188376 08/03/2010 a CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M T
CARMEL, INDIANA 46032 CASHIER OFFICE MAIL CODE 50 -10C HECK AMOUNT: $30.00
100 N SENATE AVE
CHECK NUMBER: 188376
INDIANAPOLIS IN 46204
CHECK DATE: 813/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 3861542 30.00 EMPLOYEE PEN BENEFT
In dia na Depart-ent of Environmental Management
.'N',Sen ate Aven
n
Mail Code 66-35 Invoice Number, 3861542
Indianapolis, IN 46204-2251 Renewal Fee:
$30.00
Money Receipt
(Office Only)
July 22, 201
Certificate Number DS875167
Expiration Date: 06/30/2010
DONALD R. SIMPSON Grade DSL
9137 Timpani Way Obtained By: Examination
Indianapolis IN 46231
Login ID: DS875167
Password: 580744
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
Ater Works O ae rat or Certification Renewal pee State M g n
Our records indicate your Water Works Certificate No, DS875167, Crude DSL for a class DSL Water Distribution System expires on
06/30/2010. You are required to obtain 15,00 con hours of continuing education for renewal. Our records indicate that you currently have
accumulated 23.50 contact hours towards renewal. (This may not reflect hours for courses recently attended.)
Note, If you have not recently attended an approved course, and you do not have the required number of hours, you need to attend
courses
prior to July 1, 2010. After this date you are on expired status and are not a valid certified operator. You do have until July 1, 2011
continuing education hours and renew your certification. Failure to renew by July 1, 2011 will result in termination to get y our
you will have to retest. ation of your certification,
Online Renewal Online renewal is available 24 hours a day, 7 days a week at httys://mylic nsein.go The cost for the online is
$30.00 plus an additional processing fee for each certification renewal. The forms of payment accepted online are Vis a, Master Card
rene
Discover credit and debit cards, Login ID and Password are listed above.
Mail Renewal To renew through the mail, please fill out the bottom section and return this entire letter with $30 fee payment to the
remittance address listed. Be sum to sign and date in spaces provided. Make a photocopy for your records. Please note that renewal through
the mail will take longer than an online renewal.
If you have other drinking water certifications due renewal, you can combine them in one mailing with a fee payment that covers all of them.
For example: (3 renewals x $30/per renewal) $90 combined fee.
Remit Payment to: Indiana Department of Environmental Management
Cashier's office M Code 50 -10C
100 N. Senate Avenue fr)
Indianapolis, IN 46204-2251
Cancel Certification If you do not want to renew this certification, please write "CANCEL" on this form, sign and date in spaces provided,
and mail to. the remittance address listed.
FILL OUT BOTTOM PORTION RETURN ENTIRE LETTER
rmT'- U37 L OR CANCELLING
If this certification was obtained by Examination and the facility you are employed at has changed, please add.your new employer in the.space
provided. NOTE If this certification is Grandfathered or Sit Sp it Is valid only for the location below.
Operator Number DS875167 Invoice Number: 3861542
PWS Name
CARMEL WATER DEPT MR ID
5229004
Address Change:
Home Phone Number 317
Work Phone Number: :V77/
Operator Signature:
Date: 7124,110
VOUCHER 102256 WARRANT ALLOWED
TIDEM IN SUM OF
IDEM
100 N SENATE AVENUE
INDIANAPOLIS, IN 46204 -2251 0
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
3861542 01- 6040 -05 $30.00
Voucher Total $30.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts city Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHEF;
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
TIDEM
IDEM Purchase Order No,
100 N SENATE AVENUE Terms
INDIANAPOLIS, IN 46204 -2251 Due Date 7/27/2010
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/27/2010 3861542 $30.00
hereby certify that the attached invoice(s), or bili(s) is (are) true and
correct and I have audited same in accordance with IC 5- 11- 10 -1.6
7 A v 4 L� vim
Date Officer