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RESPONSIBLE OPERATOR IN CHARGE (ROINC)

Identify the certified operator(s) designated pursuant to 35 Ill. Adm.

Code 603.103 in responsible charge of the CWS operations. The ROINC runs and oversees daily water treatment and distribution operations. A

CWS must select only one designated ROINC for treatment and one designated ROINC for distribution. The treatment ROINC and distribution

ROINC may be the same person.

Current ROINC on File:_____________________________________________________________________(print name)

Please check box that best describes status of current ROINC on File

Current ROINC on file will no longer be employed or under contract with PWS effective __________________

Current ROINC on file is still working with PWS but will no longer serving as ROINC.

NEW ROINC 1

Please Check One: ____ Full Time Employee or ____ Contract Operator (include copy of contract)

Name:

(print)_______________________________________________

Business Address

Circle Certificate Class: A

______________________________

Circle One

______________________________

: Treatment & Distribution

Treatment Only

Distribution Only

Cell#:

(_____)_______________ Work#: (_______)_______________

______________________________

Home#:

(_____)_______________

Fax#: (_______)_______________

______________________________

E-Mail:

____________________________________________________

Signature: ____________________________________________________

Date:_________________________

(Signature of ROINC 1)

NEW ROINC 2

Please Check One: ____ Full Time Employee or ____ Contract Operator (include copy of contract)

Name:

(print)_______________________________________________

Business Address

Circle Certificate Class: A

Circle One

______________________________

Distribution Only

Cell#:

(_____)_______________ Work#: (_______)_______________

______________________________

Home#:

(_____)_______________

Fax#: (_______)_______________

______________________________

E-Mail:

____________________________________________________

______________________________

Signature: ____________________________________________________

Date:_________________________

(Signature of ROINC 2)

Signature of Owner, Official Custodian, or Administrative Contact is required before Illinois EPA will add or

change a ROINC contact(s).

As Owner/Official Custodian or Administrative Contact, I ________________________________________________ (print name), accept and

assign the duties and responsibilities for the proper operation and maintenance of the public water supply facilities by the operator(s) listed above as

being in responsible charge.

Signature:

Date:_________________________

(Signature of Owner/Official Custodian or Administrative Contact)

Sample Collector/Bottle Recipient

Identify the person employed by the CWS that will collect samples and complete the

paperwork associated with sampling.

Bottle Mailing Address

Name:

________________________________________________ (print)

No P.O.Box Numbers Allowed

Cell#:

(_____)_______________ Work#: (_______)_______________

______________________________

Home#:

(_____)_______________

Fax#: (_______)_______________

______________________________

E-Mail:

____________________________________________________

______________________________

Signature:_______________________________________________

Date:_________________________

(Sample Collector’s Signature)

Completion of this form shall indicate acceptance of the duties and responsibilities for the proper operation and maintenance of the public water

supply facilities by both the owner or official custodian and the certified operators designated as being in responsible charge pursuant to 35 Ill. Adm.

Code 603.101(d). Please be advised that it is the responsibility of the owner, official custodian and the certified operator(s) in responsible charge to

notify this office within 15 days of any changes in responsible personnel. Completion and submittal of this form will satisfy the notification of

responsible personnel requirements of Title 35: Environmental Protection, Subtitle F: Public Water Supplies, Chapter I: Pollution Control Board, Part

603, Sections 603.101, 603.102, and 603.103.

Be sure to retain copies of this document for your files. Should you need additional forms, please call (217)785-0561 or download at

Return this completed form to:

Illinois Environmental Protection Agency, Bureau of Water #19, 1021 North Grand Ave East, P.O. Box 19276, Springfield, IL 62794-9276

This Agency is authorized to require this information under 415 ILCS 5/4(b)(2012). Disclosure of this information is required. Failure to do

so may result in a civil penalty up to $1,000.00. Any person who knowingly makes a false, fictitious, or fraudulent material statement,

orally or in writing, to the Illinois EPA commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony. (415

ILCS 5/44(h))

IL 532-0987/0164 (revised 01-14)

Form Il 532-0987/0164 - Notification Of Ownership And Responsible Operational Personnel - Illinois Environmental Protection Agency Page 2

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