101 (e.g., Municipality, Water District, Water Corporation, Water Cooperative, Conservancy District,
Subdivision, or Association). If an entity, only complete Entity Name, Business #, and Address (no signature required) and then complete
OFFICIAL CUSTODIAN (OC) box.
Name (Individual) or Entity Name (Municipality, Water District, Assoc., etc.)
Business Address
_____________________________________________________________
Title:
(if applicable)_________________________________________
______________________________
Cell#:
(_____)_______________ Business#: (_____)_______________
______________________________
Home#:
(_____)_______________
Fax#: (_______)________________
______________________________
E-Mail:
____________________________________________________
______________________________
If Individual, Signature:___________________________________________
Date:_________________________
(Signature of Individual)
OFFICIAL CUSTODIAN (OC)
If the owner is an Entity as listed above (Municipality, Water District, Water Corporation, Water
Cooperative, Conservancy District, Subdivision or Association, etc.) identify a person who acts on behalf and is responsible for the supply. This
person should be an elected official of a municipality, member of the board, or an officer of the organization that runs the supply (mayor, president,
chairman, etc.).
Name:
(print)_______________________________________________
Business Address
Title
(if applicable)_________________________________________
______________________________
Cell #
(_____)_______________ Business#: (_____)_______________
______________________________
Home#
(_____)_______________
Fax#: (_______)________________
______________________________
E-Mail:
____________________________________________________
______________________________
Signature:_______________________________________________
Date:_________________________
(Signature of Official Custodian)
ADMINISTRATIVE CONTACT (AC)
An owner or official custodian may designate an administrative contact to oversee daily
managerial operations of the CWS. Any notice provided by the Agency to the AC shall be considered notice to the owner or official custodian.
These notices may include, but are not limited to Sample Demand Letters, Public Notice Advisories, Violation Notice, Notice of Intent to Pursue
Legal Action, and notices of regulatory requirements and permitting transactions.
Name:
(print)_______________________________________________
Business Address
Title:
________________________________________________
_____________________________
Cell#:
(_____)_______________ Work#: (_______)_______________
_____________________________
Home#:
(_____)_______________
Fax#: (_______)_______________
_____________________________
E-Mail:
____________________________________________________
_____________________________
Signature:_______________________________________________
Date:_________________________
(Signature of AC)
Signature of the Owner or Official Custodian is required before Illinois EPA will add or change an AC contact:
I hereby duly authorize_____________________________________________________(print) as my Agent, with actual authority to conduct legal
transactions arising from the daily managerial operations of the CWS on my behalf.
Signature:_______________________________________________
Date:_________________________
(Signature of Owner or Official Custodian)
IL 532-0987/0164 (revised 01-14)
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