Loading...
HomeMy WebLinkAbout327078 07/03/18 CITY OF CARMEL, INDIANA VENDOR: 146900 ONE CIVIC SQUARE IND DEPT OF ENVIR MGT DRINKING WA}LIECK AMOUNT: $********30.00* CARMEL, INDIANA 46032 own,MAIL CODE 66-34 CHECK NUMBER: 327078 100 N SENATE AVE CHECK DATE: 07/03/18 INDIANAPOLIS IN 46204-2251 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 1091 4357004 APPLICATION 30.00 EXTERNAL INSTRUCT FEE ACCOUNTS PAYABLE VOUCHER CITY OF CARMEL VOUCHER NO. WARRANT NO. An invoice of bill to be properly itemized must show;kind of service,where performed,dates service rendered,by Vendor# Allowed 20_ whom,rates per day,number of hours,rate per hour,number of units,price per unit,etc. Indiana Department of Environmental Management Payee Drinking Water Branch--MC 66-34 100 North Senate Ave In Sum of$ Purchase Order# Indianapolis, IN 46204-2251 Indiana Department of Environmental Managemen Terms $ 30:00 Drinking Water Branch-MC 66-34 Date Due 100 North Senate Ave ON ACCOUNT OF APPROPRIATION FOR Indianapolis, IN 46204-2251 109-Monon Center PO#orInvoice Description Dept t# INVOICE NO. ACCT#IrrrLE AMOUNT Invoice Date Number (or note attached invoice(s)or bill(s)) PO# Amount 1091 Application 4357004 $ 30.00 Board Members 6122118 Application FSO Application Fee Jim Rose xx7139 $ 30.00 1 hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and that the materials or services itemized thereon for which charge is made were ordered and received except $ 30.00 Total $ 30.00 June 28,2018 1 hereby certify that the attached invoice(s),or bill(s)is(are)true and correct and I have audited same in accordance with IC 5-1'I-10-1.6 Cost distribution ledger classification if claim paid motor vehicle highway fund Signature -.20— Accounts 20_Accounts Payable Coordinator Clerk-Treasurer Title Po Xx - v-7/39 `f"'� FACILITY SPECIFIC OPERATOR (FSO) - A°_ APPLICATION FOR WATER TREATMENT PLANT AND i t;i Water Supply ID Number i; WATER DISTRIBUTION SYSTEM OPERATOR CERTIFICATION State Form 53210(R/2-15) 1 Receipt number. j f 27 IAC B-12-3 5 0&6-V� iN01ANAD€PARTMETA NLT OFIENUIRONMEI+lL.MANAGEMEN T ApprOVed: M DRINKING AW IEF'R ANCH # NOTE. A$30 fee must esu mt ed for each PWS classification(DSS,WTI).Applications must be signed by the intli ideal,an is/her supervisor. allure 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 WTI)require supporting DSS documentation that justifies this Facility Specific Operator(FSO)Certification. Water Treatment Plant WTI ❑Required schooling and tests completed? Date (mm/dd/yyyy): KEE o .. m 1. Name of Public Water Supply Central Park West Commons(2290053) 2. Contact Name at the Public Water Supply(If different from Applicant): Eric Mehl ORIC 3. Mailing address(number and street): 1195 Central Park Drive West 4. City: State: ZIP code: 7Hamilton Carmel IN 46032 J 5. Office telephone number: Other telephone number: 317-573-4031 :. ..a.%.+x 1. Name of applicant(last) Rose (first) James (middle)Andrew ®Mr. ❑Mrs. ❑Ms. 2. Mailing address(number and street): 1235 Central Park Dr. East 3. City: State: ZIP code: County: Carmel IN 46032 Hamilton 4. Office telephone number: 5. Home telephone number: 317-848-7275 317-509-8046 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 waterworks operator in Indiana? (Operator by Test, Grandparented, or FacilitLS.xecific Or eratorr ❑Yes* ®No *If yes,give the certification number(s)and the classifications: List any other FSO PWSID or Grandparent PWSID where vou are the operator- 8. Are you presently a certified water works o erator in another state? ❑Yes* ®No *If yes, give certification number and classification (attach a copy of the certificate).---- :::7: 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* ®No *If yes,please explain. Paqe 1 of 4 , ;il�en 1 .Check fhe highest grade completed Grade School ❑l ❑2❑3❑4❑5❑6❑7❑8 High School:❑9❑10❑11 ®12 years a(years):Ell E12 [:13 E14 E]5 [16®More than 6 2. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school ®Yes ❑No ❑GED 5/1978 Brownwood High School 3. College Graduate? Degree: Major: ®Yes []No Bachelor of Science Geology Date granted(mm/dd/yyyy): Name and location of college: 5/1984 University of Houston Houston,Texas 4. Training:courses,AWWA short courses,or other courses attended applicable to water industry. a. Name of course:Aquatic Facility Operator Name of school: Dates: College units or class hours: National Recreation&Parks Association 4126/18 b. Name of course: Name of school: Dates: College units or class hours: ► 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 f ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: 8/2017 Present Manager/Aquatic Facility Operator Carmel Clay Parks and Recreation Specific duties performed in day-to-day operation: Street address: -Manage and train lifeguard staff 1235 Central Park Drive, East -Test and maintain proper water chemistry of all pools and splash pads -Maintain and repair aquatic facility equipment(pumps, filters,chemical feeders, plumbing etc). City, state,ZIP code: Carmel, IN 46032 FROM: TO: Position title: Name of previous employer: 8/1987 8/2017 Supervisory Special Agent United States Department of Justice-ATF E Specific duties performed in day-to-day operation: Street address: -Conducted and directed criminal investigations of suspects for violations of 99 New York Avenue, N.E. federal law. -Led over 100 agents and task force officers in day-to-day operations -Managed division's budget and intelligence staff. City,state,ZIP code: -Planned and oversaw division's physical fitness training and tactical training. Washington, D.C.20226 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 s ` W, 1. 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 1years. 2. S;gnaturlof S1Ior - Please sign and date.{ 3. Name of Supervisor(last) McAninch 4 (first) Terese (middle)Marie ❑Mr. ®Mrs. ❑Ms. 4. Mailing address(number and street): 1235 Central Park Dr. East 5. City: State: ZIP code: County: Carmel IN 46032 Hamilton 6. Office telephone number: 7. Home telephone number: 317-573-4034 317-430-4031 ft � 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. SlgqatCj'Fo of applicant: Dates fLnm/dd/ Y.Y 0 ' 06/2212018 n eompfeted application;along with-all'requi'redfees and ments shouldbe mailed to: Cashier: �_.a ..y — --�� V a'©epartinent`of'Envrrormenal Management t>ng Water Branch–MC 66„4,orth Sa atea�ve',r w �.lnc�ianapo�is,SIN>46204=2-Z5r1` Please make all checks payable to the Indiana Department of Environmental Management DO NOT SEND CASH. Paqe 3 of 4 e " 327 IAC 8-12-3.5 Facility-specific operator reads in part..... Sec.3.5. (a) Operators of nontransient noncommunity public water systems of the following facility classifications may be granted FSO certifications: (1) Class DSS systems. (2) Class WTI systems. (3) Noncommunity public water systems of other facility classifications many be granted FSO certifications for their classifications if the commissioner determines that the FSO applicant will adequately perform the tasks necessary for proper operation of the system. (b) Operators of community public water systems serving one hundred(100)or fewer people with the following facility classifications may be granted FSO certifications: (1) Class DSS systems, (2) Class WTI systems. (c) The following requirements must be met in order for a facility-specific(FSO)certification to be granted for a public water system: (1) The owner of the system shall designate a person to be in responsible charge of the system. (2) The designee(applicant)must be an employee or member of the public water system. (3) Each applicant shall do the following: (A)Demonstrate proficiency to the commissioner in accordance with section 4.5 of this rule. (8) Meet the requirements of section 3(b)(1)of this rule. (C) Be able to do the following: (i) Maintain inventories. (ii) Order supplies. (iil)Interpret chemical and bacteriological sample reports. (4) A person may hold only one (1)FSO certification at a time unless the commissioner has determined that the FSO operator can maintain each system for which an FSO certification is requested. (d) An FSO certification is valid as follows: (1) Only at the site for which the FSO is granted. (2) For three (3)years, during which time the operator shall fulfill the continuing education requirements for the FSO.certification as listed in section 7.5 of this rule in order to be eligible for certification renewal in accordance with section 7(e)(3)of this rule. (e) An FSO certification will be invalid if the classification of water treatment plant or water distribution system changes to one (1)requiring a certified operator with more extensive education or experience, such as the following: (1) Increased capacity. (2) An increase in population served. (3) A basic change in the method of water treatment. (4) Another change in conditions that causes a more difficult or complex operation. (� If a person is granted an FSO certification fails to meet the continuing education requirement of section 7.5 of this rule within the required time set forth in subsection (d)(2), then: (1) the FSO certification is voided;and (2) the operator must become certified according to the requirements of this rule. (g) The commissioner may revoke an FSO certification due to failure to do any of the following: (1) Conduct any of the following: (A) Monitoring and reporting to meet the requirements of 3271A 8-2. (B) Reporting to meet the requirements of 3271A 8-2.1. (C) Monitoring and reporting to meet the requirements of 3271A 8-2.5 (2) Operate and maintain the system in a manner that protects human health. This fact sheet is intended solely as guidance and does not have the effect of law or represent formal Indiana Department of Environmental Management(IDEM) decisions or final actions. This fact sheet shall be used in conjunction with applicable rules and statutes. It does not replace applicable rules and statutes, and if it conflicts with these rules and statutes, the rules and statutes shall control. Paqe 4 of 4