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Home My WebLink About316716 9/29/2017 CITY OF CARMEL, INDIANA VENDOR: 00351805 ONE CIVIC SQUARE INDIANA DEPT OF ENVIR MGT CHECK AMOUNT: $........30.00" ? CARMEL, INDIANA 46032 100 N SENATE AVE,PO BOX 6015 CHECK NUMBER: 316716 y roe�,r PO BOX 6015 CHECK DATE: 09/29/17 INDIANAPOLIS IN 46206-6015 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 BASSETT 30.00 OTHER EXPENSES LA E f J U- 0 W M l 3 z t Y 1 404- 2 a z O — �ce c w � ecv a c o Ln ` �i 0 3 Q N ,,, C14O o La, r Ln W o 2 Z m 3 N coo t7L U Z O ELU u In �. O o ~ QQ� ra O ►Z� E V v 4 PUBLIC WATER SUPPLY APPLICATION FOR FOR OFFICE WATER TREATMENT PLANT AND WATER WS number DISTRIBUTION SYSTEM OPERATOR Receipt number CERTIFICATION p State Form 12094(8812-15) Approved by State Board of Accounts,2014 Approved 327 IAC 8-12.1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Denied/Reason ZA$30faem G WATER BRANCH NOTE. t be submitted for each grade of certification exam requested ust be signed by the individual,and his/her supervisor. Failure to rile a properly completed appikation may result In the application being denied. (THE APPLICATION FEE IS NONREFUNDABLE.) This is an application for Grade:(Check one-One 8 plicat/on per rade checked) Water Distribution System ❑ I ❑ ❑ PWS ID fE: I 06 F- Operator DSS DSM DSL -OCATION Water Treatment Plant Operator 13 ❑ 11 ® ❑ ❑ 1-1 Northwest W Central WTI WT2 1ArT3 WT4 WTS WT6 0.1.T IU Northeast U Southwest ❑Southeast By examination ❑By reciprocity PART 1:GENE RAL I •- ON • PRINT L EGISL Y) - 1. Name of applicant(last) (first) (middle) E7'&. ❑Mrs. ❑Ms. Bassett Kale D 2. Mailing address(numberand street) 13033 Augustus Cir unit 303 City Slate ZIP code County Fishers IN 46037 Hamilton 3. Office telephone number 4. Home telephone number 317.517.5959 317439-1343 b. Have you ever applied for Water Works oertificatbon in Indiana before?(is this exam a repeaUretake?) W Yes` ❑No 'If yes,dale(rnm/dd/yyyy):05-01-14 6. Are you presently a certified water works operator in Indiana? ®Yes' ❑No *If yes,give certification number and classification: WT140053 WT3 7. Are you presently a certified water works operator In another state? ❑Yes` EA No *If yes,give certification number and classification(attach a copy of cerltllcafe) 8. Have you ever had a certification suspended or revoked? ❑Yes P No EDUCATIONPART It: •• DIPLOMA OR GED) 9. Check the highest grade completed. Grade School: Hlph School: College(years): ❑i ❑2 ❑3 04 ❑5 06 07 ❑8 09 010 ❑11 012 ba1 0 0 0 0 0 ❑More than 6years 10. High School Graduate? Date of graduation(mmldd/}yyy) Name and location of school' P Yes ❑No ❑GED 05/1512011 South Newton High School 13102 S 50 E,Kentland,IN 11. Colleae Graduate? Degree Major (I Yes W No Date granted(mm/d&yyyy) Name and location of college (Continued on page 2.) i Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 PART[I:EDUCATION AND TRAINING(CONTINUED) 12. Training courses,short courses,or olher courses attended applicable to water industry: a. Name of course: Name of school Dates(mm/ddyM) College units or class hours AWWA Water treatment and distribution course 0810812017-10126117 72 b. Name or course: Name of school Dates(mm/ddyM) College units or class hours HISTORYPART III EXPERIENCE►Ust y ourcurrent assignment first. Show all experience in the Drinking Water field. Attach additlonal sheets,if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME/ADDRESS JOB DUTIES FROMTO Position title Name of current employer 0512016 Present Water Treatment Operator City of Carmel Specific duties performed In day-to-day operation: Address(number and street) Bench Test Iron,Manganese,Chlorine,Fluoride,and hardness samples. Monitor raw,filtered,and effluent turbidity levels. 4915 E 106th Street Backwash required Iron filters. Adjust chemicals apon demand. City,state,ZIP code Rotate pumps per runtimes. Adjust High service pumps per flow requirements. Monitor and maintain high service pumps and wells. Indianapolis,IN 46280 Check softners for iron and test hardness per softner runtime. FROMTO Position title Name of previous employer 06/2011 0412016 Utilities Superintendent Town of Morocco Specific duties performed In day-today operation: Address(number and street) Bench Test Iron,Manganese,Chlorine,Fluoride,and hardness samples. 112 E State St. Backwash Iron Filters as required. Monitor and maintain high service pumps and well pumps. City,state,ZIP code Maintain all town water mains and hydrants. Adjust chemises apon flow. Morocco,IN 47963 FROM TO Position title Name of previous employer Specific duties performed In day-to-day operation: Address(number and street) City,state,ZIP code FROM TO Position title Name of previous employer Specific duties performed In day-to-day operation: Address(number and street) City,stale,ZIP code (Continued on page 3) Page 2 of 3 PART IV:TO BE COMPLETEDOPERATOR I • •- I 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 1.5 years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): Jerry Cloud DS007769 Signa a of Certified Opera or WT947019 WT130125 w Printed name and signature of applicant's supervisor(d different than above) ApplicanPs supervisor(d different than above) Name of organization/utility/system Telephone number(include area code) Address(number and street) City Slate ZIP code PART V:SIGNATURE OF f,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. /•G/ 09/20/2017 SlgnatureofipRcant Date m The completed application,along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Drinking Water Branch,MC 66-34 100 North Senate Avenue Indianapolis,IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3