Og-21a Notice Of Violation (Nov) Abatement Form
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2ILLINOIS DEPARTMENT OF NATURAL RESOURCES
Office of Oil and Gas Resource Management
One Natural Resources Way
Springfield, Illinois 62702-1271
(217) 782-7756
OG-21A NOTICE OF VIOLATION (NOV) ABATEMENT FORM
This form required to be submitted to District Office that issued NOV. Submit form within 30 days after date of completion of remedial action.
PERMITTEE: _________________________________________________________ PERMITTEE #: _______________
WELL/FACILITY NAME: _____________________________________________________________________________________________
TANK #: ___________________________
PIT #: ____________________________
REFERENCE #: ________________________________
SECTION: __________ TOWNSHIP: ________________ RANGE: _______________
COUNTY: ____________________________________
NOV ISSUANCE DATE:_______________________________________________________________________
# OF DAYS GIVEN TO CORRECT VIOLATION(S) INCLUDING ANY EXTENSIONS GIVEN BY DISTRICT OFFICE:
_____________________
DESCRIPTION OF VIOLATION(S):
Provide detailed description of remedial actions taken. Attach any supportive documentation, invoices, photos, etc. (Use additional sheet if
necessary):
I certify, under penalty of perjury as provided by law and under penalty of refusal, suspension, or revocation of a permit to drill
or operate, that this and all statements made on this form and all attachments thereto are true, accurate, and complete to the best
of my knowledge.
___________________________________
____________________________
Permittee or Designee
Date
Department Use Only
The NOV remediation is completed pursuant to Department rules and is released.
_____________________________________________
_____________________________
Department Representative
Date
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