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HomeMy WebLinkAbout259058 05/31/16 CITY OF CARMEL, INDIANA VENDOR: 146900 j® ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M&IVECK AMOUNT: $....***180.00* CARMEL, INDIANA 46032 100 N SENATE AVENUE CHECK NUMBER: 259058 MUTON�. ROOM 1255 CHECK DATE: 05/31/16 INDIANAPOLIS IN 46204-2251 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 2200 4355300 052316 60.00 ORGANIZATION & MEMBER 651 5023990 052916 30.00 OTHER EXPENSES 601 5023990 DS875167 30.00 OTHER EXPENSES 601 5023990 WT130142 30.00 OTHER EXPENSES 651 5023990 WWO17828 30.00 OTHER EXPENSES VOUCHER # 165323 WARRANT # ALLOWED 146900 IN SUM OF $ IDEM 100 N. Senate Avenue Indianapolis, IN 46207-7060 Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code BECK,MICM 01-7040-01 $30.00 0'5" 'qt ' -SA'//t, ea"-(_o ° Voucher Total $30.00 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 146900 IDEM Purchase Order No. 100 N. Senate Avenue Terms Indianapolis, IN 46207-7060 Due Date 5/12/2016 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 5/12/2016 BECK, MICA $30.00 hereby certify that the attached invoice(s), or bill(s) is (are)true and :orrect and I have audited same in accordance with IC 5-11-10-1.6 Date Officer Indiana Department of Environmental Management 100 N. Senate Avenue IGCN Room 1255 Indianapolis, IN 46204-2251 1 1E ANNIVQRSARY Micah W. Beck 1817 Woodstream Ct Westfield IN 46074 Indiana Department of Environmental Management_ - - - - WASTEWATER TREATMENT-PLANT-0-PERATOR RENEWAL APPLICATION _ Our records in your wastewater treatment plant operator certification expires on 06/30/2016. After this date you cannot be the operator in responsible charge of any wastewater treatment plant in Indiana until your certification is renewed. This renewal application form may be submitted, and payment made prior to CEUs being received, but your license will not be reissued until we receive documentation that all required CEUs have been obtained. Licenses are renewable every two years, and all terms for renewal must be met each time before a license is renewed. There is no late fee for renewing late,although if your license expires you cannot work as an operator in responsible charge until your license is renewed. Failure to renew a o license within three years of its expiration date will require you to sit for and pass the written test before a new license is issued. License Class Wastewater Operator Class II April 29, 2016 Certification.#: WWO19724 Expiration Date: 06/30/2016 Renewal Fee: 30.00 Login Id: VMO 19724 Password: 1295127 Current Continuing Education Hours Earned: General-6.00 Technical- 10.00 Total-16.00. This may not reflect hours for courses recently attended. If you are not designated as the responsible charge operator for any facility, please write"NONE"in the following table. Please complete the table to identify each wastewater treatment facility where you are the officially designated responsible charge certified operator. If you are in responsible charge of more than four facilities, please include an attachment listing these facilities and provide the required information for each one: I am currently the responsible charge operator who signs the monthly reports(MROIMMR)at the following facilities: ,Eacili dame_ __ —. - _ _ _ Hours/Week---Permit#-- -- -- - -- City- - i y - - - Address Change: �1 Home Phone:.,7��'� 1©g"-IDI L ` ! Work Phone: ���� ��'S�9�1 Operator Signature: o,/v lei/ Date: (1) You must meet the continuing education requirement as shown below: • Classes I-SP,A-SO—5 hours earned between 7/1/20,14—6/30/2016 from IDEM approved course with at least 3.5 of those hours from courses designated as"technical." Classes I, II,A, B—10 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 7 of those hours from courses designated as"technical." • Classes III, IV, C, D—20 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 14 of those hours from courses designated as"technical." Online Renewal: Online renewal is available 24 hours a day, 7 days a week between May 1, 2016 and July 1,2016 at https://mylicense.in.gov. The cost for the online renewal,is$30.00 plus an additional$4.17 in processing fees. The forms of payment accepted online are Visa, MasterCard, &Discover credit and debit cards. Your login ID and Password to this site are provided above. Mail Renewal: If you wish to renew by mail,fill out the responsible charge information,and send this form with your$30 renewal fee to: Indiana Department of Environmental Management,Wastewater Continuing Education Coordinator, 100 N.Senate Avenue, Room 1255, Indianapolis,IN 46204-2251. Make checks payable to IDEM. Please allow 4-6 weeks for processing of your renewal. If you have two wastewater certifications due for renewal at this time,you can combine applications into one mailing and include a fee payment of$60 that covers both. Should you have any questions or concerns about the renewal process, please contact Tonja Fuller-White at(317)233-0479 or by e-mail at tfullerw(a)_idem.in.gov. (2) VOUCHER # 165351 WARRANT # ALLOWED 146900 IN SUM OF $ IDEM 100 N. Senate Avenue Indianapolis, IN 46207-7060 Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code STEWART,A 01-7040-01 $30.00 Voucher Total $30.00 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 146900 IDEM Purchase Order No. 100 N. Senate Avenue Terms Indianapolis, IN 46207-7060 Due Date 5/19/2016 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 5/19/2016 STEWART, J $30.00 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 Date Officer r Indiana Department of Environmental Management 100 N. Senate Avenue IGCN Room 1255 Indianapolis, IN 46204-22511 5 c ANNIVC-RSARY - Jason J Stewart 7955 Allisonville Rd Indianapolis IN 46250 i Indiana Department of Environmental Management -- - -- - - WASTEWATER TREATMENT PLANT-OPERATOR RENEWAL APPLICATION Our records indicate your wastewater treatment plant operator certification expires on 06/30/2016. After this date you cannot be the operator in responsible charge of any wastewater treatment plant in Indiana until your certification is renewed., This renewal application form may be submitted, and payment made prior to CEUs being received, but your license will not be reissued until we receive documentation that all required CEUs have been obtained. Licenses are renewable every two years, and all terms for renewal must be met each time before a license is renewed. There is no late fee for renewing late,although - if your license expires you cannot work as an operator in responsible charge until your license is renewed. Failure to renew a license within three years of its expiration date will require you to sit for and pass the written test before a new license is issued. License Class Wastewater Operator Class I April 29, 2016 Certification#: WW017828 Expiration Date: 06/30/2016 Renewal Fee: 30.00 Login Id: WW017828 Password: 495170 Current Continuing Education Hours Earned: General-0.50 Technical-7.00 Total-7.50. This may not reflect hours for courses recently attended. If you are not designated as the responsible charge operator for any facility; please write"NONE"in the following table. Please complete the table to identify each wastewater treatment facility where you are the officially designated responsible charge certified operator. If you are in responsible charge of more than four facilities, please include an attachment listing these facilities and provide the required information for each one: I am currently the responsible charge operator who signs the monthly reports(MRO/MMR)at the following facilities: Facility Name Hours/Week_ -___ Permit#.- ----City--- -- - - — - rL Address Change: -19 LAaKapoks t Home Phone: ASL Work Phone: 1"1 G1 2l,65q Operator Signature: Date: 510116. (1) You must meet the continuing education requirement as shown below. • Classes I-SP,A-SO—5 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 3.5 of those hours from.courses designated as"technical." Classes I, 11,A, 13—10 hours earned between 7/1/2014-:-6/30/2016 from IDEM approved course with at least 7 of those hours from courses designated as"technical." • Classes III, IV, C, D—20'hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 14 of those hours from courses designated as"technical." Online Renewal: Online renewal is available 24 hours a day, 7 days a week between May 1,2016 and July 1, 2016 at https://mylicense.in..qov. The cost for the online renewal is$30.00 plus an additional$4.17 in processing fees. The forms of payment accepted online are Visa, MasterCard,& Discover credit and debit cards. Your login ID and Password to this site are provided above. Mail Renewal: If you wish to renew by mail,fill out the responsible charge information,and send this form with your$30 renewal fee to: Indiana Department of Environmental Management,Wastewater Continuing Education Coordinator, 100 N.Senate Avenue, Room 1255, Indianapolis,IN 46204-2251. Make checks payable to IDEM. Please allow 4-6 weeks for processing of your renewal. If you have two wastewater certifications due for renewal at this time,you can combine applications into one mailing and include a fee payment of$60 that covers both. Should you have any questions or concerns about the renewal process, please contact Tonja Fuller-White at(317)233-0479 or by e-mail at tfullerw(&_idem.in.gov. I y (2) VOUCHER NO. WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev.1995) INDIANA DEPT OF ENVIRONMENTAL MGT ALLOWED 20 ACCOUNTS PAYABLE VOUCHER 100 N SENATE AVENUE IN SUM OF$ CITY OF CARMEL ROOM 1255 An invoice or bill to be properly itemized must show,kind of service,where performed,dates service INDIANAPOLIS, IN 46204-2251 rendered,by whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. $60.00 Payee ON ACCOUNT OF APPROPRIATION FOR Purchase Order# Engineering Terms Date Due PO# ACCT# DATE INVOICE# DESCRIPTION DEPT# INVOICE# Fund# AMOUNT Board Members DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT 0 43-553.00 $30.00 1 hereby certify that the attached invoice(s),or 4/29/16 0 Wastewater Operator Class B-Hoover $30.00 2200 201 2200 201 bill(s)is(are)true and correct and that the 1 0 43-553.00 $30.00 4/29/16 0 Wastewater Operator Class II-Hoover $30.00 2200 U 201 1 materials or services itemized thereon for 2200 1 201 which charge is made were ordered and received except Monday, May 23,2016 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 ,20 Cost distribution ledger classification if claim paid motor vehicle highway fund. Clerk-Treasurer Indiana Department of Environmental Management 100 N. Senate Avenue IGCN Room 1255 Indianapolis, IN 46204-2251 floll '®EMM 7 ANNIV=RSARY Aaron D. Hoover 18249 La Costa Way Westfield IN 46062 —Ind iana-Re partment_of_Envir_onmental Management. WASTEWATER TREATMENT PLANT OPERATOR RENEWAL APPLICATION Our records indicate your wastewater treatment plant operator certification expires on 06/30/2016. After this date you cannot be the operator in responsible charge of any wastewater treatment plant in Indiana until your certification is renewed. This renewal application form may be submitted, and payment made prior to CEUs being received, but your license will not be reissued until we receive documentation that all required CEUs have been obtained. Licenses are renewable every two years, and all terms for renewal must be met each time before a license is renewed. There is no late fee for renewing late,although if your license expires you cannot work as an operator in responsible charge until your license is renewed. Failure to renew a license within three years of its expiration date will require you to sit for and pass the written test before a new license is issued. License Class Wastewater Operator Class II April 29, 2016 Certification#: WW019643 Expiration Date: 06/30/2016 Renewal Fee: 30.00 Login Id: WW019644 Password: 1295467 Current Continuing Education Hours Earned: General-13.50 Technical-30.00 Total-43.50. This may not reflect hours for courses recently attended. If you are not designated as the responsible charge operator for any facility, please write"NONE"in the following table. Please complete the table to identify each wastewater treatment facility where you are the officially designated responsible charge certified operator. If you are in responsible charge of more than four facilities, please include an attachment listing these facilities and provide the required information for each one: I am currently the responsible charge operator who signs the monthly reports(MRO/MMR)at the following facilities: --Facili -Name---- —--, Houm/Week - Permit-#-- K16" ermit-#— f J Ci Address Change: Home Phone: Work Phone: /_ 9®–�6��perator Signature: 'JDate: (1) You must meet the continuing education requirement as shown below: • Classes I-S P, A-SO—5 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 3.5 of those hours from courses designated as"technical." • Classes I, 11,A, B—10 hours earned between 7/1/2014—6/30/2016 from I DEM approved course with at least 7 of those hours from courses designated as"technical." • Classes III, IV, C, D—20 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 14 of those hours from courses designated as"technical." Online Renewal: Online renewal is available 24 hours a day, 7 days a week between May 1, 2016 and July 1, 2016 at https://mylicense.in.aov. The cost for the online renewal is$30.00 plus an additional$4.17 in processing fees. The forms of payment accepted online are Visa, MasterCard,& Discover credit and debit cards. Your login ID and Password to this site are provided above. Mail Renewal: If you wish to renew by mail,fill out the responsible charge information,and send this form with your$30 renewal fee to: Indiana Department of Environmental Management,Wastewater Continuing Education Coordinator, 100 N.Senate Avenue, Room 1255, Indianapolis, IN 46204-2251. Make checks payable to IDEM. Please allow 4-6 weeks for processing of your renewal. If you have two wastewater certifications due for renewal at this time,you can combine applications into one mailing and include a fee payment of$60 that covers both. Should you have any questions or concerns about the renewal process, please contact Tonja Fuller-White at(317)233-0479 or by e-mail at tfullerw(cDidem.in.gov. (2) Indiana Department of Environmental Management 100 N. Senate Avenue IGCN Room 1255 Indianapolis, IN 46204-22511 I rDEM ANNIVQRSAi2Y - Aaron D. Hoover 18249 La Costa Way Westfield IN 46062 Indiana Department of Environmental Management - ---- - --WASTEWATER TREATMENT PLANT OPERATOR RENEWAL APPLICATION Our records indicate your wastewater treatment plant operator certification expires on 06/30/2016. After this date you cannot be the operator in responsible charge of any wastewater treatment plant in Indiana until your certification is renewed. This renewal application form may be submitted, and payment made prior to CEUs being received, but your license will not be 3 reissued until we receive documentation that all required CEUs have been obtained. Licenses are renewable every two years, and all terms for renewal must be met each time before a license is renewed. There is no late fee for renewing late,although if your license expires you cannot work as an operator in responsible charge until your license is renewed. Failure to renew a license within three years of its expiration date will require you to sit for and pass the written test before a new license is issued. a License Class Wastewater Operator Class B April 29, 2016 Certification#: WW019644 Expiration Date: 06/30/2016 Renewal Fee: 30.00 Login Id: WW019644 Password: 1295467 Current Continuing Education Hours Earned: General-13.50 Technical-30.00 Total-43.50. This may not reflect hours for courses recently attended. If you are not designated as the responsible charge operator for any facility, please write"NONE"in the following table. Please complete the table to identify each wastewater treatment facility where you are the officially designated responsible charge certified operator. If you are in responsible charge of more than four facilities, please include an attachment listing these facilities and provide the required information for each one: I am currently the responsible charge operator who signs the monthly reports(MRO/MMR)at the following facilities: Facili qq�Name Hours/Week_— -Permit-#-----_—__ __ City--- Address i Address Change: Home Phone: _ Work Phone: 317 ` 4 Operator Signature: Date: - Z (1) You must meet the continuing education requirement as shown below: • Classes I-SP,A-SO—5 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 3.5 of those hours from courses designated as"technical." • Classes I, II,A, B—10 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 7 of those hours from courses designated as"technical." • Classes III, IV, C, D—20 hours earned between 7/1/2014—6/30/2016 from IDEM approved course with at least 14 of those hours from courses designated as"technical." Online Renewal: Online renewal is available 24 hours a day, 7 days a week between May 1, 2016 and July 1, 2016 at https://mylicense.in.gov. The cost for the online renewal is$30.00 plus an additional$4.17 in processing fees. The forms of payment accepted online are Visa, MasterCard, &Discover credit and debit cards. Your login ID and Password to this site are provided above. Mail Renewal: If you wish to renew by mail,fill out the responsible charge information,and send this form with your$30 renewal fee to: Indiana Department of Environmental Management,Wastewater Continuing Education Coordinator, 100 N.Senate Avenue, Room 1255, Indianapolis,IN 46204-2251. Make checks payable to IDEM. Please allow 4-6 weeks for processing of your renewal. If you have two wastewater certifications due for renewal at this time,you can combine applications into one mailing and include a fee payment of$60 that covers both. Should you have any questions or concerns about the renewal process, please contact Tonja Fuller-White at(317)233-0479 or by e-mail at tfullerw(a idem.in.gov. J (2) VOUCHER # 161593 WARRANT# ALLOWED 146900 IN SUM OF $ IN DEPT. OF ENVIRONMENTAL MGT. OWQ, MAIL CODE 66-34 100 N SENATE AVE INDIANAPOLIS, IN 46204-2251 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code 7683669 01-6040-03 $30.00 -77�g -7 (e 4,5 Voucher Total 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 146900 IN DEPT. OF ENVIRONMENTAL MGT. Purchase Order No. OWQ, MAIL CODE 66-34 Terms 100 N SENATE AVE Due Date 5/23/2016 INDIANAPOLIS, IN 46204-2251 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 5/23/2016 7683669 $30.00 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 Date Officer Indiana Department of Environmental Management 100 N.Senate Avenue Invoice Number: 7683669 Mail Code 66-34 Renewal Fee: 30.00 Indianapolis,IN 46204-2251 Money Receipt# (Office Only) May 18,2016 Certificate Number: WT130142 Expiration Date: 06/30/2016 Jaimie L.Foreman Grade: WT5 3450 West 131st Street Obtained By: Examination Westfield IN 46074 Login ID: WT130142 Password: 582485 " INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT - - Water Works Operator Certification Renewal Fee Statement Our records indicate your Water Works Certificate No. WTI 30142, Grade WT5 for a class WT5 Water Treatment Plant expires on June 30, 2016. You are required to obtain 30.00 contact hours of continuing education for renewal; a minimum of 70%must be technical. Our records indicate that you currently have accumulated 66.50 contact hours towards renewal. (This may not reflect hours for courses recently attended.) If you need to verify the number of technical course hours obtained, you may login online using o, the instructions below. N Note: If you have not recently'attended an approved course, and you do not have the required number of hours, you need to attend courses prior to July 1, 2016.. After this date you are on expired status and are not a valid certified.operator. You do have until July 1,.2017 to get your continuing,education hours and renew your certification. Failure to renew by July 1, 2017 will result in termination of your certification, and you will have to retest. Online Renewal—Online renewal is available 24 hours a day, 7 days a week at https://mylicense.in.gov. The cost for the online renewal is $30.00 plus an additional processing fee for each certification renewal. The forms of payment accepted online are Visa, Master Card, &Discover credit and debit cards. Login ID and Password are listed above. JMail Renewal----To renew through the mail, please fill out the section on the back of this page and return this entire letter with $30 fee payment to the remittance address listed. Be sure to sign and date in spaces provided. Make a photocopy for your records. Please note that renewal through the mail will take longer than an online renewal. If you have other drinking water certifications due renewal, you can combine them in one mailing with a fee payment that covers all of them. For example: (3 renewals x $30/per renewal) = $90 combined fee. Remit Payment to: Indiana Department of Environmental Management Drinking Water,Branch, OWQ;Mail Code 66-34 100 N. Senate Avenue Indianapolis, IN 46204-2251 SEE FORM ON OTHER SIDE (1) Cancel Certification—If you do not want to renew this certification,please write"CANCEL" on this form, sign and date in spaces provided, and mail to the remittance address listed. FILL OUT & RETURN ENTIRE LETTER WHEN RENEWING BY MAIL OR CANCELLING If this certification was obtained by Examination and the facility you are employed at has changed, please add your new employer in the space provided. NOTE—If this certification is Grandfathered or Site Specific, it is valid only for the location below. Operator Number: WT130142 Invoice Number: 7683669 PWS Name PWS ID Carmel Water Department5229004 All Address Change: Home Phone Number: Work Phone Number � � Operator Signature(ll Date: (2) IDEM Indiana Department of Environmental Management ;5f'� 100 N.Senate Avenue• Invoice Number: 7685047 Mail Code 66-34 Renewal Fee: 30.00 Indianapolis,IN 46204-2251 Money Receipt# (Office Only) May 18,2016 Certificate Number: DS875167 Expiration Date: 06/30/2016 DONALD R. SIMPSON Grade: DSL 9137 Timpani Way Obtained By: Examination _ Indianapolis IN 46231 Login ID: DS875167 Password: 580744 x INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT - - _—�-- ---Water Works Operator Certification Renewal Fee Statement Our records indicate your Water Works Certificate No. DS875167, Grade DSL for a class DSL Water Distribution System expires on June 30, 2016. You are required to obtain 15.00 contact hours of continuing education for renewal; a minimum of 70%must be technical. Our records indicate that you currently have accumulated 32.00 contact hours towards renewal. (This may not reflect hours for courses recently attended.) If you need to verify the number of technical course hours obtained, you may login online using the instructions below. Note: If you have not recently attended an approved course, and you do not have the required number of hours,you need to attend courses prior to July 1, 2016. After this date you are on expired status and are not a valid certified operator. You do have until July 1, 2017 to get your continuing education hours and renew your certification. Failure to renew by July 1, 2017 will result in termination of your certification, and you will have to retest. Online Renewal–Online renewal is available 24 hours a day, 7 days a week at htt-ps://mylicense.in.gov. The cost for the online renewal is $30.00 plus an additional processing fee for each certification renewal. The forms of payment accepted online are Visa, Master Card, &Discover credit and debit cards. Login ID and Password are listed above. -Mail-R­en1&wal-To renew through the mail,please fill out the section on the back of this page and return this entire letter with $30 fee payment to the remittance address listed. Be sure to sign and date in spaces provided. Make a photocopy for your records. Please note that renewal through the mail will take longer than an online renewal. . If you have other drinking water certifications due renewal, you can combine them in one mailing with a fee payment that covers all of them. For example: (3 renewals x $30/per renewal) _ $90 combined fee. Remit Payment to: Indiana Department of Environmental Management Drinking Water Branch, OWQ,Mail Code 66-34 100 N. Senate Avenue Indianapolis, IN 46204-2251 SEE FORM ON OTHER SIDE (1) Cancel Certification—If you do not want to renew this certification,please write"CANCEL" on this form, sign and date in spaces provided, and mail to the remittance address listed. FILL OUT & RETURN ENTIRE LETTER WHEN RENEWING BY MAIL OR CANCELLING If this certification was obtained by Examination and the facility you are employed at has changed,please add your new employer in the space provided. NOTE—If this certification is Grandfathered or Site Specific, it is valid only for the location below. Operator Number: DS875167 Invoice Number: 7685047 PWS Name PWS ID CARMEL WATER DEPT 5229004 Address Change: Home Phone Number: Work Phone Number: Operator Signature: 1' \ Date: (2)