166259 11/24/2008 CITY OF CARMEL, INDIANA VENDOR: 147005 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF REVENUE CHECK AMOUNT: $90.00
CARMEL, INDIANA 46032 FUEL ENVIRONMENTAL DIVISION
5150 DECATUR BLVD CHECK NUMBER: 166259
INDIANAPOLIS IN 46241 -9564
CHECK DATE: 11/24/2008
DEPARTMENT ACCOUNT PO NUMBE INVOICE NU MBER AMOUNT DES CRIPTION
,:651 i 5023990 10800 90.00 OTHER EXPENSES
1
t �517,0�
INDIANA UNDERGROUND
FORM STORAGE TANK FEE RETURN
UST -1 FOR OFFICE USE ONLY
laid' THE DEPARTMENT OF REVENUE WILL NOT PROCESS ANY
APPLICATION WHICH DOES NOT CONTAIN A FEDERAL PM DATE
PAYMENT 1 IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER, AND A
DUE: DEC 15 SIGNATURE OF OWNER OR OFFICER OF THE COMPANY. PYMT AMT
2008 2 0 0 9
Annual Amount Due: $90.00 If late, Enter Penalty: Environmental Penalty:
Installment Payment Due: $90.00 If Late, Enter Interest: Total Amount Paid:
OWNER City Of Carmel OWNER'S IDENTIFICATION NUMBER 10800
ADDRESS 760 3RD AVE SW STE 110 FEDERAL ISSN NUMBER 356000972
CITY /ST /ZIP Carmel, IN 46032- TAXPAYER'S TID NUMBER 0003120155 -001
PLEASE CHECK OFF EACH FACILITY AND NUMBER OF TANKS THAT WERE NOT TELEPHONE NUMBER (317) 571 -2634
PROPERLY CLOSED OR REMOVED AS OF JULY 1, 2007. THE DEPARTMENT CANNOT
PROCESS ANY RETURN IF THE FACILITIES HAVE NOT BEEN CHECKED OFF PROPERLY.
Facility Tanks FacilityTanksl FacilityTanksl Facility Tanks I Facility Tanks Facility Tanks J Facility Tanks Facility Tanks
a 0079 P 1 E]I 1
r
Y
Under the penalty of perjury, I have examined this return (including any accompanying schedules and statements) and to the best of my knowledge
and belief, it is true, complete, and correct.
Signature Title Date Daytime Phone Number
MAIL THE COMPLETED RETURN AND PAYMENT TO:
Indiana Department of Revenue
Fuel and Environmental Tax Section
Ameriplex Logan Building
5150 Decatur Boulevard
Revised 10100 Indianapolis, iN 46241 -9564 State Form 46022
e M. UST-3 Indiana .Department of Revenue
State Form 50766
RIiIO -ol Environmental Tax Change Form
This form is to be used when fees paid are different than what is billed on Form UST-1.
Failure to provide this information may result in penalty and interest charges.
OumcrsName FID#
OwneCs Physical Address
(NOT a P.O. Box Number) SSN#
City State Zip Code
Owner ID
o gigiNjI 1 r o
Facility ID Ownership Number of Number of Hazardous Removal Installation
Number Date Petroleum Tanks Substance Tanks Date Date Sold. Date
Owner's
Signature
Print or Type Name Title
Telephone Date
The Department of Revenue cannot process any form that does not contain Federal identification
or Social Security Number and a signature of the owner or officer of the company.
PLEASE ATTACH THIS FORM TO THE BACK OF YOUR UST -1 FORM
Instructions for Completing the Environmental Tax Change Form
The Indiana .Department of Revenue will not process any application, which does not contain a Federal
Identification Number or Social Security Number and a signature of owner or officer of the company.
Who should file this form?
Anyone who was the owner of an underground storage tank as of July I of the current year that has made any changes to
the facility, i.e., tank removal, installment of tank(s), sold facility, etc.
Owner's Name
This area reflects your legal ownership name in which a facility /tank owner has registered with the Indiana Department of
Environmental Management (I.D.E.M.). NOT THE LEASES OR CONTRACT BUYER.
Owner's Physical Address
The owner of a facility /tank(s) must enter a physical address NOT A P.O. BOX NUMBER.
Federal Identification Number /Social Security Number
The Indiana Department of Revenue will not process any application, which does not contain an FID number or a SSN
number.
Owner's Identification Number
The Indiana Department of Environmental Management assigns this number to each owner that has registered all facilities
in accordance with State Laws. Each owner should have only one identification number.
Facility ID Number
The Indiana Department of Environmental Management (I.D.E.M.) assigns this number to identify each facility that has
been registered under specific owner identification number.
Ownership_Date
The date you took legal ownership of the facility /tank(s). If you took ownership on or before July I" of the current year,
you must pay the yearly fees. These fees are not prorated.
Number of Petroleum /Hazardous Substance Tanks
Number of tanks at facility(s) that have been removed, replaced or installed.
Removal :Date
The actual date the tank(s) were removed out of the ground. If the tank(s) were still in the ground as of July 1s' of the
current year, you must pay the yearly fees in full. These fees are not prorated.
Installation Date
The actual date the tank(s) were installed into the ground. If the tank(s) were installed on or before July Is' of the current
year, you must pay the yearly fees in full. These fees are not prorated.
Sold Date
The legal date of sale. if you have sold your facility(s) during the past year, you must complete the UST -4, Change of
Ownership Form, and attach to the UST -I Form along with the UST -3, Environmental Tax Change Form. If you were the
owner as of July I" of the current year, you are responsible for the yearly fees. These fees are not prorated.
Signature. Title Telephone Number and Date
The Indiana Department of Revenue will not process any application, which does not contain a signature of the owner or
officer of the company.
PLEASE ATTACH THIS FORM TO THE BACK OF YOUR UST 1 FORM
�•��m, UST -4 Indiana Department of Revenue
StateForm 50767
Rv10 UST Change of Ownership Form
This form s'46 beu'sed if you have sold a facility or facilities BEFORE July 1'' of the current year.
Please complete the following information and attach to the back of your UST4 -form.
gr If you were the owner of thetank(s) 'and it was still in the
liable f or pa id in full by the owner of the tank(s).
Previous Tank Owner Information
A P.O. Box, Number is .NOT Acceptable for an Owner's Address.
Owner's LD.,Number: Date oCOwnership: Federal I.D. Number /Social Security Number
Owner's Name:,(The person who OWNS the tank(s) not the Leasee)
Owner's Physical Address: (NOT a P.O. Box'or facility address): City State Zipcode
Date Sold: Facility Number Sold:
New Owner's Name: (The person who OWNS the tank(s) not the Leasec
Owner's Physical Address: (NOT a P.O. Box or facility address): City State Zipcode
Date Sold: Facility Number Sold:
New Owner's Name: (The person who OWNS the tank(s) not the Leases
Owner's Physical Address: (NOT a P.O. Box or facility address): City State Zipcode
Date Sold: Facility Number Sold:
New Owner's Name: (The person who OWNS the tank(s) not the Leases
Owner's Physical Address: (NOT a P.O. Box or facility address): City State Zipcode
The Department of Revenue will not process any application which does not contain a Federal
Identifica'tion'Number or Social Security Number and signature of owner or of the company.
Under the'peiia fC '6f peijtiry, I have examined this return (including any accompanying schedules and statements) and to the best of my
knowledge and'belief, it is true, complete and correct.
Signature: Title: Date: Daytime Phone Number:
Instructions for Completing the UST 4, Change of Ownership Form
The legal owner of the facility(s) that is being sold must complete this form.
If you were the legal owner as of July 1" of the current year, you are responsible for the yearly fees. These fees are not
prorated. If the;facility.(s) has,been sold on contract or is being leased, the legal owner of =the facility(s) -is responsible
for all tank fees under State Laws.
Owner's I.D. Number
Enter your owner ideiitification'riumber thafwas assigned to you by the Indiana Department' of
Management (I.D.E.M.).
Date
The date you too af'ownership of.the facility(s).
Federal I.D.7 Nu'mber
The Indiana Department of Revenue will not process any application, which does not contain a Federal Identification or
SoFial`Security Number'
Owner's Name
The �legal_owner.of the facility(s)- under..State Law. Not the leasee or contract buyer.
Owner's Physical Address
This must be'a h sical address, not a' R:O. Bo
ox.number.or the address of the facilify(s).
Date Sold
Thc date the buyer took legal possession of the facility(s). If you were the legal owner as of July V of the current year,
you are responsible for the yearly fees and payment must be sent in with your UST -1 Form. These fees are not prorated.
Facility Number Sold
Enter the facility number of each facility that has been sold.
New Owner's'Name 'and Address
Enter the name and physical address of the new owner of the facility(s) for each facility sold. Not the leasee or contract
o i AND/OR TANK(s) IS
RES PONSIBLE OR ALL TANK FEES NOT THE LEASEE O. CONTRA
Signature, Title, Telephone Number and Date
The Indiana Department of Reyenue will not process any application which does not contain a-signature of the owner-or
responsible officer of the company.
Should you' have•any questions concerning your facility(s) or tank(s), you may call the Indiana
Department of Environmental Management at (3l 7) 234 -0343.
Should you have any questions about your payment, you! may call the Indiana Department of Revenue
at (317) 615- 2590.
PLEASE ATTACH THIS FORM WITH.THE ENVIRONMENTAL TAX. CHANGE_ FORM. TO THE
BACK OF YOUR UST I FORM.
Instructions for the UST -1 Packet
Rev. 10 -03
Enclosed is your UST -1 Underground Storage Tank Fee Return(s) for the current year. If the
amount due is $500 or more, you have the option of paying your Underground Storage Tank fees
in four installments.
Enclosed are four UST -1 forms, which are color -coded based on the due date of the return. Each
UST -1 lists all of the facilities associated with your Owner Identification Number.
You must place a check mark on the form next to each facility for which you are paying taxes. If
taxes are not being paid for a particular facility, it should be crossed out on the UST -1 and you
must attach a completed UST -3 Environmental Tax Change Form (enclosed) with an explanation
for nonpayment. If you have sold a facility or facilities, you need to complete a UST -4 Change
of Ownership Form (enclosed); it should then be attached to the UST -1 along with a completed
UST -3 Environmental Tax Change Form. A Federal Identification Number (FID) or the owner's
Social Security Number is required on these forms. The Department cannot process any. form
without a proper identification number and a company owner's or officer's signature.
If your fee return payment is late because of an error in submission, you may be assessed
additional penalties and interest. Please make checks payable to: Indiana Department of
Revenue.
If you are submitting a payment for any facility or facilities other than your own, you must
obtain the original forms from the taxpayer for whom you are paying. The original completed
UST -1 forms for those facilities must be submitted with payment.
For questions about the UST -1, please call the Indiana Department of Revenue at (3 17) 615
2590. For any questions regarding your facility /facilities, call the Indiana Department of
Environmental Management at (317) 234 -0343.
$2,000 per Tank Penalty I.C. 13- 23 -12 -7
Failure to pay Underground Storage Tank fees by the appropriate-due dates will result in the
assessment of a penalty of not more than $2,000 per Underground Storage Tank for each year
that passes after the fee becomes due but before the fee is paid.
Disclaimer
The Indiana Department of Revenue is a collection agent for the Indiana Department of
Environmental Management (I.D.E.M.). Any questions concerning billing should be addressed
to I.D.E.M., 100 N. Senate Avenue, Room N -1 101, Attn: UST Section, Indianapolis, IN 46204.
I.D.E.M. can be reached by phone at (317) 234 -0343.
Instructions for UST -1
Underground Storage Tank Fee Return
Who Should File This Form? Owner's Name and Address.
Anyone who owns an underground storage tank as of July I of This area reflects your legal ownership name and address. It is
the current year must file this return and pay the fee unless
very important that a physical address (not a P.Q. Box Number)
exempted by State Law. This form was mailed because our he provided. This will help to ensure your underground storage
records indicate an underground storage tank(s) was in use on fee return will be received in a timely manner. However, you
the assessment day of July I" of the year in question. If you may include a P.O. Box number alone with your physical
believe the tanks are exempt from this fee, you must complete address.
the notification form and send it to the Indiana Department of
Annual Amount Due, Installment Payment Due.
Environmental Management (I.D.E.M.).
If your annual amount due is $500.00 or less. you must pad the
Tanks Exempted Under State Law. total amount due by the due date indicated on the First Payment
Underground storage tanks which are exempt from this fee UST -I Form. If your annual amount due is over $500.00. you
include: (a) regulated tanks properly and permanently closed or may pay by installment payments. Each UST form has a due
removed before July I" of the year in question; (b) tanks used date in which your installment is due It is extremely imporlanr
for storing heating fuel for use on the same premises: (c) farm or that you nay your fees timey to avoid the Environmental
residential tanks storing motor fire) for noncommercial use, with Penalty of up to a2, 000.00 per tank, per day. for each year past
a capacity of less than 1,000 gallons. the due dare.
For more information on exemptions or state rules and Owner Identification Number.
guidelines regarding permanent closure of regulated tanks, The Indiana Department of Environmental Management assigns
contact the Indiana Department of Environmental Management this number to each owner that has registered all facilities in
(I.D.E.M.) at 317- 308 -3064. accordance with State Laws. Each owner should have only one
owner identification.
Now Are These Fees Used? Facility Identification Number.
The purpose of the fee is for the Excess Liability Fund that The Indiana Department of Environmental Management assigns
provides financial support to "qualified" underground storage
tank applicants for leaking underground storage tank cleanups this number to identify each facility that has been registered
Applicants must comply timely with all State Laws regarding under a pacific owner identification number.
the notification maintenance and fee payment requirements for
underground storage tanks in order to be eligible for assistance. Facility and Tank information.
For more information about the Excess Liability Fund and its Each facility number has the number of tanks registered to that
qualifications, contact I.D.E.M. at (317) 308 -3080. facility and 'a box next to it. It is very important that you check
off each facility you want your payment to be applied to.
Who Do 1 Pay These Fees To? Failure to provide this information may delay the processing of
Fees must be made payable to the Indiana Department of your return and cause penalty and interest to be applied to your
Revenue. These fees are mandated by law and serve a very account. if the number of tank(s) is incorrect you may make
useful purpose. This money supports an Excess Liability Fund the correction and the Notification Form must be completed and
that is available to address financial concerns related to attached to your return showing the correct number of tanks at
underground storage tank cleanups. However, these funds are that facility. This information will be forwarded to the
only available to '`qualified" applicants. which means you must Department of Environment Management (I.D.E.M.).
have met all filing requirements and have paid all your tank fees
timely. In many respects, these fees are similar to insurance Penalty and Interest.
premiums, i.e. you derive a direct benefit from paying them if your return is mailed after the due date, you must include
timely if you ever need access to the fund. penalty and interest. .Penalty for filing after the due date is 10 o
of the fee due. To obtain the interest amount due. call the
Are Tank Fees Prorated? Department of Revenue at (3 7) 615 -2590. For information
No. The underground storage tank fees are not rorated concerning Environmental Penalties please call the Department
These fees are calculated on a fascia) year beginning July 1 on of Environmental Management (I.D.E.M.) at (317) '_34- 034.
any tank that has not been properly closed or removed before 411 penalties and interest should be sent with your payment.
the billing date according to State Law.
Questions?
Federal Identification Number. if you have any questions concerning your billing_ please call the
The Indiana Department of Revenue will not process any. Indiana Department of Revenue at (317) 615 -3590. if you have
application which does not contain a Federal Identification questions about tank regulation or registration or the
Number or Social Security ?number and a signature of the owner environmental penalty, please call the Department of
or officer of the company. Failure to provide this information Environmental Management (I.D.E.M.) at (.317) 308 -3061.
may result in penalty and interest.
INSTRUCTIONS FOR UST -1
Enclosed is your Underground Storage Tank fee return(s) for the current year. If the amount due is $500.00 or more
you have the option of paying your Underground Storage Fees in four installments.
Enclosed are four different color -coded UST -1's based upon the due date of the return. Each UST -1 will list all
facilities that belong to your Owner Identification Number. You must put a check mark next to each facility for which
you are paying. If you are not paying for all the facilities listed, please mark a line through the specific facility not
being paid. Also, fill out the enclosed Change Form with an explanation for nonpayment If you have sold a facility or
facilities, you will need to complete the USTA Sold Form and attach it along with the UST -3 Change Form and the
UST -1 Form. The company Federal Identification Number (FID) or owner's Social Security Number (SSN) is required
on these forms.
The Department of Revenue cannot process the UST -1 Form that does not contain the FID or SSN number
and an officer or owner signature.
DO NOT SEND A CHECK WITHOUT THE UST-1 FORM
OR
THE UST -1 FORM WITHOUT A CHECK
IT WELL BE SENT BACK TO YOU.
This may cause your fee return to be late thus penalty and interest will be assessed by the
Indiana Department of Revenue.
Please make check payable to: Indiana Department of Revenue.
11 you are paying tank fees other than your own, you must acquire the original forms from the
taxpaver(s) you are paving for. Failure to submit the proper UST -1 may result in ,penalty and
interest being accessed,
IC 6- 8.1 -10 -1 IC 6- 8.1- 10 -2.1.
Should you have any questions about you facility/facilities, you may call the
Indiana Department of Environmental Management at (317) 2340343.
Should you have any questions about your UST -1 Form, feel tree to call the
Department of Revenue at (317) 615 -2590
$2000.00 PER TANK PENALTY
UNDER INDIANA CODE: IC 13.23 -12 -7
An owner of an Underground Storage Tank who is required to pay the Tank Fee and fails to pay the fee when
due shall be assessed a penalty of not more than two thousand dollars ($2000.00) per Underground Storage
Tank for each year that passes after the fee becomes due and before the fee is paid.
DISCLAIMER
THE INDIANA DEPARTMENT OF REVENUE IS A COLLECTION AGENCY FOR THE INDIANA DEPARTMENT OF ENVIRONMENTAL
MANAGEMENT (I.D.E.M.). THEREFORE, ANY QUESTIONS CONCERNING A BILLING SHOULD BE ADDRESSED TO THE INDIANA
DEPARTMENT OF ENVIRONMENTAL MANAGEMENT (I.D.E.M.), 100 NORTH SENATE AVENUE, ROOM N -1101,
ATTN: UST SECTION, INDIANAPOLIS IN. 46204
(3 17) 234 -0343
VOUCHER 086685 WARRANT ALLOWED
7 9548 IN SUM OF
INDIANA DEPT OF REVENUE
F:z-;el Env. Section
1.00 N. Senate Ave IGCN Rm N240
Indianapolis, IN 46204
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
10800 01- 7750 -08 $90.00
Voucher Total $90.00
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 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
79548
INDIANA DEPT OF REVENUE Purchase Order No.
Fuel Env. Section Terms
100 N. Senate Ave IGCN Rm N240 Due Date 11/18/2008
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/18/2001 10800 $90.00
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