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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