Form IL 406-1605 Livestock Waste Lagoon Liner Certification of Construction or Modification - Illinois

Form IL406-1605 is a Illinois Department of Agriculture form also known as the "Livestock Waste Lagoon Liner Certification Of Construction Or Modification". The latest edition of the form was released in January 1, 2001 and is available for digital filing.

Download a PDF version of the Form IL406-1605 down below or find it on Illinois Department of Agriculture Forms website.

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L
W
L
L
IVESTOCK
ASTE
AGOON
INER
C
C
M
ERTIFICATION OF
ONSTRUCTION OR
ODIFICATION
A. General Lagoon Location Information
:
(please provide the following information)
__________________
__________
__________
____________
County Name
Township #
Range #
Prin. Meridian
_________
____________
____________
Section #
1/4 Section
1/4-1/4 Section
B. Facility Information:
Name:
Mailing Address:
Phone Number:
C. Owner or Operator Information:
Name:
Company:
Mailing Address:
Phone Number:
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Livestock Management
Facilities Act (510 ILCS 77). Failure to provide this information shall prevent this form from being processed. This form has been approved by the State Forms Management Center.
IL 406-1605 (1-01)
L
W
L
L
IVESTOCK
ASTE
AGOON
INER
C
C
M
ERTIFICATION OF
ONSTRUCTION OR
ODIFICATION
A. General Lagoon Location Information
:
(please provide the following information)
__________________
__________
__________
____________
County Name
Township #
Range #
Prin. Meridian
_________
____________
____________
Section #
1/4 Section
1/4-1/4 Section
B. Facility Information:
Name:
Mailing Address:
Phone Number:
C. Owner or Operator Information:
Name:
Company:
Mailing Address:
Phone Number:
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Livestock Management
Facilities Act (510 ILCS 77). Failure to provide this information shall prevent this form from being processed. This form has been approved by the State Forms Management Center.
IL 406-1605 (1-01)
D. Certification Statement (
:
please provide a signature and stamp/seal)
“I hereby certify that the livestock waste liner herein described meets all the applicable
requirements of the Livestock Management Facilities Act (510 ILCS 77/1 et seq.) and the
rules promulgated thereunder.”
Registered Professional Engineer’s Signature
Stamp / Seal
Engineer’s Name: _______________________________________________________________
Company Name:________________________________________________________________
Address: _ ______________________________________________________________________
City / State / Zip code: ___________________________________________________________
Telephone:_______________________
Fax: _______________________
E. Supporting Justification and Data:
Pursuant to 8 Ill. Adm. Code 900.605(a), supporting justification and data relative to the construction or
installation of the liner is required as part of the engineer’s certification.

Download Form IL 406-1605 Livestock Waste Lagoon Liner Certification of Construction or Modification - Illinois

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