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Home My WebLink About236416 08/27/14 C,q CITY OF CARMEL, INDIANA VENDOR: 00351805 ONE CIVIC SQUARE IND DEPT OF ENV MANAGEMENT CHECK AMOUNT: $*****"**60.00* CARMEL, INDIANA 46032 CASHIER'S OFFICE-MAIL CODE 50-10C CHECK NUMBER: 236416 100 N SENATE AVE CHECK DATE: 08/27/14 INDIANAPOLIS IN 46204-2251 DEPARTMENT ACCOUNT 'PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 WT3/WT5 60.00 OTHER EXPENSES PUBLIC WATER SUPPLY APPLICATION FOR ' WATER TREATMENT PLANT AND WATER INS number: •> DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number: State Form 12094 (R6 12-06) 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 properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an applicatiomfor Grade:(check one.-One application per grade checked):. Water Distribution System ❑ ❑ ❑ PWS ID#: Operator DSS DSM DSL PLEASE C. EC EX LOCATION Water Treatment Plant Operator ❑ ❑ El El _E1 WT1 WT2 vv 1'3 WT4 WT5 WT6 O.I.T ❑ Northwest [Central .. [INortheast .. ElSouthwest El Southeast VBy examination- ❑By.reciprocity, PART 1:GENERAL •- • •- PRINT LEGIBLY) 1. Nlne of applicant(last)( (first) lin � ) (middle) L9Mr. ❑Mrs.'❑Ms.' )J G � 1.r l G+T!�{ lgJ. LrC�r%,., 2. Mailing address(number and street): 12.4qo W d hdrn pcksS City: State: ZIP code: County: 3. Office telephone number: 4. Home telephone number: 5 7 1 -ylyl 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) . []Yes. L1/No *If yes,date(mm/dd/yyyy): 6. Are y;Nc upp esently a certified waterworks operator in Indiana? ❑Yes* *If yes,give certification number and classification: 7. Are you presently a certified water works operator in another state? - ❑Yes* M40 *If yes,give certification number and classification(attach a copy of certificate) ` 8.- Have you ever had a.certification suspended or revoked? []Yes IN/0 - 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.' EDUCATIONPART II: . TRAINING(APPLICANTS MUST HAVE A HIGH SCHOOL DIPLOMA OR GED) 10. Check the highest grade completed. Grade.School: High School: College(years) [:11 [12E13E]4[]5[16E17[18F-19F-110[311E112 01,02 03 IJ4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name,and location of school: L 1�Yes ❑No ❑GED C /31 200-7 Le loq r on Seh;or- H:yh 5c,6ol J Lt 6 ct nan ZN 12. C lege Graduate? Degree: Major: C-- Yes ❑No IJoic.ke lOr- Law cxv%J Si'i;G+,!APre_-L4u/ Date granted(mm/dd/yyyy): Name and location of college: Pu c,< o n;mrsi f-y rd 2/1<z/2011 W,#,54_ L*fa {4e TA) (Continued on.page 2) Proof of education must be submitted when used as a substitution for experience. - — page 1-of 3 PART II:EDUCATION AND TRAINING(CONTINUED) 13. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: W T S Class Name of school: Dates: College units or class hours: fpm-tr:can Vq}-cr Feh— A 201 W. 3 Z 6 r� b. Name of course: w T3 G[a5 Name of school: Dates: College units or class hours: kWWA- Avg Z- Oc,+LS 2.0(14 HISTORYPART III:EXPERIENCE► 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: jllo�uhn . �13 Gu rr"I•I ra I�or i v� -1- h; r+ C; of Cqr Specific duties performed in day-to-day`operation: W 1-3 4 nd Uj 7-S Address: (number and street) Runp14Y1 wa+-tr sgA%pL s, qdd and d{was Onc. Giv•c S�[ugnc U (,1�in.:La I amovy d-s, backwash 0-0n -P;Ikr oldj(.sj- Flow flows, 6 ac,k w as h S d>-+-h.c rS I c.h-cc.k we I Is City,state,ZIP code: A�10n WI"*h d J-hur PIani- dpt,vs w'g+tor, Urad-c +� C0.r'n`� SIV �Ibo3L Su �vuidrl of l;n ct n3td O rt for. FROM: TO: Position title: Name of previous employer: f 1�1 q trc h ZoI 3 Nd wjn btr MS l a 6orc,v/P/a ))4-S. C,34.A Carm-CA Specific duties performed in day-to-day operation: Address: (number and street) H'4-'[P ma;h1-"L'► PIG11 +-S; -Pi J PV�PS�N%q3� f�rVil.� of'lt. C;4iL Sgvar4- c.hc.ck WC-)f J � S CWT3 and Wry) -Fid or bu,i d ele r ��41 City,state,ZIP code: Pam I5 4eU„oI(5 op Pian+s. HIC IP " n►a;,�q 4 h a h rl-0J jr.i c-a( g n d c 1 w+r;CdL( a r�'S d f Pio n t- �1 N q6632, opctra flow. FROM: TO: Position title: Name of previous employer: 0co - Zo12, March 2013 (a6ortr/Q,s�rvba�ton Cr+ o-P CW(re,� Specific duties performed in d�=to-day operation`_. _ _ ____ _ _=Addressr=(number-and-street)-- - — - - 14 (Vurn+;an ;r►;PAL 5 t-hV C,+vrc of 4.hc. ON- Clwc S'.'Aua*ei W4 4r rna.n s for d;i sd-r v bq+%o n 53S+e-1A Rtl°a''rcd wa4�v' rna;n brc4 )C5, .Str uic cd d h d rt pa;r•c d fi City,state,ZIP code: Curd TrJ H(903Z 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 l PART IV:TO BE COMPLETED BY CERTIFIED 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/6 _ years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): r17— �1,30 143— Signa re of Certified Operator: W( `I a 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) G: Cir' /111,/arXe 31 7 - 7 Address:(number and street) Is 11 W" Ise �S City: State: ZIP code: CA CnAnt, PART V:SIGNATURE OF APPLICANT 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. ,�O�ralj - 7/1,91ZoR Signature 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 thedndiana Department of Environmental-Management - - - - - - (3240-4114-00-140000) DO NOT SEND CASH. Page-3 of 3 ui VVJ IIUIIIUCI. WATER TREATMENT PLANT AND WATER DISTRIBUTION'SYSTEM OPERATOR CERTIFICATION Receipt number: State Form 12094 (R612-06) 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 rile.a properly 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 C I Water Treatment Plant Operator 1❑l El 9 l WT5 11 O❑.I.T ElNorthwest Central El Northeast ❑Southwest El southeast [VBy examination ElBy reciprocity PART 1:GENERAL •- • • PRINT LEGIBLY) - 1. Ni,,�ne of applicant(last)(� L (first) L (middle) Mr. ❑Mrs.'❑Ms.' Bl i GIk-d A tT►►� tt} �{r o h 4- 2. Mailing address(number and street): 126yO W; d ham PaSS City: � State: ZIP code: County: Ca Pme � ' Jq 4c 3Z Nc�►n.; +en 3. Office telephone number: 4. Home telephone number: 5 ? ( -ylyl 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) ❑Yes* EM/No 'if yes,date(mm/dd/yyyy): 6. Are y;Nc upp esently a certified water works operator in Indiana? ❑Yes' *If yes,give certification number and classification: 7. Are you presently a certified water works operator in another state? ❑Yes* L4No *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes L�}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. EDUCATIONPART 11: •• - • •- 10. Check the highest grade completed. Grade School: High School: College.(years): Ell E12[13[]4[35 E16[17 08 ❑9❑10[Ill E112 Ell [121--13 �4.❑5❑6❑More than 6 years 11. Higr�nn School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school Vyes ❑No ❑GED 5/31/3ZOo 7 LGIog hO h S&h;or- �- :3 5 c,l�o l Lc 6 ctrian ZN 12. C lege Graduate? Degree: Major: p Yes []No Qachclor LAW af%j �i;c,+,')/ re-L4;-1 Date granted(mm/dd/yyyy): Name and location of college: Ou rOUf V n;VC V $i') (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 PART II:EDUCATION AND • 13. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: W T S class Name of school: Dates: College units or class hours: Am<r;cah Wq 1-4v' i r% 14 fOr Feb- /& 2o! 3 Z_ b. Name of course: V 1-3 G[a r2 Name of school: Dates: College units or class hours: �ww� �g z_ o�+ZS ZoIW ? Z hrs PART III:EXPERIENCE HISTORY • EMPLOYERS) ► 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: Position title: Name of current employer: Aven r2o 13 Gu rr �- rdt 4,or ;� +hay n; h C;i--n pf caro'-p-A Specific duties performed in day-today operation: �-3 a hd 1M�5 f 14 n 4f Address: (number and street) Ron14)1 >}-S' +cS �- w4 -tr sq nplej/ add clnd dt Ong' Gtv•c S�va� asc. Gd►cn►:�a 1 aneouy 1-.S, back—wash lrvn -',Ikr P Iqn+' PIovS, 10 4c_k w as�► Sd�}-►�.¢v'S Lh{c we I is, City,state, ZIP code: Mon W,'A di•40 Plani< O��'�t�-ions Uhd-s� Cq,f`n`� �1V C4 60'S2. Sv Avision 01, (:n Ce ns,td iJ r-a-for. FROM: TO: Position title: Name of previous employer: ala-c,h Zo13 1VovCM6-er &13 l a borer//`/"4-5 C14A Of Cilar/r-CA Specific duties performed in day-to-day operation: Address: (number and street) 1P mai'n�-JVAI P 1a $S; -�'; � Po nP5/14;jh 5<,-t, C One, c;V;C, S eval6c- c,hc,C-k we,I t � S LVT3 an4 VrS7 -FiA or bv;(dele �ytd�5 ��. City,state, ZIP code: a v% �� ►,ill 5 op P l[ n s- Ham.l p " ma ew4l h Ca�1 rM �1 63 L a h d e. c c, Ca, a rte's 0f 04 111-1- oPert%viti,s. FROM: TO: Position title: Name of previous employer: oc"� 2012- Marsh 2013 1a6orer/0i S�jvbd+ton Cr+-n of Ce O--e-� Specific duties performed in day-to-day operation: Address: (number and street) t,1p lftaty%+iar r►fires d-rvc-}��L of ¢h.c, Oht GtViG $�ua,-v %/a 4 r m a.n s for d i S d-r v bq�;ov% 5')S+e_m. Rtra-'rtd &v.z4 ,r rn a n brc41c5, 5ervic-ed cth d rtpet.h,a -'i ki City,state, ZIP code: :A g6O32 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 PART IT:To BE COMPLETED-13T RTIFIEI�ERATOR 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 1-b 3 years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): Signature of Certified Operator: -10 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) �;�- fir' G,/a�►�-�-� 31-7- 7 3J X&a S Address:(n mber and street) J-C) w City: State: ZIP code: CA r rv, c-(60PART V:SIGNATURE OF APPLICANT 7 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. ��Ilj 7/1g/ZoP Signature of applicant: I 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 -- (3240-41-14-00-140000)=: _. -- --- -- DO NOT SEND CASH. —- Page 3 of 3 VOUCHER # 141497 WARRANT# ALLOWED TIDEM IN SUM OF $ IDEM 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 VVT3/VVT5 01-6040-03 $60.00 Voucher Total $60.00 Cost distribution ledger classification if claim paid under vehicle highway fund 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 8/18/2014 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 8/18/2014 WT3MIT5 $60.00 I hereby certify that the attached invoice(s), or bill(s) is (are) true and LLLLcorrectand I have audited same in accordance with IC 5-11-10-1.6 Date Icer