Form OG-21A Notice of Violation (Nov) Abatement Form - Illinois

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ILLINOIS 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
ILLINOIS 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
The Office of Oil and Gas Resource Management has adopted this new form in order to track the
completion of all remedial work related to Notices of Violation and to ensure that all NOV’s are abated
by the Department in a timely manner.
Please contact your local District Office if you require an extension to complete all remedial work.
INSTRUCTIONS:
1)
COMPLETE ALL REQUIRED REMEDIAL WORK.
2)
COMPLETE AND SIGN FORM.
3)
ATTACH ANY SUPPORTING DOCUMENTATION SHOWING THAT THE REMEDIAL
ACTIONS HAVE BEEN COMPLETED. SUPPORTING DOCUMENTATION MAY
INCLUDE, BUT IS NOT LIMITED TO:
A)
BEFORE AND AFTER PHOTOGRAPHS
B)
INVOICES AND/OR RECEIPTS FOR EQUIPMENT, PARTS, SUPPLIES AND/OR
LABOR RELATED TO REMEDIAL WORK
C)
INVOICES AND/OR RECEIPTS FOR REMOVAL OR DISPOSAL OF ANY
CONTAMINATED SOIL OR OTHER MATERIAL
D)
WORK LOGS MEMORIALIZING WORK COMPLETED
4)
SUBMIT FORM AND ATTACHENTS TO LOCAL DISTRICT OFFICE BY MAIL OR
EMAIL.
A)
OFFICE OF OIL AND GAS RESOURCE MANAGEMENT
SPRINGFIELD DISTRICT OFFICE
ONE NATURAL RESOURCES WAY
SPRINGFIELD, IL 62702-1271
217/558-2037
DNR.OOGRMSpfldDist@illinois.gov
B)
OFFICE OF OIL AND GAS RESOURCE MANAGEMENT
CENTRALIA DISTRICT OFFICE
800 S. LOCUST STREET
CENTRALIA, IL 62801
618/533-8979
DNR.OOGRMCent@illinois.gov
C)
OFFICE OF OIL AND GAS RESOURCE MANAGEMENT
MT. CARMEL DISTRICT OFFICE
2517 W 9TH STREET, SUITE C
MT. CARMEL 62863
618/262-2106
DNR.OOGRMMtc@illinois.gov
5)
KEEP A COPY FOR YOUR RECORDS.

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