Ill. Admin. Code tit. 35, § 620.APPENDIX D – Information Required for Groundwater Management Zone Application under 35 Ill. Adm. Code 620.250(b) and Corrective Action Completion Certification under 35 Ill. Adm. Code 620.250(d)

1. Provide a general description of the type of industry and the facility's location and size, as well as the products manufactured and raw materials used at the facility.

2. What specific units (operating or closed) are present at the facility that are or were used to manage waste, hazardous waste, hazardous substances, or petroleum? Include units regardless of whether they are considered sources of groundwater contamination.

	YES	NO
Landfill
Surface Impoundment
Land Treatment
Spray Irrigation
Waste Pile
Incinerator
Storage Tank (above ground)
Storage Tank (underground)
Container Storage Area
Injection Well
Water Treatment Units
Septic Tanks
French Drains
Transfer Station
Other Units (describe)

3. Provide an extract from a USGS topographic or county map showing the location of the site. Provide a more detailed scaled map of the facility identifying each unit checked "yes" in item 2 and each known or suspected release source. Map scale must be specified and the Township, Range, and Section of the facility must be provided. Also provide engineering drawings showing the facility and units at the facility.
4. Has the facility ever conducted operations that involved the generation, manufacture, processing, transportation, treatment, storage, or handling of "hazardous substances" as defined by the Illinois Environmental Protection Act? Yes ___No ___ If the answer to this question is "yes", generally describe these operations.
5. Has the facility ever generated, stored, or treated "hazardous waste" as defined by the Resource Conservation and Recovery Act (RCRA)? Yes ___ No ___If the answer to this question is "yes", generally describe these operations.
6. Has the facility ever conducted operations that involved the processing, storage, or handling of petroleum? Yes ___No ____If the answer to this question is "yes", generally describe these operations.
7. Has the facility ever held any of the following permits?
1. a. Permits for any waste storage, waste treatment, or waste disposal operation. Yes ___ No ___ If the answer to this question is "yes", identify the IEPA permit number or numbers.
2. b. Interim Status under RCRA (filing of a RCRA Part A application). Yes ___ No ___ If the answer to this question is "yes", attach a copy of the last approved RCRA Part A application.
3. c. RCRA Part B permits. Yes ___ No ___ If the answer to this question is "yes", identify the permit log number or numbers.
8. Has the facility ever conducted the closure of a RCRA hazardous waste management unit? Yes ___ No ___
9. Have any of the following State or federal government actions taken place for a release at the facility?
1. a. Written notification regarding known, suspected, or alleged contamination at the property (e.g., a Notice under Section 4(q) or Section 31(a) or (b) of the Illinois Environmental Protection Act)? Yes ___ No ___ If the answer to this question is "yes", identify notice's caption and date of issuance.
2. b. Consent Decree or Order under RCRA, the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), Section 22.2 of the Illinois Environmental Protection Act (State Superfund), or Section 21(f) of the Illinois Environmental Protection Act (State RCRA). Yes ___ No ___
3. c. If either item 9(a) or 9(b) is answered "yes", is the notice, order, or decree still in effect? Yes ___ No ___
10. Provide a statement of the classification or classifications of groundwater at the facility.
Class I ____ Class II ____ Class III ____ Class IV ____
If more than one Class applies, explain.
11. What classification will the groundwater within the proposed groundwater management zone be subject to at the completion of the remediation?
Class I ____ Class II ____ Class III ____ Class IV ____
If more than one Class applies, explain.
12. Describe the circumstances under which the release to groundwater was identified.
Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of my knowledge and belief, true and accurate.
Facility Name Signature of Owner/Operator
Location of Facility Name of Owner/Operator
EPA Identification Number Date
Part II: Release Information
1. Identify the chemical constituents released to the groundwater. Attach additional documents as necessary.
Chemical Description Chemical Abstract No.
2. Describe how the site will be investigated to determine the source or sources of the release.
3. Describe how groundwater will be monitored to determine the rate and extent of the release, and whether the release has migrated off-site.
4. Has the release been contained on-site?
5. Describe the groundwater monitoring network and groundwater and soil sampling protocols in place at the facility.
6. Provide the schedule for investigating the extent of the release and for monitoring.
7. Describe the laboratory quality assurance program used for the investigation.
8. Provide the results of available soil testing and groundwater monitoring associated with the release, along with a summary of those results. Include the following information: dates of sampling; types of samples taken (soil or water); locations and depths of samples; monitoring well construction details with well logs; sampling and analytical methods; analytical laboratories used; chemical constituents for which analyses were performed; analytical detection limits; and concentrations of chemical constituents in parts per million or "ppm" (levels below detection must be identified as non-detect or "ND").
9. Provide scaled drawings identifying the horizontal and vertical boundaries of the proposed groundwater management zone.
Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of knowledge and belief, true and accurate and confirm that the actions identified in this submittal will be performed in compliance with the schedule in this submittal.
Facility Name Signature of Owner/Operator
Location of Facility Name of Owner/Operator
EPA Identification Number Date
Part III: Remedy Selection Information
1. Describe the selected remedy and why it was chosen. Include a description of the fate and transport of contaminants with the selected remedy over time.
2. Describe other remedies that were considered and why they were rejected.
3. Will waste, contaminated soil, or contaminated groundwater be removed from the site during this remediation? Yes ___ No ___ If the answer to this question is "yes", where will the contaminated material be taken?
4. Describe how the selected remedy will accomplish the maximum practicable restoration of beneficial use of groundwater.
5. Describe how the selected remedy will minimize any threat to public health or the environment.
6. Describe how the selected remedy will result in compliance with the standards for the applicable class or classes of groundwater. Include the results of groundwater contaminant transport modeling or calculations showing how the selected remedy will achieve compliance with these standards.
7. Provide a schedule for design, construction, and operation of the remedy, including dates for the start and completion.
8. Describe how the remedy will be operated and maintained.
9. Have any of the following permits been issued for the remediation?
a. Construction or operating permit from the Agency's Division of Water Pollution Control. Yes __ No ___ If the answer to this question is "yes", identify the permit number or numbers.
b. Land treatment permit from the Agency's Division of Water Pollution Control. Yes ___ No ___ If the answer to this question is "yes", identify the permit number or numbers.
c. Construction or operating permit from the Agency's Division of Air Pollution Control. Yes ___ No ___ If the answer to this question is "yes", identify the permit number or numbers.
10. How will groundwater within the proposed groundwater management zone be monitored after completion of the remedy to ensure compliance with the standards for the applicable class or classes of groundwater?
Based on my inquiry of those persons directly responsible for gathering the information, I certify that the information submitted is, to the best of my knowledge and belief, true and accurate and confirm that the actions identified in this submittal will be performed in compliance with the schedule in this submittal.
Facility Name Signature of Owner/Operator
Location of Facility Name of Owner/Operator
EPA Identification Number Date
Part IV: Corrective Action Completion Certification
This certification must accompany documentation that includes soil and groundwater monitoring data demonstrating completion of the corrective action.
Facility Name
Facility Address
County
Standard Industrial Code (SIC)
Date
Based on my inquiry of those persons directly responsible for gathering the information, I certify that the corrective action approved by the Illinois Environmental Protection Agency has been completed and the following concentrations of released chemical constituents remain in groundwater within the groundwater management zone:
Chemical Name Chemical Abstract No. Concentration (mg/L)
Facility Name Signature of Owner/Operator
Location of Facility Name of Owner/Operator
EPA Identification Number Date

Within any class of groundwater, a groundwater management zone (GMZ) may be established as a three-dimensional region containing groundwater being managed to mitigate impairment caused by a release of one or more contaminants that is subject to a corrective action process approved by the Illinois Environmental Protection Agency (Agency). See 35 Ill. Adm. Code 620.250(a). A GMZ cannot be established before the site owner or operator submits a GMZ application to the Agency under 35 Ill. Adm. Code 620.250(b). A GMZ is not established until the Agency issues a written approval of the GMZ, including its corrective action process, under 35 Ill. Adm. Code 620.250(c)(2).

When an owner or operator completes the Agency-approved corrective action, the owner or operator must submit to the Agency appropriate documentation under 35 Ill. Adm. Code 620.250(d), including the information required for a corrective action completion certification. A GMZ is terminated when the Agency issues a written determination to that effect under 35 Ill. Adm. Code 620.250(c)(2)(i), (c)(2)(ii), (d)(1), or (f).

Note 1.	Parts I, II, and III of this Appendix D specify the information required for the GMZ application that the owner or operator submits to the Agency. See 35 Ill. Adm. Code 620.250(b). Part IV of this Appendix D specifies the information required for the corrective action completion certification that the owner or operator submits to the Agency. See 35 Ill. Adm. Code 620.250(d). The owner or operator is neither required to use the form specified in Part I, II, III, or IV of this Appendix D nor precluded from including information in addition to that required by this Appendix D. See 35 Ill. Adm. Code 620.250(b)(2), (b)(3), (d).
Note 2.	The issuance of a permit by the Agency's Division of Air Pollution Control or Water Pollution Control for a treatment system does not imply that the Agency has approved any corrective action process.
Note 3.	Parts I, II, and III of this Appendix D are not for use in establishing a GMZ under the Site Remediation Program (35 Ill. Adm. Code 740). See 35 Ill. Adm. Code 620.250(h).
Note 4.	If the GMZ would extend off-site, the GMZ application must include each off-site property owner's written permission to the establishment of the GMZ on its property. If effectively implementing the off-site portion of the GMZ requires accessing an off-site property, the GMZ application must also include the off-site property owner's written permission for that access. If the applicable written permission or permissions from an off-site property owner are not obtained—whether permission to establish the GMZ off-site, access the off-site property, or both—the GMZ will not include that off-site property. See 35 Ill. Adm. Code 620.250(b)(1).
Note 5.	If a response to any item in this Appendix D requires additional explanation or clarification, provide it in an attachment to the submittal.

Part I:	Facility Information
	Facility Name

	Facility Address

	County

Standard Industrial Code (SIC)

(Source: Amended at 49 Ill. Reg. 4488, effective March 28, 2025)


Facility Name		Signature of Owner/Operator

Location of Facility		Name of Owner/Operator

EPA Identification Number		Date

Chemical Description		Chemical Abstract No.

Chemical Name	Chemical Abstract No.	Concentration (mg/L)