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Home My WebLink About331187 10/17/18 CITY OF CARMEL, INDIANA VENDOR: 00351805 4,. . �,• ONE CIVIC SQUARE IN DEPT OF ENVIRONMENTAL MGMT CHECK AMOUNT: $***....*30.00* s• CARMEL, INDIANA 46032 100 N SENATE AVENUE CHECK NUMBER: 331 187 MAIL CODE 66-34 CHECK DATE: 10/17/18 INDIANAPOLIS IN 46204-2251 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 WT5BASSETT 30.00 OTHER EXPENSES VOUCHER NO. 182986 WARRANT NO. Prescribed by State Board of Accounts City Form No.201(Rev 1995) ALLOWED 20 Vendor# 00351805 IN SUM OF$ ACCOUNTS PAYABLE VOUCHER IN DEPT ENVIRONMENTAL MGMT CITY Of CARMEL MAIL CODE 66-34 An invoice or bill to be properly itemized must show: kind of service,where performed, INDIANAPOLIS, IN 46204-2251 dates service rendered, by whom, rates per day, number of hours, rate per hour, numbers of units, price per unit,etc. Payee 30.00 00351805 Purchase Order No. ON ACCOUNT OF APPROPRATION FOR IN DEPT ENVIRONMENTAL MGMT Terms Carmel Water Utility MAIL CODE 66-34 Due Date BOARD MEMBERS I hereby certify that that attached invoice(s), INDIANAPOLIS,IN 46204-2251 or bill(s)is(are)true and correct and that PO# ACCT# the materials or services itemized thereon for DATE INVOICE# Description DEPT# INVOICE# Fund# AMOUNT which charge is made were ordered and DEPT# FUND# (or note attached invoice(s)or bill(s)) AMOUNT WT5BASSEf 01-6040-03 $30.00 and received except 10/9/2018 WT5BASSEtT $30.00 T r' 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 Cost distribution ledger classification if claim paid motor vehicle highway fund. 20_ Clerk-Treasurer PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER INS number DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number State Form 12094(R812-15) Approved by State Board of Accounts,2014 Approved 327 IAC 1112-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Denied/Reason DRINKING WATER BRANCH NOTE: A$30 fee mus be submitted foreach grade of certification exam requested ust be signed by the individual,and his/her supervisor. Failure to file a property completed application may result in the application being denied. (THE APPLICATION FEE IS NONREFUNDABLE.) This is an application for Grade:(Check one-One application per grade checkecO Water Distribution System ❑ ❑ ❑ PWS ID#:-J00 Operator DSS DSM DSL Water Treatment Plant Operator W❑f1 1 O2 11 0 0 +>06 0❑i,T ❑Northwest 0 Central Northeast [I Southwest E]Southeast 0 By examination ❑By reciprocity JffqR • •- 1. Name of applicant{last) (first) (middle) 1Z Mr. ❑Mrs. ❑Ms. Bassett Kole D 2. Mailing address(number and street) 3676 S 500 E City State ZIP code County Kokomo IN 46902 Howard 3. Office telephone number 4. Home telephone number 317-517-5959 1. 317-439-1343 S. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeatiretake?) ®Yes• ❑No "If yes,date(mm/dd4Wy): -2L0_,-1 6. Are you presently a certified water works operator in Indiana? ®Yes• ❑No `If yes,give certification number and ctasslficatlon: WT140053 WT3 7. Are you presently a certified water works operator in another state? ❑Yes• ®No *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever hada certification suspended or revoked? ❑Yes 14 No 9. Check the highest grade completed. Grade School: High School: College(years): ❑1 ❑2 03 04 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10 ❑11 ❑12 01 ❑2 ❑3 Q ❑5 ❑6 [1 More than 6years 10. High School Graduate? Date of graduation(mmrdd/yyyy) Name and location of school' QI Yes ❑No El GED 5-15-2011 South Newton High School 13102 S 50 E Kentland,IN 11. Coll e a Graduate? Degree Major I�Yes No Date granted(mm/dd/y)W) Name and location of college IUPUI (Continued on page 2.) 'Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 • . pplpill . , 12. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: Name of school Dates(mm/dd/yyyy) College units or class hours AWWA Water Treatment and Dlstribufion Course 8-8-17 to 10-26-17 72 b. Name of course: Name of school Dates(mrn/dd/yyyy) College units or class hours . • MKkUS EMPLOYERS) Io 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 05-2016 Present Water Treatment Operator City of Carmel Specific duties perforated in day-to-day operation: Address(number and street) Bench test Iron,Manganese,Chlorine,Fluoride,and hardness samples.Monitor 4915E 106th St Raw,filtered,and effluent turbidity levels. Backwash required iron filters.Adjust chemicals upon demand.Rotate pumps per runtimes.Adjust high service pumps per flow requirements.Monitor and maintain high service pumps and welts.Check City,state,ZIP code softeners for iron and test hardness per softener runtime. Indianapolis,IN 46280 FROMTO Position Lille Name of previous employer 06-2011 04-2016 Utilities Superintendent Town of Morocco Speck duties performed in day-to-day operation: Address(number and street) Bench test iron,manganese,chlorine,fluoride,and hardness samples. 112 E State 5t Backwash iron filters and softeners as required. Monitor and maintain high service pumps and wells. Maintain all town water mains and hydrants. City,state,ZIP code Adjust chemicals upon flow. Morocco,IN 47963 FROM TO Position title Name of previous employer Specific duties performed In day-to-day operation: Address(numberand 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,state,ZIP code (Continued on page 3.) Page 2 or 3 . : •- I hereby certify the information contained in this section of this application is true and correct to the best of my kn()vdedge. I have supervised this individual for years. Name of Certified Operator un erwhose supervision experience obtained Certification Number(s): J Leo(AbSoo-nGR Signature of rtifiedOperator WIT ON1 d A WT 13v 115 Printed name and signature of applicant's supervisor(if dih`erent than above) Applicant's supervisor(if different than above) Name of organizationfutliitytsystem 'telephone number(include area code) Address(number and street) City State ZIP code PART V:.SIGN,�TURE • 1,the undersigned,certify that I am the above applicant;that all statements made and information contained In the above application are true and correct t the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for,o revocation of any certificate granted. I also consent to verification of my qualifications for the certificate forwhich I have applied. Signature of applicantDate(mm/d I y) 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