157980 04/01/2008 CITY OF CARMEL, INDIANA VENDOR. 146900 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M
CARMEL, INDIANA •16032 CASHIER'S OFFICE -MAIL. cOCE 50 -10c FIECK AMOUNT: $50.00
100
N 46207 -7060 CHECK NUMBER: 157980
CHECK DATE: 4/1/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTIO
651 5023990 50.00 OTHER EXPENSES
I
MUNICIPAL NPDES PERMIT
COMPLETENESS CHECKLIST
SUBMITTAL FORM
MAIL TO
Indiana Department of Environmental Management
Cashiers Office -Mail Code 50 -IOC
100 North Senate Avenue
Indianapolis, Indiana 46204
NPDES PERMIT No. IN00
Facility Name
Mailing Address
Facility Location
Contact Telephone Phone:
REQUIRED INFORMATION
REQUIRED WITH ALL APPLICATIONS TECHNICAL APPLICATIONS
X $50.00 Permit Application Fee Semi Public Minor Municipal Application
X Affected Parties Identification Form X Major Municipal Application EPA Form
X Request for Information Form X Whole Effluent Toxicity Test
An issued Construction Approval is required with all applications for a NEW NPDES
permitted facility.
The Permit Fee, Affected Parties Form and Request for Information Forms are required with all
applications. Whole Effluent Toxicity Testing is required for all Major facility renewal
applications in accordance with regulations specified in 327 IAC 5- 2 -3(g) (1) and (2). Please
check the information that is included, and insure that all forms are completely filled out with date and
signature.
(Account No. Revenue Code; 2830 411200. 100600)
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT
We make Indiana a cleaner, healthierrlace.to live.
Mitchell E. Daniels, Jr. 100 North Senate Avenue
Governor Indianapolis, Indiana 46204
Thomas W. Easterly (317) 232 =8603
Commisslaner (800) 451 -6027
www.in.gov /idem
TO: All NPDES Permit Xoplicants
FROM: NPDES Permit Section
Office of Water Quality
SUBJECT: Request for Information
We request that you fill in the blanks on this form and return it along with your NPDES PERMIT application. The
information provided will be helpful in our personal contact with officials of our municipality, industry or other facility in
assuring prompt delivery of correspondence, etc. Thank you for your cooperation.
I. CURRENT NPDES PERMIT.NO. INOO (New applicants will be assigned a number later)
II. WASTEWATER TREATMENT PLANT FACILITY LOCATION ADDRESS (PHYSICAL LOCATION OF
FACILITY)
Facility Name:
Address:
City: State: Zip:
III. MAILING ADDRESS IF DIFFERENT FROM FACILITY LOCATION
Address:
City: State: Zip:
IV. OWNER OR LEGALLY RESPONSIBLE PARTY (TOWN BOARD /COUNCIL PRESIDENT, MAYOR,
SUPERINTENDENT)
Name: Title:
Address:
City: State: Zip:
Phone:
V. WASTEWATER TREATMENT PLANT CERTIFIED OPERATOR
Name: Certification
Address:
City: State: Zip:
Work Phon Classification:
(Account No. Revenue Code: 2830 411200- 100600) updated 01%05 sc
VOUCHER 085086 WARRANT ALLOWED
146900 IN SUM OF
100 N. Senate Avenue
Gndianapolis, IN 46207 -7060
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
00 $50.00
7 36 j.oS
Voucher Total $50.00
,1st distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995) r'
ACCOUNTS PAYABLE VOUCHER
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
146900
IDEM Purchase Order No.
100 N. Senate Avenue Terms
Indianapolis, IN 46207 -7060 Due Date 3/18/2008
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
3/18/2008 00 $50.00
c1
hereby certify that the attached invoice(s), or bill(s) is (are) true and
:orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer