Form PWS294 (IL532-2984) "Consumer Confidence Report Certification Form" - Illinois

What Is Form PWS294 (IL532-2984)?

This is a legal form that was released by the Illinois Environmental Protection Agency - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2021;
  • The latest edition provided by the Illinois Environmental Protection Agency;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PWS294 (IL532-2984) by clicking the link below or browse more documents and templates provided by the Illinois Environmental Protection Agency.

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Consumer Confidence Report Certification Form
Water System ID:_____________________________ Water System Name: __________________________________________
This section must be completed for all submittals
Method of Delivery Population Category - Circle One:
500 or Less
501 to 10, 000
greater than 10,000
CCR Method of Delivery (MOD) Used (see attachment) - Circle One:
MOD A
MOD B
MOD C
Connected System Requirements - Circle One, if applicable: Purchase Water
Sell Water
You are required to submit this form to certify that your Consumer Confidence Report (CCR) has met all state and federal
requirements. The owner, administrative contact, or responsible operator in charge must sign this Certification Form acknowledging
compliance with Illinois Environmental Protection Agency’s Primary Drinking Water Standards found in Part 611 Subpart U:
Consumer Confidence Reports.
Detailed CCR instructions and regulation requirements are listed in Chapter 2 of the Sample Collectors Handbook (SCH). Also
included in the handbook, is a check list that can be used to verify that all required elements have been included, prior to issuing the
CCR. It is recommended that you review this chapter and check list prior to issuing your CCR. The SCH can be viewed and/or
downloaded at the following Internet web address: https://www2.illinois.gov/epa/topics/compliance-enforcement/drinking-
water/Pages/sample-collectors-handbook.aspx
th
By July 10
, complete the delivery certification, sign, and return it along with a copy of the issued CCR and the URL Notification
if applicable, to the Illinois EPA, CCR Coordinator, BOW/CAS #19, P.O. Box 19276, Springfield, Illinois 62794-9276. Alternatively,
you may e-mail all required documents to
EPA.PWSCompliance@Illinois.gov
CERTIFICATION OF DELIVERY: Depending on your delivery requirements, you MUST
complete ONE of the following METHOD OF DELIVERY certification sections.
METHOD “A” DIRECT DELIVERY
 
DELIVERY DATE REQUIRED
(enter delivery date)
Our CCR or electronic CCR URL notification was mailed on_____________________________________ 
  
 
Please check all items that apply.
1. 
_____ 
CCR was distributed by mail or hand delivered (enter delivery date above) 
2. 
_____ 
Notification that CCR is available on Web site via a direct uniform resource locator (URL) was mailed. 
(Submit a copy of the URL notification, i.e. water bill, newsletter, etc.) (enter delivery date above) 
3. 
_____ 
E‐mail – direct URL to CCR (submit a sample copy of the e‐mail) 
4. 
_____ 
E‐mail – CCR sent as an attachment to the e‐mail (submit a sample copy of the e‐mail) 
5. 
_____ 
E‐mail – CCR sent embedded in the e‐mail (submit a sample copy of the e‐mail) 
6. 
_____ 
Other: ____________________________________________________________________________ 
 
 
CWS serving => 100,000, Posted CCR on a publicly accessible Internet site at the following address: 
___________________________________________________________________________________
METHOD “B” DELIVERY
Since our supply serves a direct population between 501 and 10,000 and had no drinking water violations during 2020, the CCR 
was not mailed to each customer.  However, as required, our CCR was published in its entirety in one or more newspapers of 
general circulation.  In addition, customers were also informed that the CCR was not going to be mailed; and that copies are 
available upon request.   LIST NEWSPAPERS AND INCLUDE A COPY. 
Newspaper 
 
Published 
 
1: 
_________________________________________ 
On: 
_______________________________________ 
Newspaper 
 
Published 
 
2: 
On: 
_________________________________ 
_______________________________________ 
_________________________________________ 
Consumer Confidence Report Certification Form
Water System ID:_____________________________ Water System Name: __________________________________________
This section must be completed for all submittals
Method of Delivery Population Category - Circle One:
500 or Less
501 to 10, 000
greater than 10,000
CCR Method of Delivery (MOD) Used (see attachment) - Circle One:
MOD A
MOD B
MOD C
Connected System Requirements - Circle One, if applicable: Purchase Water
Sell Water
You are required to submit this form to certify that your Consumer Confidence Report (CCR) has met all state and federal
requirements. The owner, administrative contact, or responsible operator in charge must sign this Certification Form acknowledging
compliance with Illinois Environmental Protection Agency’s Primary Drinking Water Standards found in Part 611 Subpart U:
Consumer Confidence Reports.
Detailed CCR instructions and regulation requirements are listed in Chapter 2 of the Sample Collectors Handbook (SCH). Also
included in the handbook, is a check list that can be used to verify that all required elements have been included, prior to issuing the
CCR. It is recommended that you review this chapter and check list prior to issuing your CCR. The SCH can be viewed and/or
downloaded at the following Internet web address: https://www2.illinois.gov/epa/topics/compliance-enforcement/drinking-
water/Pages/sample-collectors-handbook.aspx
th
By July 10
, complete the delivery certification, sign, and return it along with a copy of the issued CCR and the URL Notification
if applicable, to the Illinois EPA, CCR Coordinator, BOW/CAS #19, P.O. Box 19276, Springfield, Illinois 62794-9276. Alternatively,
you may e-mail all required documents to
EPA.PWSCompliance@Illinois.gov
CERTIFICATION OF DELIVERY: Depending on your delivery requirements, you MUST
complete ONE of the following METHOD OF DELIVERY certification sections.
METHOD “A” DIRECT DELIVERY
 
DELIVERY DATE REQUIRED
(enter delivery date)
Our CCR or electronic CCR URL notification was mailed on_____________________________________ 
  
 
Please check all items that apply.
1. 
_____ 
CCR was distributed by mail or hand delivered (enter delivery date above) 
2. 
_____ 
Notification that CCR is available on Web site via a direct uniform resource locator (URL) was mailed. 
(Submit a copy of the URL notification, i.e. water bill, newsletter, etc.) (enter delivery date above) 
3. 
_____ 
E‐mail – direct URL to CCR (submit a sample copy of the e‐mail) 
4. 
_____ 
E‐mail – CCR sent as an attachment to the e‐mail (submit a sample copy of the e‐mail) 
5. 
_____ 
E‐mail – CCR sent embedded in the e‐mail (submit a sample copy of the e‐mail) 
6. 
_____ 
Other: ____________________________________________________________________________ 
 
 
CWS serving => 100,000, Posted CCR on a publicly accessible Internet site at the following address: 
___________________________________________________________________________________
METHOD “B” DELIVERY
Since our supply serves a direct population between 501 and 10,000 and had no drinking water violations during 2020, the CCR 
was not mailed to each customer.  However, as required, our CCR was published in its entirety in one or more newspapers of 
general circulation.  In addition, customers were also informed that the CCR was not going to be mailed; and that copies are 
available upon request.   LIST NEWSPAPERS AND INCLUDE A COPY. 
Newspaper 
 
Published 
 
1: 
_________________________________________ 
On: 
_______________________________________ 
Newspaper 
 
Published 
 
2: 
On: 
_________________________________ 
_______________________________________ 
_________________________________________ 
METHOD “C” DELIVERY
Since our supply serves a direct population of 500 or less and had no drinking water violations during 2020, the CCR was not 
mailed to each customer.  However, as required, customers were notified that a CCR was prepared and is available upon 
request.
The CCR notice of availability was delivered on:
____________________________________________ (enter date)
Insert  method  here  (i.e.,  newspaper,  posted,  hand 
_______________________________________________
delivered, etc.)
GOOD FAITH EFFORT:
at a minimum, one good faith effort must be used to reach non-bill paying consumers
Check all that apply:
 
Posted CCR on a publicly accessible internet site 
 
Mailed the CCR to postal patrons within the service area (attach 
____
list of zip codes) 
www.__________________________________________ 
____ 
 
 
 
 
____ 
Advertised availability of CCR in the news media (attach 
____ 
Published  CCR  in  local  newspaper  (attach  copy  of  newspaper 
copy of announcement) 
announcement) 
 
 
 
 
____ 
Posted the CCR in public places (attach a list of locations) 
____ 
Delivered multiple copies to single bill addresses serving several 
persons such as apartments and businesses 
 
 
 
 
____ 
Delivered to community organizations (attach a list) 
____ 
Other________________________________________________ 
 
 
 
 
 
Electronic  announcement  of  CCR  availability  via  social 
 
_____________________________________________________ 
____ 
media outlets (attach list of social media outlets utilized) 
 
 
 
 
 
Signature of Official Custodian (OC), Administrative Contact (AC), or Responsible Operator in Charge (DO)
The Certification Form signature must match one of the above contacts that
are on file at the Agency, if you are not listed as the OC, AC, or DO for the water
system, you do not have the authority to sign this document.
Any person who knowingly makes a false, fictitious, or fraudulent material statement, orally or in writing, to the Illinois EPA
commits a Class 4 felony. A second or subsequent offense after conviction is a Class 3 felony. (415 ILCS 5/44(h))
I ___________________________________ (print name), hereby certify that our CCR was distributed following the requirements
specified under METHOD_____ (enter method of delivery A, B, or C) DELIVERY. If delivery was made using the Electronic
CCR method, the CCR was made available to customers requesting a paper copy of the CCR.
Signature: ___________________________________________ Date: ________________________________________
Title: _______________________________________________ Telephone No.: (_____)_________________________
This Agency is authorized to require this information under 415 ILCS 5/17.5. Failure to disclose this information may result in a civil penalty of not to exceed
$50,000 for the violation and an additional civil penalty of not to exceed $10,000 for each day during which the violation continues (415 ILCS 5/42). This has been
approved by the Forms Management Center.
IL532-2984
PWS 294 (3/2021)
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