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Home My WebLink About252044 12/02/1 5 I c�AM S% CITY OF CARMEL, INDIANA VENDOR: 370094 ONE CIVIC SQUARE CURTIS MANIFOLD CHECK AMOUNT: $" ""**"77.00' CARMEL, INDIANA 46032 1007 LANCASHIRE LN CHECK NUMBER: 252044 PENDLETON IN 46064 CHECK DATE: 12/02/15 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 651 5023990 77.00 OTHER EXPENSES APPLICATION FOR VOLUNTARY COLLECTION SYSTEM OPERATION CERTIFICATION Administered by the Indiana Water Environment Association's Collection System Committee EXAM DATES: April 28 and October 27 at Clay Township/April 30 and October 29 at Fort Wayne NOTE:A complete application form is required, including a$65.00(non-refundable)application fee for class I&H examinations and$75.00(non refundable)application fee for class III&IV examinations;detailed employment information;supervisor's and applicant's signatures;and verification of your post high school educational qualifications attached The application is to be typed,or neatly printed. Checks shall be payable to IWEA. Failure to return a completed application form by the final filing date will result in your ineligibilityfor that examination and forfeiture of your application fee. ALL EDUCATIONAND EXPERIENCE REQUIREMENTS MUST BE MET AND CLEARLY STATED. FAILURE TO MEET OR VERIFY EITHER OF THESE WILL RESULT IN INELIGIBILTY FOR THE EXAMINATION. AU applications must be received prior to the 2nd Thursday in March for the April Examination and the 2ndThursday in September for the October Examination CERTIFICATION EXAMINATION APPLICATION,CLASS: CS-I CS-H CS-III CS-IV (CIRCLE ONE) DATE: AA �-20INN I. APPLICANT INFORMATION A. NAME Manifold Curtis L. Last First Middle B. MAILING ADDRESS 1007 Lancashire Lane Street Pendleton Indiana 46064 Madison City State Zip Code County C. WORK PHONE NUMBER: 317 1 719-2181 HOME PHONE NUMBER:( 765 1 778-7126 Area Code&Number Area Code&Number D. E-mail Address: cmanifold@carmel.in.gov E. What is the preferred way of contacting you?(Certifications will still be sent to mailing address. All other correspondence will occur by your preference) CIRCLE ONE Mailing Address E-mail Address F. Have you previously applied for a Collection System Certificate? YES NO (CIRCLE ONE) G. What certifications do you presently hold? List all that apply: Certification Number State Grade(Class) Water Treatment Water Distribution Municipal Wastewater Treatment Industrial Wastewater Treatment Wastewater Collection System Other II. EDUCATION AND TRAINING A. High School: Name of School:_Kokomo High School Location:_Kokomo,IN Years Attended: 4 Date of Graduation: 1972 B. College: Name of School:_Ball State University Location: Muncie,IN Years Attended: 4 Date of Graduation: 1978 C. NOTE: Attach verification of your post-high school educational qualifications. Copies of college transcripts or certificates of completion for courses related to wastewater treatment/collection provide acceptable proof of educational qualifications. You may list training courses,short courses,or other courses in the wastewater field that you have attended on Page 4. Include only post high school information IIl. WORK EXPERIENCE HISTORY List your present employment first then any additional employment. Give a detailed description of your collection system work experience as designated below. If you are not a full-time Collection Systems Operator, speck the average number of hours per week that are spent in the actual operation and maintenance of the collection system. NOTE. If you are applying for a Class III or IV examination, clearly define AND document your "in-charge"experience andgualil<cations (supervision does not necessarily dictate "in-charge"experience). CURRENT EMPLOYMENT: Current Employer: City of Cannel Dates—From 6 /11 /12 to Present Job Title: Inspector Number of Persons Supervised: None Job Description: Perform duties required to conduct inspection of plant and field construction and rehabilitation projects Collection System Duties: Provide assistance in locating and inspecting collection system infrastructure Classification of Wastewater Treatment Plant: Municipal- 1 11 ID (Circle One) Industrial- I-SP A-SO A B C D Wastewater Treatment Plant Capacity: I Z,064bj 00® Gallons Per Day(gpd) Supervisor's Name: Jason Stewart Address: 9609 Hazel Dell Parkway Indianapolis,IN 46280 Phone No.: (317)361-2154 PRIOR EMPLOYMENT: Past Employer: M.K.Betts Engineering Dates—From 9 /1 /02 to 6 /1 /12 Job Title: Superintendent Number of Persons Supervised: Varied 1 to 10 Job Description: Field supervision of industrial and municipal construction projects Collection System Duties: None Classification of Wastewater Treatment Plant: Municipal- 1 11 III ry (Circle One) Industrial- I-SP A-SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day(gpd) Supervisor's Name: Keith Betts Address: 333 Sycamore St. Anderson,tN 46018 Phone No.: (765)649-1294 III. WORK EXPERIENCE HISTORY(Continued) PRIOR EMPLOYMENT: Past Employer: Delphi Automotive Systems Dates—From 6/1 /95 to 8 /1 /02 Job Title: Manufacturing Engineer Number of Persons Supervised: None Job Description: Perform duties related to manufacturing engineering for battery manufacturing division.Including implementation and Validation of manufacturing and test equipment Collection System Duties: None Classification of Wastewater Treatment Plant: Municipal- I II III IV (Circle One) Industrial- I-SP A-SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day(gpd) Supervisor's Name: Dave Arnold Address: Phone No.: ( ) PRIOR EMPLOYMENT: Past Employer: Magnequench International Dates—From 5 /1 /89 to 6 /1 /95 Job Title: Hot Pressed Magnet Advisor Number of Persons Supervised: None Job Description: Provide technical and logistical support to personnel operating hot pressed magnet department Collection System Duties: None Classification of Wastewater Treatment Plant: Municipal- I II 111 IV (Circle-One) Industrial- I-SP A-SO A B C D Wastewater Treatment Plant Capacity: Gallons Per Day(gpd) Supervisor's Name: Tim Trueblood Address: Phone No.: ( ) IV. ADDITIONAL EDUCATION(Attach Copy of Completion Verification and/or Transcripts) 1. NAME/DESCRIPTION OF COURSE: (Location) (Dates) (College Units or Class Hours) 2. NAME/DESCRIPTION OF COURSE: (Location) (Dates) (College Units or Class Hours) 3. NAME/DESCRIPTION OF COURSE: (Location) (Dates) (College Units or Class Hours) 4. NAME/DESCRIPTION OF COURSE: (Location) (Dates) (College Units or Class Hours) I V. SUPERVISOR'S VERIFICATION OF CURRENT EMPLOYMENT(to be completed by present Employer) I hereby verify that the informa ion contained in the current employment section of the application made by&JxtY MDAWXU o be true and correct to the best of my knowledge and belief. -Ssy� Date Supe sor' Signature a—"4 azLwwA— 1gZ +2l r%�2 F�hi Title Printed VI. SIGNATURE OF APPLICANT 1,the undersigned,certify that I am the above applicant;that all statements made and information contained in this application are true 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. I also consent to a thorough investigation of my employment record and other qualifications in related activities for the purpose of verification of my qualifications for the certificate for which I have applied. / D / (Signature Appl' (Date) Completed application form with check/money order for proper amount,and payable to IWEA,should be returned to: IWEA 200 South Meridian Street Suite 410 Indianapolis,IN 46225 NOTE:DUE DATE FOR APPLICATIONS,MARCH 12,2015.FOR SPRING EXAM/SEPTEMBER 10,2015 FOR FALL EXAM LATE APPLICATIONS WILL NOT BE REVIEWED. CURTIS L. MANIFOLD, 5037 LINDA LEA MANIFOLD 70-2199n19 1007 LANCASHIRE LN. 050 PENDLETON,,IN 46064-9127 Dace Pay to the -7' V 1 $165,00 1 Order of � � .,.. ix rY J Ile /GQ 7 Dollars 8 ae... ®a PNCBANK PNC Bank,N.A. 071r For G.rC�LLFXr;idi✓ �y3�%�� G�[/�/t'{ �` - Q 1:071921890: 46222595761° 5037 �ft�CWka II VOUCHER # 156745 WARRANT # ALLOWED T0668 IN SUM OF $ Manifold, Curtis Wastewater Plant Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code MANIFOLD,C 01-7042-05 $65.00 01-70ya-OS Ia.0o Voucher Total ---"6o 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 T0668 Manifold, Curtis Purchase Order No. Wastewater Plant Terms Due Date 11/24/2015 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 11/24/201! MANIFOLD, $65.00 I 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 �i 1z //s C1-e1/✓n^-m�--- Date Officer