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HomeMy WebLinkAbout229055 2/11/2014 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL MCAT ECK AMOUNT: $180.00 i•'�•?o CARMEL, INDIANA 46032 CASHIER OFFICE-MAIL CODE 50-10C Fi 100 N SENATE AVE CHECK NUMBER: 229055 INDIANAPOLIS IN 46204 CHECK DATE: 2/11/2014 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 PERMITS 180 . 00 OTHER EXPENSES 104EM INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT We Protect Hoosiers and Our Environment. -tea Michael R. Pence 100 North Senate Avenue i Governor Indianapolis, Indiana 46204 (317) 232-8603 Thomas W. Easterly Toll Free (800) 451-6027 Commissioner www.idem.IN.gov December 04, 2013 66-34 Jacen H. Rayle 23690 Dunbar Rd. Arcadia, IN 46030 Dear Mr. Rayle: Re: Water Works Operator Certification Examination This is to notify you that you have either failed to attend or received an unsatisfactory grade (less than 70%) for the Grade OIT WT5 Water Works Operator Certification Examination held on November 7, 2013. Exam scores have been posted at http://www.in.gov/idem/5091.htm. You will need to use your exam sign-in number to view your score (usually the last 4 digits of your social security number). Should you wish to apply for the May 1, 2014, certification examination, you must complete and return the section indicated on page two along with the application fee to the IDEM Cashier's Office, Mail Code 50-10C, 100 N. Senate Avenue, Indianapolis, Indiana 46204-2251. In order to meet the application deadline, this information must be postmarked no later than March 17, 2014. There is also an exam tentatively scheduled for November 6, 2014, if you would like to retake your exam at that time. You may review your examination papers in the IDEM Drinking Water Branch office by January 31, 2014, by appointment only via a written request. You may send your written request to review your exam via standard mail to the attention of Dennis Henderson, via fax at 317/234-8106 or via email to DRHENDER@idem.in.gov . Although any examinee that failed may review their exam, we strongly encourage those having scored 65 to 69 to do so. - Any person affected or aggrieved by this agency's decision to deny application for operator certification may request review, provided that a petition for administrative review is filed as required by IC 4-21.5-3-7. The petition must be submitted to the following within eighteen (18) days of the date of mailing of this notification. Jacen H. Rayle Page Two Office of Environmental Adjudication 100 N. Senate Avenue Government Center North, Room 501 Indianapolis, IN 46204 The petition must include the facts demonstrating that you are either the applicant, a person aggrieved or adversely affected by the decision or otherwise entitled to review by law. In order to assist the Permit, Certification and Capacity Section staff in tracking appeals, we request that you submit a copy of your petition to Sherri Winters, Section Chief, Permits, Certification and Capacity Section, Drinking Water Branch, Indiana Department of Environmental Management, Mail Code 66- 34, 100 North Senate Avenue, Indianapolis, Indiana 46204-2251. Additionally, IC 13-15-6-2 requires that your petition include: 1. The name and address of the person making the request; 2. The interest of the person making the request; 3. Identification of any persons represented by the person making the request; 4. The reasons, with particularity, for the request; 5. The issues, with particularity, proposed for consideration at the hearing, and 6. Identification of the conditions which, in the judgment of the person making the request, would be appropriate in the case in question to satisfy the requirements of the law governing operator certification of the type granted or denied. If you have any questions, please do not hesitate to contact Ms. Ruby Keslar at 317/234-7431. Please note-that the-Drinking Water Branch office is located on the 12th floor of the Indiana Government Center North building at 100 N. Senate Avenue, Indianapolis, Indiana. Sincerely, Sherri Winters, Section Chief Permits, Certification and Capacity Section Drinking Water Branch Office of Water Quality I would like to be scheduled for the May 1, 2014 November 6, 2014 Grade'JT waterworks operator certification examination. JA c C til 2iL1 LL �---- Applicant (printed name) pplicant (signature) 'OEM INDIANA DEPARTMENT Or ENVIRONMENTAL MANAGEMENT We Protect Hoosiers and Our Environment. rs Michael R. Pence 100 North Senate Avenue Governor Indianapolis, Indiana 46204 (3 17) 232-8603 Thomas W. Easterly Toll Free (800) 451-6027 Commissioner www.idem.IN.gov December 04, 2013 66-34 William A. Bell Jr 5419 South 225 West Atlanta, IN 46031 Dear Mr. Bell Jr: Re: Water Works Operator Certification Examination This is to notify you that you have either failed to attend or received an unsatisfactory grade (less than 70%) for the Grade WT5 Water Works Operator Certification Examination held on November 7, 2013. Exam scores have been posted at http://www.in.gov/idem/5091.htm. You will need to use your exam sign-in number to view your score (usually the last 4 digits of your social security number). Should you wish to apply for the May 1, 2014, certification examination, you must complete and return the section indicated on page two along with the application fee to the'IDEM Cashier's Office, Mail Code 50-10C, 100 N. Senate Avenue, Indianapolis, Indiana 46204-2251. In order to meet the application deadline, this information must be postmarked no later than March 17, 2014. There is also an exam tentatively scheduled for November 6, 2014, if you would like to retake your exam at that time. i You may review your examination papers in the IDEM Drinking Water Branch office by January 31, 2014, by appointment only via a written request. You may send your written request to review your exam via standard mail to the attention of Dennis Henderson, via fax at 317/234=8106 or via email to ' DRHENDER@idem.in.gov . Although any examinee that failed may review their exam, we strongly encourage those having scored 65 to 69 to do so. Any person affected or aggrieved by this agency's decision to deny application for operator certification may request review, provided that a petition for administrative review is filed as required by IC 4-21.5-3-7. The petition must be submitted to the following within eighteen (18) days of the date of mailing of this notification. William A. Bell Jr Page Two Office of Environmental Adjudication 100 N. Senate Avenue Government Center North, Room 501 Indianapolis, IN 46204 The petition must include the facts demonstrating that you are either the applicant, a person aggrieved or adversely affected by the decision or otherwise entitled to review by law. In order to assist the Permit, Certification and Capacity Section staff in tracking appeals, we request that you submit a copy of your petition to Sherri Winters, Section Chief, Permits, Certification and Capacity Section, Drinking Water Branch, Indiana Department of Environmental Management, Mail Code 66- 34, 100 North Senate Avenue, Indianapolis, Indiana 46204-2251. Additionally, IC 13-15-6-2 requires that your petition include: 1. The name and address of the person making the request; 2. The interest of the person making the request; 3. Identification of any persons represented by the person making the request; i 4. The reasons, with particularity, for the request; I 5. The issues, with particularity, proposed for consideration at the hearing, and j 6. Identification of the conditions which, in the judgment of the person making the request, would be appropriate in the case in question to satisfy the requirements of the law governing operator certification of the type granted or denied. If you have any questions, please do not hesitate to contact Ms. Ruby Keslar at 317/234-7431. Please note that the Drinking Water Branch office is located on the 12th floor of the Indiana Government Center North building at 100 N. Senate Avenue, Indianapolis, Indiana. Sincerely, , Sherri Winters, Section Chief Permits, Certification and Capacity Section Drinking Water Branch Office of Water Quality would like to be scheduled for the May, 1, 2014 November 6, 2014 Grade l Jr5 waterworks operator certification examination. Applicant (printed name) Applicant (signature) '®EM INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT We Protect Hoosiers and Our Environment. 411M Michael R. Pence 100 North Senate Avenue Governor Indianapolis, Indiana 46204 z ~ (3 17) 232-8603 ` Thomas W. Easterly Toll Free (800) 451-6027 Commissioner www.idem.IN.gov December 04, 2013 66-34 Kris C. Anthis 11955 Cable Dr. Indianapolis, IN 46236 Dear Mr. Anthis: Re: Water Works Operator Certification Examination This is to notify you that you have either failed to attend or received an unsatisfactory grade (less than 70%) for the Grade WT5 Water Works Operator Certification Examination held on November 7, 2013. Exam scores have been posted at http://www.in.gov/idem/5091.htm. You will need to use your exam sign-in number to view your score (usually the last 4 digits of your social security number). Should you wish to apply for the May 1, 2014, certification examination, you must complete and return the section indicated on page two along with the application fee to the IDEM Cashier's Office, Mail Code 50-10C, 100 N. Senate Avenue, Indianapolis, Indiana 46204-2251. In order to meet the application deadline, this information must be postmarked no later than March 17, 2014. There is also an exam tentatively scheduled for November 6, 2014, if you would like to retake your exam at that time. You may review your examination papers in the IDEM Drinking Water Branch office by January 31, 2014, by appointment only via a written request. You may send your written request to review your exam via standard mail to the attention of Dennis Henderson, via fax at 317/234-8106 or via email to DRHENDER@idem.in.gov . Although any examinee that failed may review their exam, we strongly encourage those having scored 65 to 69 to do so. Any person affected or aggrieved by this agency's decision to deny application for operator certification may request review, provided that a petition for administrative review is filed as required by IC 4-21.5-3-7. The petition must be submitted to the following within eighteen (18) days of the date of mailing of this notification. Kris C. Anthis Page Two Office of Environmental Adjudication 100 N. Senate Avenue Government Center North, Room 501 Indianapolis, IN 46204 The petition must include the facts demonstrating that you are either the applicant, a person aggrieved or adversely affected by the decision or otherwise entitled to review by law. In order to assist the Permit, Certification and Capacity Section staff in tracking appeals, we request that you submit.a copy of your petition to Sherri Winters, Section Chief, Permits, Certification and Capacity Section, Drinking Water Branch, Indiana Department of Environmental Management, Mail Code 66- 34, 100 North.Senate Avenue, Indianapolis, Indiana 46204-2251. Additionally, IC-13-15=6-2 requires that your petition include: 1. The name and address of the person making the request; 2. The interest of the person making the request; 3. Identification of any persons represented by the person making the request; 4. The reasons, with particularity, for the request; 5. The issues, with particularity, proposed for consideration at the hearing, and 6. Identification of the conditions which, in the judgment of the person making the request, would be appropriate in the case in question to satisfy the requirements of the law governing operator certification of the type granted or denied. If you have any questions, please do not hesitate to contact Ms. Ruby Keslar at 3171234-7431. Please note that the Drinking Water Branch office is located on the 12th floor of the Indiana Government Center North building at 100 N. Senate Avenue, Indianapolis, Indiana. Sincerely, Sherri Winters, Section Chief Permits, Certification and Capacity Section Drinking Water Branch Office of Water Quality I would like to be scheduled for the May 1, 2014 `� November 6, 2014 Grade waterworks operator certification examination. i Applicant (printed name) /Pplicant (signature) 3 PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER ws number: DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number: State Form 12094 (R612-06) Approved by Slate Board of Accounts 2006 Approved: 327 IAC 8-12-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied/Reason: NOTE: A$30 fee must be submitted with each application for certification. Applications must be signed by the individual,and his/her supervisor. Failure to rile a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This Is an application for Grade:(check one-One application per grade checked): Water Distribution System ❑ ❑ ❑ PWS ID#: Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator0 El 11 0 11 ❑ 1 W`T2 WT3 WT4 W`175 W76 O.I.T ❑Northwest ❑Central �, " ❑Northeast El Southwest ❑Southeast �y examination ❑By reciprocity e- • J 2111111111 •- 1. N�a�of applicant(lest) (first) (middle) IJMr. ❑Mrs. Elms. WLI-S" / L 2. iling�r (numberand st et): � ;&� &�.t City: State: IIZIP e: County: 3. Office telephone numb r. 4. Home telephone number: 7� Z.J 0 /15- 5. Have youever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) []Yes* Ldtvo 'If yes,date(mm/ddWyy): 6. Are you presently a�certified waterworks operator in Indiana? []Yes* Leo 'If yes,give certification number and classification: 7. Are you presently a certified water works operator In another state? []Yes* 9<0 'If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes L1flo 9. Social Security number:' Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure Is voluntary and you will not be penalized for refusal. • • e •e e s e- • r ck the highest grade completed. hool: High School: College&Vp ❑l ❑2❑3❑4❑5❑6❑7❑8 ❑9❑10❑11 ❑12 01 ❑2 ❑4❑5 06❑More than 6 years 11. Hi ool Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': / es []No ❑GED zC J�l� 7 an 12. College Graduate? Degree: Major: Oyes lo- Date granted(mm/dd/yyyy): N e and to ation of (lege: Continued on page 2) ' Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 � o � • e 13. Training courses,short courses,or other courses attended applicable to water Industry: a. Name of course: Name of school: Dales: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: o- • • ► List your current assignment first. Show all experience In the Drinking Water field. Attach additional sheets,If necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME I ADDRESS JOB DUTIES FROM: TO Position tittlle:/J 4,,7-�y f Name of current employer: /' r Specific duties performed in day-to-day operation:: Address:(number and street) City,stale,ZIP code: FROM: TO: Position title: Nme of pre lousp mployer: Specific dd�u/utties performed In day-to-day operation: / / p Address:(number and street) /e/� �57�7t(/tt04 1�6iL �i� d�(Q�/�i�C�/ � � (_ �i�i ver i�n/ vC¢i/�s✓ sG�gd(Ce iPra�/hnMcF�tµ'f��Pl�u , .,�� City,state,ZIP code: FROM: TO: Position tillpg /C&" Name of previous employer: -e' l ,G� 00, Specific duties performed in day-today operation: fddress:(number ancl street) Z/ SGS �l1iL'fr►'d 'T 4 —S tYice, ?{�" r�S�rr.��.r�-��� City,state,ZIP code: CytyG -rir FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) City,stale,ZIP code: (Continued on page 3) Page 2 of 3 q PART IV� 0 ,BEZOMPLETE�R'BYX,ER�TIIFIED OPERATOR I hereby certify the Information contained in this section of this application Is true and correct to the best of my knowledge. I have supervised this individual for a years. Name f Certified Operator der whose supervision experience obtained Certification Number(s): Sig re of Coftified Operato Printed name and signature of applicant's supervisor:(if different than above) Applicant's supervisor:(if different than above) Name of organization/utility/system: Telephone number:(include area code) Address:(number and street) City: State: ZIP code: e I,the undersigned,certify that I am the above applicant;that all statements made and information contained in the above application are true and correct to the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result In Ineligibility for the examination applied for,or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied. Signature of pplicant: Date(mm/dd/yyyy): The completed application,along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office,Mail Code 50-10C 100 North Senate Avenue Indianapolis,IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 A 3 � PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER WS number: DISTRIBUTION SYSTEM OPERATOR Receipt number: CERTIFICATION State Form 12094 (R6/2-06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8-12-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Dented/Reason: NOTE A$30 fee must be submitted with each application for certification. Applications must be signed by the individual,and his/her supervisor. Failure to file a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade:(check one-One application per grade checked): Water Distribution System ❑ ❑ ❑ PWS ID#: Operator DSS DSM DSL Water Treatment Plant Operator VV71 a 2 3 O 4 WT5 WT6 O❑I.T ❑Northwest ❑Central ❑Northeast ❑Southwest ❑Southeast 134Y examination ❑By reciprocity •- • •- !11!1I11J1�!1;I11 !121.101 1. Nam of applicant(last) `/` Cist) ( addle) OMr. ❑Mrs. ❑Ms. oU�is 2. Mailinaddress(number an street): S lQ Yl r ! City: State: ZIP code: County: 1 6111'a Q Z ce, 1 3. Office telephone numbdr: 4. Home telephone number: 1 44Z 1312 A2_30 5. Have youever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) ❑Yes* cxo -If yes,date(mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? ❑Yes* ONo *If yes,give certification number and classification: 7. Are you presently a certified water works operator in another state? ❑Yes* d1Vo *If yes,give certification number and classification(attach a copy of certificate) 8. Have you �ever had a certification suspended or revoked? ❑Yes leol 9. Social Security number' *Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 10. Check the highest grade completed. Grade School: High School: College(ye ): 0 [12 03[14[35 06 07 08 [19[110[311C312Ell [123❑4 05❑6❑More than 6 years 11. High School Graduate? Dale of graduation(mm/dd/yyyy): Name and location of school': / - r I CWs ❑No ❑GED -7` -4,4Q'Al elf C 12. College Gra ? Degree: Major: ❑Yes o Date granted(mm/dd/yyyy): Name and llgpatiop o coil ge: L 6 (Continued on page 2) 'Proof of education must be submitted when used as a substitution for experience. Pagel of 3 PART • o e •NTIN • 13. Training courses,short courses,or other courses attended applicable to water Industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: No. List your current assignment first. Show all experience In the Drinking Water field. Attach additional sheets,if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME 1 ADDRESS JOB DUTIES FROM: TO: /tom( PQatilLo:�. ` � Ne o current em toyer: �/ L 1 ,�' /, y d� (/ttV Specific duties performed in day-to-day operation: Address:(number and street) rnQ,,ale. 4-(_L Phis cl _LCity,state,ZIP code: FROM: TO: Position title: Name of previouj_ /?d loye /` � 1-v' 0-�6a /¢L Tea /.e_' Specific duties performed in day-to-day operation: Address:(number and street) LL' ,( City,state,ZIP code: FROM: TO: Positiop title: Name of pre lous employer: r Specific dutl s performed in day-to-day operation: Address:(number and street) e1��'o�,dre.n ��- .�►�'u,���7�i�n1 � r�ul��'�e City,state,ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed In day-to-day operation: Address:(number and street) City,state,ZIP code: (Continued on page 3) Page 2 of 3 � •C PART IV:T6,BE COMPLETEDBYXERTIFIED 0 I hereby certify the Information contained in this section of this application is true and correct to the best of my knowledge. •1 I have supervised this individual for_ years. Nam of Certified Oper or under whose supervision experience obtained Certification Number(s): A AA-AY Sig ure of C rtifie erator: Printed name and signature of applicant's supervisor:(if different than above) Applicant's supervisor:(If different than above) Name of organization/utility/system: Telephone number:(include area code) Address:(number and street) City: State: ZIP code: a I,the undersigned,certify that I am the above applicant;that all statements made and Information contained in the above application are true and correct to the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result In Ineligibility for the examination applied for,or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied. z 4-=-A ignature of applicant: Date(mm/dd)yyyy): The completed application,along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office,Mail Code 50-10C 100 North Senate Avenue Indianapolis,IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 PUBLIC WATER SUPPLY APPLICATION FOR WS number: WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number: State Form 12094 (R6/2-06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8-12-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied/Reason: NOTE: A$30 fee must be submitted with each application for certification. Applications must be signed by the individual,and his/her supervisor. Failure to file a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade:(check one-One application per grade checked): Water Distribution System ❑ ❑ ® PWS ID#: 064 Operator DSS DSM DSL PLEASE HECK EXAM LOCATION Water Treatment Plant Operator E 1 11 V❑VT3 0 4 11O 6 O❑.I.T ❑Northwest ®Central ❑Northeast F_1 Southwest Southeast ❑By examination ❑By reciprocity 1. Name of applicant(last) /J (first) (middle) ®Mr. ❑Mrs. OMs. kA L ,ACiti 2. Mailing address(number and street): Ll O i City: State: ZIP code: County: ytC'03c, City: State: -T 3. Office telephone number: 4. Home telephone number: 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) R]Yes' ❑No 'If yes,date(mm/dd/yyyy): ,jo QCT,ILt - aT 3 C`E'r*Ic41,11..s 6. Are you presently a certified water works operator in Indiana? ©Yes' []No 'If yes,give certification number and classification: �� 2-C?-C WT 3 7. Are you presently a certified water works operator in another state? []Yes* RNo 'If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes ®No 9. Social Security number:' 'Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 10. Check the highest grade completed. Grade School: High School: College(years): ❑l ❑2 E]3[--14❑5 06E17❑8 ❑9❑10 Ell ©12 ❑1 ❑2❑3 04❑5❑6[]More than 6 years 11. High School Graduate? Date of graduation(mmidd/yyyy): Name and location of school': ®Yes ❑No ❑GED / .? / 12. College Graduate? Degree: Major: ❑Yes S&No Date granted(mm/dd/yyyy): Name and location of college: (Continued on page 2) 'Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 e • 0 0 0MESEEM 13. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school:}T Dates: College unfits or Cclass hours: ► List your current assignment first. Show all experience in the Drinking Water field. Attach additional sheets,if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME/ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: 1 2011 ��P T 0T•3 C44zfnLL SnDpecific duties performed in day-to-day operation: Address:(number and street) fC�IJ —res—r fnc1I_ C1 rY ..y`IA; 7iLL-i7,: C---t-r' P0:17 s G1nXrArn.0A W ybc7 City,state,ZIP code: FROM: TO: tPosition title: Name of previous employer: I I ut(si I ZC t� ,JISTs'ta} Teo.! LH6c�e_ Specific duties performed in day-to-day operation: Address:(number and street) 1}IAWTA) RE�A)a WA7i +��57eZ1t3�>ic% St�57cM. 34. . 1.)5_T _ST. City,state,ZIP code: Ic���k tf1:�, 'T4r✓i C ���►� N+61* Scxa,LC Pu-p5 : Q�P�tt2- )fes) L11Pc>7y III PXL-A5�5 CXLl m 4 FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) City,state,ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) City,state,ZIP code: (Continued on page 3) Page 2 of 3 I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge. I have supervised this individual for years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): 934 716 Signature of Certified Operat r.' Printed name and sign,atur/e of applicant's sup isor:(if different above) Applicant's supervisor:(if different than above) L vee (_-fC1"/19 tame of organization/utili /system: Telephone number:(include area code) X11 � i -A41 Address:(number n s reet) i rec-4 City; State: ZIP code: I,the undersigned,certify that I am the above applicant;that all statements made and information contained in the above application are true and correct to the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for,or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied. t�� I I Z8 holy Signa re of applica t: Date(mm/dd/yyyy): The completed application,along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office,Mail Code 50-10C 100 North Senate Avenue Indianapolis,IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 Prescribed by State Board of Accounts City Form No.201 (Rev 1995) ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL An invoice or bill to be properly itemized must show, kind of service, where performed, dates of service rendered, by whom, rates per day, number of units, price per unit, etc. Payee TIDEM IDEM Purchase Order No. 100 N SENATE AVENUE Terms INDIANAPOLIS, IN 46204-2251 Due Date 2/5/2014 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 2/5/2014 WT5 $180.00 Lao) hereby certify that the attached invoice(s), or bill(s) is (are)true and correct and I have audited same in accordance with IC 5-11-10-1.6 1-7 Date Officer VOUCHER# 134011 WARRANT# ALLOWED TIDEM ) i 41 IN SUM OF $ IDEM 'nom 100 N SENATE AVENUE INDIANAPOLIS, IN 46204-2251` Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code WT5 01-6040-03 $180.00 Voucher Total $180.00 Cost distribution ledger classification if claim paid under vehicle highway fund