HomeMy WebLinkAbout338833 05/14/19CITY OF CARMEL, INDIANA
ONE CIVIC SQUARE
CARMEL, INDIANA 46032
VENDOR: 146900
INDIANA DEPT OF ENVIRONMENTAL MQ°'j,1ECK AMOUNT: $ * * * * * * * *30.00*
ATTN: RULE 13 MAIL CODE 65-42 CHECK NUMBER: 338833
100 N SENATE AVE ROOM 1255 CHECK DATE: 05/14/19
INDIANAPOLIS IN 46204-2251
DEPARTMENT
ACCOUNT PO NUMBER INVOICE NUMBER
651 5023990 WW013898
AMOUNT
30.00
DESCRIPTION
OTHER EXPENSES
FILL OUT AND RETURN ENTIRE LETTER WHEN RENEWING BY MAIL OR CANCELLING
Cancel Certification-If you do not want to renew this certification, please write"Cancel"on this form,sign and date in the
spaces provided,and mail to the remittance address listed.
Online Renewal: Responsible Charge Operator—Please review, add or delete any changes prior to making payment.
Mail Renewal-If you are not designated as the responsible charge operator for any facility,please write"NONE"in
the table. Please review,add or delete any changes below 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
�10 1\1:P•
•
Address Change:
Home Phone:
Work Phone:
Operator Signature: , U ) (,{/J Date: 5- 10 ' 1 �l
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 tfullerwPidem.in.gov.
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