Appendix 617.APPENDIX B

Ill. Admin. Code tit. 35, § 617.APPENDIX B

Potential Route and Source Registration Form

Effective Sep 1, 200125 Ill. Reg. 10350AUTHORITY: Implementing Section 17.4 and authorized by Section 27 of the Environmental Protection Act [415 ILCS 5/17.4 and 27].POLLUTION CONTROL BOARD

SECTION 617.APPENDIX B – PLEASANT VALLEY PUBLIC WATER DISTRICT POTENTIAL SOURCE AND ROUTE REGISTRATION FORM

DATE:
COMPANY/FACILITY NAME:
MAILING ADDRESS:
		PHONE: ( )
COMPANY/FACILITY CONTACT NAME:
		PHONE: ( )
EMERGENCY CONTACT NAME:
		PHONE: ( )
PROPERTY OWNER'S NAME:		PHONE: ( )
PROPERTY OWNER'S ADDRESS:

BRIEF DESCRIPTION OF BUSINESS ACTIVITIES AND PROCESSES:




BRIEF DESCRIPTION OF SPECIFIC CHEMICAL SUBSTANCES USED:

(Source: Added at 25 Ill. Reg. 10350, effective September 1, 2001)