HomeMy WebLinkAbout311402 05/17/17 t�us S�gMt
a, �` CITY OF CARMEL, INDIANA VENDOR: 356491
A ONE CIVIC SQUARE TARA WASHINGTON CHECK AMOUNT: S""`"`113.29"
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CARMEL, INDIANA 46032 5253 COMANCHE TRAIL CHECK NUMBER: 311402
•'Mlrtie- CARMEL IN 46033 CHECK DATE: 05/17/17
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 113.29 OTHER EXPENSES
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HAMPTON INN MERRILLVILLE
8353 GEORGIA ST
MERRILLVILLE,IN 46410
United States of America
TELEPHONE 219-736-7600 *FAX 219-736-7676
Reservations
www.hamptoninn.com or 1 800 HAMPTON
WASHINGTON,TARA Room No: 302/KXTD
Arrival Date: 4/27/2017 4:03:00 PM
5253 COMANCHE TRAIL Departure Date: 4/28/2017 7:40:00 AM
Adult/Child: 1/0
CARMEL IN 46033 Cashier ID: KBADTEN
UNITED STATES OF AMERICA Room Rate: 101.15
AL:
HH#
VAT#
Folio No/Che 292374 B
Confirmation Number:81653304
HAMPTON INN MERRILLVILLE 4/28/2017 7:40:00 AM
DATE IREF NO IDESCRIPTION CHARGES
2/12/2017 775339 Advance Deposit Bank Transfer ($101.15)
4/27/2017 783955 GUEST ROOM $101.15
4/27/2017 783955 STATE TAX $7.08
4/27/2017 783955 COUNTY TAX $5.06
4/28/2017 784024 DEPOSITORY PAYMENT $12.14
4/28/2017 784025 ADVANCE PURCHASE 2.9%DISCOUNT ($24.28)
**BALANCE** $0.00
EXPENSE REPORT SUMMARY
4/27/2017 STAY TOTAL
ROOM AND TAX $113.29 $113.29
DAILY TOTAL $113.29 $113.29
Page:1
4k'' WASTEWATER OPERATOR/APPRENTICE CONTNUING To ensure proper credit,the wastewater
EDUCATION CREDIT REPORT approval number MUST be provided.
State Form 51139(R3/4-08) Training Course Approval Number:
" ' INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENTxo
WWT17-2958-T05-G00
Operator ❑ Apprentice Technical Contact Hours Earned: 5
General Contact Hours Earned: 0
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In accordance with 327 IAC 5-22-17(c),the training provider must submit this form with ninety(90)days of the conclusion of the wastewater
treatment continuing education course. Mail the completed form to:
Wastewater Continuing Education Coordinator
Indiana Dept.of Environmental Management
100 N.Senate Ave—Mail Code 65-42
Indianapolis,IN 46204-2251
Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM.
Partial course credit shall not be given to instructors,speakers,or students participating in less than a complete wastewater treatment
continuing education course.
The training provider must retain a copy of this form for their records for a three(3)year period following the presentation of each
wastewater treatment continuing education course.
Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified operator/
apprentice attending the entire wastewater operator continuing education course.
CERTIFIES OPERATOR ;�[APRfE N rICE INFO>tM#►710N
1.NAME: \ � ����\\��,, �C� 1�►
2.HOME ADDRESS(number and street):
City: State: ZIP code: Telephone number:
Work: ❑ Home/Cell:
Check here if this is an address change E-mail Address: \'.3s,
COURSE INFORIIiIAT1OpI" £
y
3. NAME OF TRAINING COURSE: MOTORS &CONTROLLERS - 5 HOUR
4. NAME OF TRAINING COURSE PROVIDER: 5. NAME OF ORGANIZATION SPONSORING COURSE:
Walters Environmental Consulting, Inc. Walters Environmental Consulting, Inc.
6. DATE(S)ATTENDED(month,day,year): 7. LOCATION ATTENDED:
4/28/2017 MERRILLVILLE, IN - COMFORT SUITES
8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATOR/APPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE
PROVIDER:
Technical Contact Hours: 5 General Contact Hours: 0
9. CERTICICATE OF COMPLETION IS REQUIRED FOR ALL ON-LINE COURSES.
I,the undersigned,certify under penalty of law that this document(and any attachments)were prepared under my direction or supervision and that the information
submitted is,to the best of my knowledge and belief,true,accurate,and correct.I also understand that any omissions or misrepresentations may result in the denial of
continuing education credit for this course.
10. SIGNAT R FA]ST 11. PRINTED NAME OF INSTRUCTOR:
Phil Burkholder
12. SIGNATURE OF RA 13. PRINTER NAME OF CERTIFIED OPERATOR/APPRENTICE,•
14.CONTINUINGEDUCATION CREDIT HOURS ARE TO BE APPIED TO:
Operator certification/apprentice number:O Class: Expiration date-
- (' ,
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Operator certification/apprentice number: Class: Expiration date: