Section 1500.70  Forms

 

a)         License Application Form

 

1)         The following is a summary of information that shall be completed on the License Application Form to receive a license certificate.

 

A)        Drycleaning facility name, address, contact person, phone number and date facility began drycleaning operations.

 

B)        Drycleaner operator information, including name, mailing address, contact person, phone number, type of legal entity (i.e., sole proprietorship), corporation, partnership, Federal ID or social security number, Illinois Business Tax ID number.

 

C)        Information pertaining to the owner of the real estate, including owner name, mailing address, contact person, phone number, type of legal entity, Federal ID or social security number.

 

D)        Information pertaining to the annual fee involving the quantity of drycleaning solvents purchased for the preceding year or estimated to be used in the current year if it is a new drycleaning facility.

 

E)        Information regarding the drycleaning solvent supplier, including name of supplier, contact person, phone number, mailing address, Illinois Business Tax ID number.

 

2)         The license form must be signed by the applicant and returned with the appropriate application form and proof of payment of license fee in order to receive a license from the Drycleaner Environmental Response Trust Fund Council of Illinois.

 

b)         Insurance Application Form. The following is general information that must be completed on  an insurance application form in order to receive pollution liability insurance coverage from the Fund.

 

1)         Facility name, address, contact person, drycleaner license number and phone number.

 

2)         Operator name, mailing address, contact person, legal entity, type of legal entity, whether the operator is the owner of the land, buildings or both.

 

3)         Owner information, including name, mailing address, contact person, type of legal entity.

 

4)         Where correspondence regarding this application should be sent.

 

5)         Information on the mortgagee, including name, mailing address.

 

6)         Site specific information such as:

 

A)        Number of drycleaning units not in use or temporarily out of use at the location.

 

B)        Site conditions, including distance in feet to the nearest building off premises.

 

C)        Distance in feet to nearest water well.

 

D)        Distance in feet to nearest water/sewer main.

 

E)        Location of the property in terms of residential, commercial or industrial area.

 

F)         A diagram of the facility showing location of the building, drycleaning units, stored drycleaning solvents, stored hazardous waste containers, etc., should be listed on the diagram.

 

G)        What type of hazardous waste generator facility is at this location and if the facility is operating in accordance with the requirements for the type of hazardous waste generator facility that is indicated.

 

H)        Does the facility participate in and meet all the requirements of the Drycleaning Compliance Program approved by the Council.  If the answer is yes, the applicant must provide the name of the program and documentation of participation.  In addition, the applicant must indicate if the facility is compliant with all the requirements of the Compliance Program.

 

I)         Does the drycleaning unit have an Illinois EPA air operating permit? If so, the type of permit must be indicated.

 

7)         Has a site investigation been conducted to identify soil and groundwater contamination of the facility? If it has, a copy of the entire report should be submitted with the application.

 

8)         An indication of whether the applicant has ever reported a release or spill on this site to the Illinois Emergency Management Agency.  If the response is yes, the applicant should explain when, what and the current status of the cleanup.  If the response is no, the applicant should indicate if he/she is aware of a release or spill that has occurred at this facility that would impact soil and groundwater.

 

9)         Specific information on each individual drycleaning unit at the facility, including:

 

A)        Date each unit installed.

 

B)        Was the unit new at installation?

 

C)        Identification of the type of drycleaning solvent currently used.

 

D)        Indicate what type of drycleaning unit it is, i.e., dry to dry, transfer, other.

 

E)        What is the average amount of drycleaning solvent used per month in each unit?

 

F)         Does the unit have a pollution control mechanism on it? If so, identify what type.

 

G)        What is the size of each unit, based on pounds of clothes that each unit holds per cycle?

 

H)        Generation of drycleaning unit.

 

10)        Hazardous Waste

 

A)        Does the site maintain drycleaning solvent hazardous waste in approved containers that are labeled hazardous waste and properly dated?

 

B)        Is wastewater from the drycleaning solvent discharged into a sanitary sewer/septic tank service or groundwater?

 

C)        Are all drycleaning solvent wastes generated at this facility managed in accordance with applicable State waste management laws and rules in accordance with the Environmental Protection Act [415 ILCS 5] and 35 Ill. Adm. Code 722?

 

11)       Pollution Prevention Measures

 

A)        Does the unit have a containment dike or structure around each unit for the entire drycleaning area in which any drycleaning solvent is utilized that is capable of containing a spill or leak?

 

B)        Is the surface of the dike floor in which the drycleaning solvent may leak, spill or otherwise be released sealed or impervious?

 

C)        Are regular visual inspections conducted of the unit, solvent containers, waste containers and other areas where the solvent waste is located?

 

D)        Are the repairs done on a timely basis and a log kept of all repairs?

 

E)        Is the drycleaning solvent delivered to the facility by means of a closed direct-coupled delivery system?

 

12)       An insurance application form must be signed and dated by the applicant.

 

c)         Claim Application Form. The following is a summary of information that shall be completed on a claims form to apply for remedial action or insurance benefits.

 

1)         Business facility information including:

 

A)        Name and address of property where release occurred and name, address and phone number of person filing claim.

 

B)         Indication of whether the claim is for remedial account program benefits or insurance account program benefits.

 

C)        An insurance policy number, if applicable.

 

D)        The number of drycleaning units at this facility, whether they are still in use, and the drycleaning solvents that were stored in the drycleaning units.

 

E)        Questions as to other types of drycleaning machines, equipment, or underground or aboveground tanks, besides the drycleaning units, that store drycleaning solvent located at this facility that may contain any product that is chlorine or petroleum based.

 

F)         The name of the owner of the land on which the drycleaning units are located.

 

G)        The name of the owner of the facility and drycleaning units.

 

H)        The name of the owner and operator of the business at the location, including the length of time the business has been in operation and how long the current operator has operated the business.

 

2)         General information about the spill or leak.

 

A)        When did the person filing the claim first learn about the spill or leak?

 

B)        How was the spill or leak discovered?

 

C)        When and how was the problem reported to the Illinois Emergency Management Agency or the Illinois Environmental Protection Agency?

 

D)        Information regarding the source of contamination.

 

E)        Information regarding an awareness of any person who has suffered bodily injury or property damage as a result of this release.

 

F)         Statement regarding whether the contamination has migrated beyond the property.

 

G)        Has a site investigation been prepared?

 

H)        Have cleanup activities commenced at the site?

 

I)         The name of the licensed professional engineer performing remediation on this site, if applicable.

 

3)         General Information about other insurance at the facility.

 

A)        Whether other insurance specifically providing pollution liability coverage has existed for this property. If the response is yes, provide the name of the company, policy number and a copy of the policy.

 

B)        Has the incident been reported to the insurance company?

 

C)        Has the person filing the claim requested payment from anyone else for costs associated with the claim? If the response is yes, provide information on the payment request from a third party.

 

d)         Claim Reimbursement Form. The following is a summary of general information that shall be completed on the claim reimbursement request form:

 

1)         Claimant information, including name, address, social security or Federal Tax ID number. In addition, site information regarding where the remedial activities were performed, including site name, physical address and city.

 

2)         Contractor information in the form of contractor name, address and telephone number.

 

3)         Remediation activities. An indication of the activities that were completed and the amount being billed at this time.

 

4)         Reimbursements from other programs. An indication of whether the claimant has applied for reimbursement from any other source for the invoices being submitted with this form.

 

5)         Original invoices.

 

6)         A summary of the eligible costs, broken down by cost category, and certification that the information is accurate and complete.

 

7)                  A schedule of detail to support the cost categories reported.

 

(Source:  Amended at 30 Ill. Reg. 7939, effective April 13, 2006)