309237 03/16/17 CITY OF CARMEL, INDIANA VENDOR: 00351805
} ONE CIVIC SQUARE IN DEPT OF ENVIRONMENTAL MGMT CHECK AMOUNT: $.`""''""60.00'
CARMEL, INDIANA 46032 100 N SENATE AVENUE CHECK NUMBER: 309237
M�ruH.c°. MAIL CODE 66-34 CHECK DATE: 03/16/17
INDIANAPOLIS IN 46204-2251
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1091 4357004 APP 30.00 EXTERNAL INSTRUCT FEE
1125 4357004 APP 30.00 EXTERNAL INSTRUCT FEE
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FACILITY SPECIFIC OPERATOR(FSO) OFFICE USE
FOR
�� �• APPLICATION FOR WATER TREATM Public Water Supply ID Number:
a� L' WATER DISTRIBUTION SYSTEM OPE ED
CE
RTIFICATION
State Forth 53210(R/2-15) MAR 1 3 201] Receipt number:
327 IAC 8-12-3.5
INDIANA DEPARTMENT OF ENVIRONMENTAL MAN NT
DRINKING WATER BRANCH ............• Approved:
NOTE.
A$30 fee must be submitted for each PWS classification(DSS,WT1).Applications must
be signed by the individual, and his/her supervisor. Failure to file a properly completed Denied/Reason:
application may result in the application being disapproved. (THE APPLICATION FEE IS
NONREFUNDABLE.)
This PWS site has the following classifications: (check all that apply)
Water Distribution System ❑ Other Public Water Supply classifications(other than DSS and/or WT1)require supporting
DSS documentation that justifies this Facility Specific Operator(FSO)Certification.
Water Treatment Plant
1
❑ Required schooling and tests completed? Date (mm/dd/yyyy):
PART 1: PUBLIC WATER SUPPLY •- • • -
1. Name of Public Water Supply:
Tw 5 22 ao 3
2. Contact Name atthePublic Water Supply(If different from Applicant):
MZ 1 O
3. Mailing address(number and street):
4. City: State: ZIP de: Cou ty:
5. Office
telephone number: Other telephone nu ber:
PAR 1 2: APPLICANT INFORMATION (PLEASE TYOR PRINT LEGIBLY)
1. -
1. Na []Mrs.me of applicant(last) ����t�d (first) Nell i� (middle) A
Mr. Mrs. OMs. l'
2. Mailing address(number and street):
NZ-7 F
/IG41,% s t.
3. Ca�mv-I State:T 1 t ZW603 Z IP code: Coty' ��•OI�
-L N
4. O ce telphone number: 5. Home telephone number:
3ll s�3 - (40LI4
6. Have you ever applied for a Water Works certification in Indiana before?
❑Yes* No *If yes,date(mm/dd/yyyy)
7. Are you presently a certified water works operator in Indiana? (Operator bTest, Grandparented, or Facility Specific Operator)
❑Yes* 9KVo *If yes,give the certification number(s)and the classifications:
List any other FSO PWSID or Grandparent PWSID where you are the operator:
8. Are you presently a certified water works operator in another state?
[]Yes' Q91No
*If yes,give certification number and classification (attach a copy of the certificate):
9. Are you an employee of the company or member of the organization that owns this Public Water Supply?
❑Yes ❑No* *If no,please explain your relationship to this Public Water Supply.
10. Have you ever had a certification suspended or revoked?
❑Yes* _IKNo *If yes, please explain.
Page 1 of 4
. . .T 3: EDUCATION
1. Check the highest grade completed.
Grade School: College (years): ❑l ❑2❑3 DJ4 05 ❑6[]More than 6
❑1 ❑2❑3❑4❑5❑6❑7❑8 High School: ❑9❑10 ❑11 ❑12 years
2. High School Graduate? Date of graduation (mm/dd/yyyy): Name and location of school:
(QYes ❑No ❑GED MCC.A�tocK f6. .CffC TIV
3. College Graduate? Degree- Major:
CRYes ❑No 8.S . AfiICC�'1
Date granted (mm/dd/yyyy): Name and location of college:
aril S+a t V„%t W.C'%1 M ur-c le.
4. Training courses,AWWA short courses,or other courses attended applicable to water industry:
a. Name of course:
Name of school: Dates: College units or class hours:
b. Name of course:
Name of school: Dates: College units or class hours:
HISTORYPART 4: EXPERIENCE • 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/ADDRESS
JOB DUTIES
FROM: TO: Position title: Name of current employer:
G��K�n� � s >rY1a1A'}C/ldhCC C,c►tw►e� Cha rk �tS `t ReG{t0.'6b0%
Specific duties performed in day-to-day operation: Street address:
14 V7 E. 116 .
City,state,ZIP code:
Carm l LTJ q 603`Z
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-to-day operation: Street address:
City, state,ZIP code:
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-to-day operation: Street address:
City,state,ZIP code:
Page 2 of 4
PART 5: TO BE COMPLETED •-
1. 1 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 , years.
2. Signature of Su ervir Please sign and date.
3. Name of Supervisor(last) (first) (middle)
p1r. ❑Mrs. []Ms. TVI
t_ a
i
77 Mailin address(number and s reet): If
L5-. 11644-
5. City: State: ZIPcode: C y:
��2-
6. Office telephone number: 7. Home elephone number:
PART 6: SIGNATURE OF
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.
Si a of app c Date(mm/dd/yyyy):
2017
The completed application, along with all required fees and attachments should be mailed to:
Cashier:
Indiana Department of Environmental Management
Drinking Water Branch—MC 66-34
100 North Senate Ave.
Indianapolis, IN 46204-2251
Please make all checks payable to the Indiana Department of Environmental Management
DO NOT SEND CASH.
Page 3 of 4
=r' FACILITY SPECIFIC OPERATOR (FSO) FOR OFFICE
APPLICATION FOR WATER TREATMENT PLANT AND Public Water Supply ID Number:
WATER DISTRIBUTION SYSTEM OPE
CERTIFICATION R 'C.�'" Mh
State Forth 53210(R/2-15) MAR
Receipt number:
327 IAC 8-12-3.5 MAR 1 3 2017
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAC EMENT Approved:
DRINKING WATER BRANCH
NOTE: BY:...............................
A$30 fee must be submitted for each PWS classification(DSS,WT1).Applications must
be signed by the individual, and his/her supervisor. Failure to file a properly completed Denied/Reason:
application may result in the application being disapproved. (THE APPLICATION FEE IS
NONREFUNDABLE.)
This PWS site has the following classifications: (check all that apply)
Water Distribution System
11 Other Public Water Supply classifications(other than DSS and/or WT1)require supporting
DSS documentation that justifies this Facility Specific Operator(FSO)Certification.
Water Treatment Plant
WT1
❑Required schooling and tests completed? Date (mm/dd/yyyy):
WATERPART 1: PUBLIC •- • • PRINT LEGIBLY)
-
1. Name
�� of[Public Water Supply:
Ir
(./NT/4 / ✓&I4 �G C! N ZZ• �C7S
2. Contact Name at the Public Water Supply(If different from Applicant):
Ilf_
3. Mailing address(number and street):
G �t� !r✓1.
4. City: State: ZIP code: County:
s d 3 Z-
5. Office telephone number: Other telephone number:
3/7-57"S • n 3/
PART 2: APPLICANT • - • • PRINT LEGIBLY)
-
1. Napie of applicant(last) (first) (middle)
Mr. ❑Mrs. ❑Ms. 4ro e--
2.
2. Mailing address(number and street):
Z
3. City: State: ZIP code: County:
eaepk 'YGo?z 14 h% 1A0
4. Office telephone number: 5. Home telephone number:
317'
6. Have you ever applied for a Water Works certification in Indiana before?
❑Yes* [W *If yes,date(mm/dd/yyyy)
7. Are you presentl a certified water works operator in Indiana? (Operator by Test, Grandparented, or FaE&Specific Operator)
❑Yes* o
If yes,give the certification number(s)and the classifications:
List any other FSO PWSID or Grandparent PWSID where you are the operator:
8. Are you pmently a certified water works operator in another state?
❑Yes* o *If yes,give certification number and classification(attach a copy of the certificate):
9. Are you an employee of the company or member of the organization that owns this Public Water Su I ?
If no,please explain your relationship to this Public Water Supply.
Yes ❑No*
10. Have you ever had a certification suspended or revoked?
❑Yes*
*If yes, please explain.
o
Page 1 of 4
PART 3: EDUCATION • TRAINING
1. Check the highest grade completed.
Grade School: College(years): ❑1 ❑2 Z-3"[34❑5❑6❑More than 6
❑l ❑2❑3❑4❑5❑6❑7❑8 High School: ❑9 E]10 E]11 El 12 years
2. NO School Graduate? Date of gradu tion(mm/dd/yyyy): Name and location of school: /
[ fes ❑No ❑GED f JO Z ra,;r b..t k-r, 1'�-t4 se • v
3. College Graduate? Degree: Major:
❑Yes [1Io
Date granted (mm/dd/yyyy): Name and location of college:
4. Training courses,AVWVA short courses,or other courses attended applicable to water industry:
a. Name of course:
Name of school: • Dales- College units or class hours:
,delL c�• �+SJ es1112;&1&
b. Name of course:
Name of school: Dates: College units or class hours:
HISTORYPART 4: EXPERIENCE • 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/ADDRESS
JOB DUTIES
FROM: TO: Position title: Name of current employer:
Specific duties performed in day-today operation: Street address:
Gi,,,�s� a� IYG,aUo ct�4*0
.nb6,;.J7 Itis' �.,,,,r,�/�..�. �,. �•►tt
te*IV.
t✓4 >7'{� - 3 :PI�t� !S City,state,ZIP code:
i•tI�l:.,,S �•..ttw •fvw.d..,•,z-�, lora..L► , �l�
V&037—
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-today operation: Street address:
City,state,ZIP code:
FROM: TO: Position title: Name of previous employer:
Specific duties performed in day-today operation: Street address:
City,state,ZIP code:
Page 2 of 4
PART 5: TO BE COMPLETED •-
1. 1 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 3 years.
2. Si 7
e f ery or Please sign and date.
. , I� h 13 2.017
3. Name of Supe sor(last) (first) (middle)
Mr. ❑Mrs. TJMs.
gavtnn arAWr L
4. Mailing address(number and street):
1135 1Cent1%1 park
5. City: State: ZIP code: County:
cwmel 114 y603Z 14arv►:I�or+
6. Office telephone number: 7. Home telephone number:
31-1- 513-52396 31"1-b01-0$IS
PART 6: SIGNATURE OF
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.
Signature of applicant: Date(mm/d ):
I-
93 / & rw 1
The completed application,along with all required fees and attachments should be mailed to:
Cashier:
Indiana Department of Environmental Management
Drinking Water Branch—MC 66-34
100 North Senate Ave.
Indianapolis, IN .46204-2251
Please make all checks payable to the Indiana Department of Environmental Management
DO NOT SEND CASH.
Page 3 of 4