246635 06/24/15 (9,
CITY OF CARMEL, INDIANA VENDOR: 229400
ONE CIVIC SQUARE IND DEPT OF HOMELAND SECURITY CHECK AMOUNT: $********50.00*
CARMEL, INDIANA 46032 302 W WASHINGTON ST RM E243IFISCAL CHECK NUMBER: 246635
DEPT CHECK DATE: 06/24/15
INDIANAPOLIS IN 46204
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 50.00 MATERIALS & SUPPLIES
STATE OF INDIANA
Department of Homeland Security
Boiler and Pressure Vessel Division
18th`
June 10, 2015 Number of Invoices
attached Total Due
CARMEL CITY OF 2 $ 50.00
C/O LISA KEMPA
760 3RD AVE SW SUITE 110 Owner Id/Reference#: 651680
CARMEL IN 46032
If you have questions concerning your equipment , please call 317-232-1921.
Past Due Payment Information
Our records indicate that the amount noted above and itemized on the attached invoice(s) is
past due for payment.
Please send all payments / payment inquiries to:
Department of Homeland Security
302 W. Washington St. Rm. E243/Fiscal Dept.
Indianapolis, IN 46204
Fax number : 317-233-0401
*Method of payment as follows:
-You can pay all your payments online at IDHS web site
https://myoracte.in.govldfbslidhsFeesFineslstart.do with Visa/Master Card/Discover
cards.
Note: Use Owner Id on this letter or Indiana State Number on the invoice to pull up
information when paying the dues online.
-Check
-Money Order
-Mastercard or Discover or American Express ONLY...no exceptions (if you use the form)
(credit card form enclosed with letter)
**Make all checks payable to: Department of Homeland Security
James Greeson
State Fire Marshal
Division of Fire and Building Safety
1 of Indiana Department of Homeland Security
&'nnTfio INVOICE FOR INSPECTION / CERTIFICATE FEES
°k State Form 356(R4/9-93)
wi n Approved by the State Board of Accounts-1991
y\.......�-/moi.
1.Mail checks payable to DEPARTMENT OF HOMELAND SECURITY
INSTRUCTIONS:
2. Mail 2nd copy&check to DEPARTMENT OF HOMELAND SECURITY
402 W WASHINGTON ST.,RM 246
INDIANAPOLIS IN 46204-2739 Current Due
Fax:(317)234-8436
INDIANA STATE CARMEL CITY OF LATEST PLEASE
NUMBER INVOICE PAY THIS
C/O LISA KEMPA DATE AMOUNTI
290011 760 3RD AVE SW SUITE 110
CARMEL, IN 46032 05/15/2015
Owner number User Name&Location of vessel WASTE WATER TREATMENT PLT Fee
9609 HAZEL DELL PKWY $ 25.00
INDIANAPOLIS IN 46280
Serial number Description of vessel Manufacturer Date Last Inspected
FT Boiler BURNHAM 03/23/2015
National Board No. Inspection agency Name of inspector (This fee is
28519 TRAVELERS REEVES JOSEPH prescribed by
IC 22-12-6-10)
INVOICE FOR INSPECTION CERTIFICATE FEES
State Form 356(R4/9-93)
t Approved by the State Board of Accounts-1991
1.Mail checks payable to DEPARTMENT OF HOMELAND SECURITY
INSTRUCTIONS:
2. Mail 2nd copy&check to DEPARTMENT OF HOMELAND SECURITY
402 W WASHINGTON ST.,RM 246
INDIANAPOLIS IN 46204-2739 Current Due
Fax(317)234-8436
INDIANA STATE CARMEL CITY OF LATEST FAMOUNTI
NUMBER INVOICE
C/0 LISA KEMPA DATE
308699 760 3RD AVE SW SUITE 110
CARMEL, IN 46032 05/15/2015
Owner number User Name&Location of vessel CARMEL WASTE WTR UTILITIES Fee \/
9609 HAZEL DELL PKWY $ 25.00
CARMEL IN 46280
Serial number Description of vessel Manufacturer Date Last Inspected
FT Boiler HURST 03/23/2015
National Board No. Inspection agency Name of inspector (This fee is
14935 TRAVELERS REEVES JOSEPH prescribed by
IC 22-12-6-10)
2of3
Prescribed by State Board of Accounts
Form No.301-S(Rev.1997) ACCOUNTS PAYABLE VOUCHER
TO
ADDRESS
Invoice Date Invoice Number Item Amount
I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or services
itemized thereon for which charge is made were ordered and received except
Mo. Day Yr. Signature Title
I hereby certify that the attached invoice(s), or bill(s), is (are)tr e and correct and I have audited same in accordance
with IC 5-11-10-1.6.
Mo. Day Yr. IV
icer Title
Voucher No. Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
MUNICIPAL WASTEWATER UTILITY ACCT.
CARMEL, INDIANA No.
��oiylE�{jvJPCf�///
o� w wAsA,"tip
1,tr Y62o y
Total Amount of Voucher $
Deductions
oa
® oS
Amount of Warrant $
Month of Yr
Acct.
VOUCHER RECORD No.
Collection System
Pumping
Treatment&Disposal
Customer Accounts
Administrative&General
Reclaimed Water Treatment
Reclaimed Water Distribution
Total
Allowed
Board Members
Filed
ROYCE FORMS•SYSTEMS 1-800-382-8702 325