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HomeMy WebLinkAbout200904 08/30/2011 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M CHECK AMOUNT: $210.00 CARMEL, INDIANA 46032 CASHIER OFFICE MAIL CODE 50 -10C 100 N SENATE AVE CHECK NUMBER: 200904 INDIANAPOLIS IN 46204 CHECK DATE: 8130/2011 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 DIST 150.00 OTHER EXPENSES 601 5023990 PLANT 60.00 OTHER EXPENSES PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER WS number: s r DISTRIBUTION SYSTEM OPERATOR a CERTIFICATION Receipt number: State Form 12094 (R6 12 -06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE. A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and his /her supervisor. Failure to file a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One app ation per grade checked): Water Distribution System PWS ID 5 a 9pb Operator DSS DSM DSL P CHECK EXA LOCATION Water Treatment Plant Operator Northwest L7 Central WT1 WT2 WT3 WT4 WT5 WT6 O.I.T Southeast [:j Northeast Southwest By examination By reciprocity o• a On o- 1. tJqme of applicant (last) (first) (middle) Mr. ❑Mrs. []Ms. D a 2. Mailing address (number and street): 2 07 w S4 City: State: ZIP ode: Caun y: N f o 7 r 3. Office telephone number: 4. Home telephone number: Z 3I J%7 5 5 6 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeatlretake ❑Yes' Po *If yes, date (mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? ❑Yes' �110 *If yes, give certification number and classification: 7. Are you presently a certified water works operator in another state? []Yes* i;No *If yes, give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes 66 9. Social Security number:* *Your Social Security number is being requested by this state agency in order to expedite j V- 2 o L./ processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 1 r e o e B 8 0 10. Check the highest grade completed. Grade School: High School: College (years): ❑l [12 [33 ❑4 L15 ❑6 [17 E38 [39 ❑10 Ell 12 ❑l ❑2 ❑3 ❑4 ❑5 ❑6 ❑More than 6 years 11. High School Graduate? Date of graduation (mm /ddtyyyy): Name and location of school �Ves ❑No ❑GED 07 d' 9 12. College �r duate? Degree: Major: ❑Yes /�No Date granted (mm /dd /yyyy): Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Pagel of 3 13. Training courses, short courses, or other courses attended applicable to water industry a. Name of course Name of school: Dates: College units or class hours. b. Name of course: Name of school: Dates: College units or class hours: o- R1 r, o t► 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 1 ADDRESS JOB DUTIES FROM: T0: Position title: Name of current employer: 7 7 P" ,4.,J' 1 4! L '-d i> 3 i +ems r3 t� ri Specific duties performed in day -to -day operation: Address: (number and street) 41 .4jd A- c.J,rj5f_ D 3v p 4`4 ,0 J �j�So� r�r�� 5`a i r1 /3I� vT 5�•� t o r ry 14-rd /AAA fl— F t /f-•>� l y �!L✓1 U 5 T� f'r !L r �'f-- d" City, state, ZIP code: -7 FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: -7 FROM: T0: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code. (Continued on page 3) Page 2 of 3 i o 0 0 0 0• o 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 years. Name of Certified Operator under whose supervision experience obtained Certification Numbers): 1 oLrG Sig re of Certified Operator Printed name and signature of applicant's supervisor: (it different than above) Applicant's supervisor: (if different than above) Name of organizationiutility /system: Telephone number: (include area code) C a L')4T r �2t v r �,,r 7) 7 3 1 5 2g S S Address: (number and street) Cl State: ZIP code r a 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 certifcate granted. I also conse v ification of my qualifications for the certificate for which I have applied. Signature of apph nt V Dat (m m/ d /yyyy): The completed application, along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204 -2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) 00 NOT SEND GASH. Page 3 of 3 PUBLIC WATER SUPPLY APPLICATION FOR o• o WATER TREATMENT PLANT AND WATER WS number; ti r DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number Stale Form 12094 (R6 12-06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE: A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and his/her supervisor. Failure to file a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One appliviflon per grade checked): Water Distribution System PVVS ID S a gL`L Operator DSS DSM DSL Water Treatment Plant Operator E] E) WT1 WT2 WT3 W74 WT WT6 O.I.T Northwest Central B examination Northeast Southwest Southeast y By reciprocity S 1. Name of applicant (last) (first) (middle) [•]Mr. ❑Mrs. []Ms. C AID O ACOW/A) 2. Mailing address (number and street): City: State: ZIP code: County: 3. Office telephone number 4. Home telephone number: c/ St 7 7 3 3 2 ys"S 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeat/retake []Yes' [$No 'if yes, date (mm/dd/yyyy); 6. Are you presently a certified water works operator in Indiana? []Yes' [$No *If yes, give certification number and classification. 7. Are you presently a certified water works operator in another state? RNo 'If yes, give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? [Dyes [ENO 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite S /-I– Z6-79 processing of your application. Disclosure is voluntary and you will not be penalized for refusal. o a e o0 0 0 o e 10. Check the highest grade completed. Grade School: High School: College (years): ❑1 ❑2 ❑3 04 ❑5 ❑6 ❑7 ❑8 ❑9 ❑10 ❑11 ❑12 ❑l 22 03 ❑4 05 ❑6 ❑More than 6 years 11. High School Graduate? Date of graduation (mm/ddfyyyy): Name and location of school ®Yes []No ❑GED 03/ S 12. College Graduate? Degree. Major: ❑Yes [RNo Date granted (mm/dd/yyyy); Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 13. Training courses. short courses, or other courses attended applicable to water industry: a, Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: .w o c 1111 e List your current assignment first. Show at/ experience in the Drinking Water field. Attach additional sheets, if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME 1 ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: '7- Id �s>!�� C' r; L Specific duties performed in day -to -day operation: Address n s: (umber and street) Ma r.a ,J C A jz c' ci (D 1 5 r C� J €i J 5 yS T ;r vt `f I S r I��P� r c- ,1�T�✓"�}. r rJ S f�,�A r fR-' F� l'�� 1-/�,� City, state, ZIP code: S !L L1p0 �q FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: T0: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: (Continued on page 3) Page 2 of 3 i ..k. 9 0 O .j✓p ti C to y 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 5 years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): Col, K, O "&p Signature of Certified Operator: A Printed name and signature of applicant's supervisor: (if different than above) Applicant's supervisor: (if different than above) Name of organization /utility /system: Telephone number: (include area code) C' t_ 6 r r�tS Address: (number and street) City: State: ZIP code: BMW 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. 0Y Signa ure of applicant: Date (mm /dd /yyyy): The completed application, along with all required fees and attachments should be mailed lo: Indiana Department of Environmental Management Cashier's Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204 -2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 F a PUBLIC WATER SUPPLY APPLICATION FOR a WATER TREATMENT PLAINT AND WATER WS number: ,a DISTRIBUTION SYSTEM OPERATOR Receipt number: CERTIFICATION State Form 12094 (R6 12 -06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE: A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and hislher supervisor, Failure to file a properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One appl' ation per grade checked): Water Distribution System PINS ID 5 .a- 7 G t7 Operator DSS DSM DSL PLEASE M LOCA Water Treatment Plant Operator L1 El L] Northwest Central WT1 WT2 WT3 WT4 WT5 WT6 O.I.T u 1 Southeast ouwest By examination By reciprocity Northeast El Southwest 0 0 0• 1. Name of applicant (last) (first) (middle) 26r. OMs. ZVE Z 2 D SA-4�F S 2. Mailing address (number and street): 3q City: State ZIP code: County: 7 gQMc loo 7 PAA1TL7v,'1J 3. Office telephone number: 4. Home telephone number: (Z 'l3 3 -55 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeallretake ❑Yes' to `If yes, date (mm/dd/yyyy): 6. Are you presently a certified waterworks operator in Indiana? Dyes' [9<o 'If yes, give certification number and classification: 7. Are you presently a certified water works operator in another state? Dyes* 9<0 'If yes, give certification number and classification (attach a copy of certificate) S. Have you ever had a certification suspended or revoked? ❑Yes �o 9. Social Security number:' 'Your Social Security number is being requested by this state agency in order to expedite 31,9 ga Cv a9 processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 0 o e O oe o 0 o s 10. Check the highest grade completed. Grade School: High School: College (years): F11 [32 ❑3 [:14 [15 [16 [17 [18 [19 010 ❑l1 [1<2 D ❑2 ❑3 ❑4 ❑5 ❑6 F-1 More than 6 years 11. H Graduate? Date of graduation (mmlddlyyyy): Name and location of school Ly1'es ❑No ❑GED U.1cST� �i Co 1n l q i `7 P 1 12. College Graduate? Degree: Major: ❑Yes Date granted (mmlddlyyyy) Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 o m m m r i 3. Training courses, short courses, or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: I "Illi�illi II m m o 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 I ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: Z (o °'o �D 7/L4 Y1�jd2 -1i vT It,l 1 +`z Specific duties performed in day -to -day operation: Address: (number and street) ,2 r 3 A I .J C P �rG 7)1-9 t 3 .3 C) �r41 w A 411- /"A. T City, state, ZIP code: y �R ✓�r�/ �S r o r �2 Smu'L�/ t C L.r4- �2sNr c.- 0 '7 FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code. FROM: TO: Position title: Name of previous employer: Specific performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: (Continued on page 3) Page 2 of 3 BENZ. o v o u- I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge. r I have supervised this individual for years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): G P t- L ✓a- -i p Signa ure of Certified Operator: 61 DS 'a 7 Z Printed name and signature of applicant's supervisor: (if different than above) Applicant's supervisor: (if different than above) Name of organization /utilitylsystem: Telephone number: (include area code) 614-_7fM c- 3 5 Address (number and street) 22 City: State: ZIP code: Oil 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. lure of applicant: Date (mm /dd /yyyy): The completed application, along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204 -2251 Please make all checks payable to the Indiana Department of Environmental Management (3240- 4114 -00- 140000) DO NOT SEND CASH. Page 3 of 3 PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER WS number: DISTRIBUTION SYSTEM OPERATOR Receipt number CERTIFICATION State Form 12094 (R6 12 -06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL_ MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE: A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and his/her supervisor. Failure to file a properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One app ation per grade checked): Water Distribution System PW5 ID Operator DSS DSM DS PLEASE CHECK EXAMLOCATIO Water Treatment Plant Operator 0 WT1 WT2 WT3 WT4 WT5 WT6 O.LT Northwest Central Southeast Northeast El Southwest By examination [I By reciprocity o- o- 1. Name of applicant (last) (first) (middle) ©Mr. []Mrs. []Ms. —t— 6J- 8 k6-F— P, O!l1 2. Mailing address (number and street): G212 Woo Q5 t> F, City: State: ZIP code: County: V 3-.E-s tJ I C_ L `frd O& Z M /G4"-/ 3. Office telephone number: 4. Home telephone number: 3i? 2q_, 5. Have you ev r applied for Water Works certification in Indiana before? (is this exam a repeat/retake ❑Yes' la `If yes, date (mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? ❑Yes' 'If yes, give certification number and classification: 7. Are you 7pres tly a certified water works operator in another state? ❑Yes' 'If yes, give certification number and classification (attach a copy of certificate) 8. Have y ad a certification suspended or revoked? ❑Yes o 9. Social Security number:* "Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 0 4 e oa e o m o 10. Check the highest grade completed. Grade School: Z High School: Colle�ge� ars): Ell E12 [13 []4 E35 06 E17 [19 ❑10 El 11 12 [11 1 L33 ❑4 05 ❑6 ❑More than 6 years 11. Higb,8chool Graduate? Date of graduation (mm/dd/yyyy): Name and location of school': es ❑No ❑GED DSABF_- CoMMJNrre 12. College GraXate? Degree: Major ❑Yes RNo NA- AA- Date granted (mm/dd/yyyy): Name and location of college: N A- N A (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 o o a o a 13. Training courses. short courses, or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: 10� 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 l ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: L r Specific duties performed in day -to -day operation: Address: (number and street) .7q t r j C +G.[- 71 5 i YU J3 c� n cm� S �l S -�-x 3 Z 5o w II 13 s i FI y r7� Lv S f 5 City, slate, ZIP code G ARm�L 4 4 0- 7`� FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer. Specific duties performed in day -to -day operation: Address: (number and street) City, State, ZIP code: (Continued on page 3) Page 2 of 3 v 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 4 years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): 1 O L LYa—y Signature of Certified Operator: l� 2 Printed name and signature of applicant's supervisor. (if different than above) Applicant's supervisor: (if different than above) Name of organization /utilitylsystem: Telephone number: (include area code) /4 -T 6 a -r —ID l 3 `7 3 S Address: (number and street) City: State: ZIP code: r oc,, T e 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. O to I� Signature of applicant: Date (mml d/yyyy): The completed application, along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204 -2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 A A3& PUBLIC WATER SUPPLY APPLICATION FOR m•r� k,., a WATER TREATMENT PLANT AND WATER WS number: ti�y,�yr DISTRIBUTION SYSTEM OPERATOR CERTIFICATION ReceiPt number: State Form 12094 (R61 2 -06) Approved by Stale Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and his /her supervisor. Failure to rite a property completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One app ation per grade checked): Water Distribution System PWS iD SD a G Operator DSS DSM DSL Water Treatment Plant Operator El El 11 WT WT2 WT3 WT4 WT5 WT6 O.l.T Northwest Central Northeast ❑Southwest El Southeast By examination 0 By reciprocity m- a o- 1. Name of applicant (last) (first) (middle) ®Mr. ❑Mrs. ❑Ms. rq C `4 {f 0 A 2. Mailing address (number and street): I b 7 3 c� N ��.r1C Iry City: 11 State: ZIP code: {�r County: J. y1 t� 1 ::L f I y 14 A M i 110 r'\ 3. Office telephone number: 4. Home telephone number .3 k-1 733 IV5S7 311 9314 l aI66 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeal/retake ❑Yes' IRNo 'If yes, date (mmldd/yyyy): 6. Are you presently a certified water works operator in Indiana? []Yes' ®No 'If yes, give certification number and classification: 7. Are you presently a certified water works operator in another state? ❑Yes' ®No 'If yes, give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? []Yes ®No 9. Social Security number" 'Your Social Security number is being requested by this state agency in order to expedite 3 LCl Ca o DL processing of your application. Disclosure is voluntary and you will not be penalized for refusal. INIM m s mm m o o- m 10. Check the highest grade completed. Grade School: High School: College (years): ❑l ❑2 ❑3 ❑4 ❑5 ❑6 ❑7 06 0 ❑10 F-1 11 [4 12 ❑l ❑2 ❑3 ❑4 ❑5 ❑6 ❑More than 6 years 11. High School Graduate? Date of graduation (mm/dd/yyyy): Name and location of school': ®Yes []No ❑GED 1 .2 C-) 0 C" C" t ene- S c 1 12. College Graduate? Degree: Major: ❑Yes ❑No Date granted (mm/dd/yyyy): Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 cf 3 13. Training courses. short courses, or other courses attended applicable to water industry: a. Name of course: Name of school. Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours. c D 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 t ADDRESS JOB DUTIES FROM: TO: Position title: Name of cu rrent employer MC'q%k a vv-tSx Lc. b o r G; 41 f bIF Ccir i vA c,tt r S Specific duties performed in day -to -day operation Address: (number and street) Cr v i L C. -1 Y1n t4 r 3 c 11 S w rA F:w riv-@. t VIVI+ City, slate, ZIP code: 4 -46 6 7'/ S�.+hplcS FROM: TO: Position title: Name of previous employer. Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Narne of previous employer: Specific duties performed in day -to -day operation: Address: (number and street) City, state, ZIP code: (Continued on page 3) Page 2 of 3 yy I hereby cerlify 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 years. Name of Certifie Operator under whose supervision experience obtained Certification Number(s): en (.ac, d o(.l -A Sig cure of Certified Operator: 7 Printed name and signature of applicant's supervisor, (if different than above) Applicant's supervisor: (if different than above) Name of organizationlutilitylsystem: Telephone number: (include area code) Address: c (number and street) City: State: ZIP I code. 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. 5W 7 9 Signature o pplican Date (mm /dd /yyyy): The completed application, along with all required fees and attachments should be mailed to Indiana Department of Environmental Management Cashier's Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204.2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 PUBLIC WATER SUPPLY APPLICATION FOR y WATER TREATMENT PLANT AND WATER WS number: .a„ d DISTRIBUTION SYSTEM OPERATOR Receipt number: CERTIFICATION State Form 12094 (R612 -06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8 -12 -1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied /Reason: NOTE: A $30 fee must be submitted with each application for certification. Applications must be signed by the individual, and hisrher supervisor. Failure to file a properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade: (check one One application per grade checked): Water Distribution System PWs ID .522 Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator WT1 WT2 W73 WT4 WT5 WT6 0_13 El Northwest Z Central Northeast Southwest Southeast )Py examination By reciprocity e s 1. Name of applicant (last) (first) (middle) XMr. ❑Mrs. ❑Ms. Am A l i-ew QQ 2. Mailing address (number and street): F 10 6% City: State: ZIP code: County: r ZA/ 407 Z VS 3. Office telephone number: 4. Home telephone number: S7/ 2 3/7— 3.6 S 0_71 5. Have you ever applied for Water Works certification in Indiana before? (Is this exam a repeaVretake ❑Yes` ;9No `If yes, date (mm/dd/yyyy). 6. Are you presently a certified water works operator in Indiana? ❑Yes' ;9No 'If yes, give certification number and classification: 7. Are you presently a certified water works operator in another state? ❑Yes" PNo `If yes, give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? Dyes P(No 9. Social Security number:" *Your Social Security number is being requested by this state agency in order to expedite 3 S processing of your application. Disclosure is voluntary and you will not be penalized for refusal. r e r •o r• e- e 10. Check the highest grade completed. Grade School: High School: College (years): ❑l ❑2 1- 04 ❑5 ❑6 07 ❑8 ❑9 010 011 E112 ❑1 02 ❑3 04 05 ❑6 ❑More than 6 years 11. Hi h School Graduate? Date of graduation (mm/dd/yyyy): Name and location of school Yes [-]No ❑GED O I A" /1 4 h 12. College Graduate? Degree: Major: ❑Yes �No Date granted (mm/dd/yyyy): Name and location of college: I (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 0 0 0 0 0• o 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 years. J AjeAj 4 f A,S e r'' b ,Z 1 f Name of Certified Operator under whose supervision experience obtained Certification Number(s): sign ture of Certified Operat P S C) ,r ra r Printed name and signature of applicant's supervisor: (if different than above) Applicant's supervisor: (if different than above) Name of organizationlutitity /system: Telephone number. (include area code) t✓, t 6 4/L 1 1 "7 E? j J Address: (n umber and street) j v 1� s I S 1 City: State: ZIP code: 11 p ill law a 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. ZLIdd. r e 61231Lo// ature of applicant: Date (mm/dd/yyyy). The completed application, along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashiers Office, Mail Code 50 -10C 100 North Senate Avenue Indianapolis, IN 46204 -2251 Please make all checks payable to the Indiana Department of Environmental Management (3240 4114 -00- 140000) DO NOT SEND CASH. Page 3 of 3 13. Training courses, short courses, or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: i 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 1 ADDRESS JOB DUTIES FROM: TO:: Position title: Name of current employer: gl'GYI V rPP! OT T o L4tae� Sp e cific du 'es performed in day -to -day operation: Addre (number and street) 1�t* t L 4bs 4� all A/vw�s Mad. ®'I e�iewee./ aaelyrws &IAV7 Ar'4; SW/w .0/es Re 1 V4IW1 Lo /lalc� f�'o" SvaP&'j MRb prep 3 131 City, state, ZIP code: Well &"0' dowers rr 4 c yw0i 4 414frs 4 4d d6lvAw 4pl S ANe+r s ca' we mow- /ev s .-i+t �'/u D FROM: TO: Position titles: Name of revious em foyer: �lgvt 0 d 1 M q r e4 /Lo OC 4r -7 ar7 c_.— Specific duties performed in day today operation: Address. (number and street) �.004 Wq *e- maihs 41-1 Serwlw a lrheJ Me4- a4 3 ro W 13 Sf a m e 4 ers City, state, ZIP code: C�grme Al Gay FROM: TO: Position title: Name of previous employer: Specific duties performed in day today operation: Address: (number and street) City, state, ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day today operation: Address: (number and street) City, state, ZIP code: (Continued on page 3) Page 2 of 3 '®Eller INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Psi We Protect Hoosiers and Our Environment. Mitchell E. Daniels Jr. 100 North Senate Avenue Governor Indianapolis, in 46204 (317) 232 -8603 Thomas W. Easterly Toll Free (800) 451 -6027 Commissioner www.idem.IN.gov May 25, 2011 66 -35 Kris C. Anthis 11955 Cable Dr. Indianapolis, IN 46236 Dear Mr. Anthis: Re: Water Works Operator Certification Examination This is to notify you that you have either failed' to attend or received an unsatisfactory grade (less than 70 for the Grade WT3 Water Works Operator Certification Examination held on May 5, 2011. Exam scores have been posted at httos /secure.in.gov /idem/5091.htm You will need to use your exam sign -in number to view your score: Should you wish to apply for the November 3, 2011, certification examination, you must complete and return the section indicated on page two along with the application fee to the IDEM Cashier's Office, Mail Code 50 -10C, 100 N. Senate Avenue, Indianapolis, Indiana 46204 -2251. In order to meet the application deadline, this information must be postmarked no later than September 19, 2011. There is also 'an exam tentatively scheduled for May 3, 2012, if you would like to retake your exam at that time. You may review your examination papers in the IDEM Drinking Water Branch office by August 5, 2011, by appointment only via a written request. You may send your written request to review your exam via standard mail to the attention of Dennis Henderson or via email to DRHENDER@idem.in.gov. You may also request a rescore, hand score or diagnostic profile (strength and weakness) from the Association of Boards of Certification (ABC) by submitting a $15 fee, along with a letter indicating the name and level of the exam, the state in which the exam was taken, the date the exam was taken, your name and-exam identification number (the last four digits of your social security number). The mailing addressfor ABC is Association"of Boards of Certification, 2805 S.W. Snyder Boulevard, Suite 535, Ankeny, Iowa 50023. Any person affected or aggrieved by this agency's decision to deny application for operator certification may request review, provided that a_ petition for administrative review is filed as required by IC 4- 21.5 -3 -7. The petition must be submitted to the following within eighteen (18) days of the date of mailing of this notification. Kris C. Anthis Page Two Office of Environmental Adjudication 100 N. Senate Avenue Government Center North, Room 501 Indianapolis, IN 46204 The petition must include the facts demonstrating that you are either the applicant, a person aggrieved or'adversely affected by the decision or otherwise entitled to review by law. In order to assist the Permit, :Certification and Capacity Section staff in tracking appeals, we request that you submit a copy your petition to Patrick Carroll, Chief, Drinking Water Branch, Indiana Department of Environmental Management, Mail Code 66 =34, 100 North Senate Avenue, Indianapolis, Indiana 46204 -2251. Additionally, IC 13- 15 -6 -2 requires that your petition include: 1. The name and address of the person making the request; 2. The interest of the person making the request; 3. Identification of any persons represented by the person making the request; 4. The reasons, with particularity, for the request; 5. The issue's, with proposed for consideration at the hearing, and 6. Identification of the conditions which, in the judgment of the person making the request, would be appropriate in the case in question to satisfy the requirements of the law governing operator certification oh he type granted or denied. If you have any questions, please do not hesitate to contact Ms. Ruby Keslar at 3171234 -7431. Please note thatthe Drinking Water Branch office has relocated to the 12th floor of the Indiana Government Center North building at 100 N. Senate Avenue, Indianapolis, Indiana. Sincerely, Patrick Carroll, Chief Drinking Water Branch I would like to be scheduled for the November 3, 2011 May 3, 2012 Grade ��-T waterworks operator certification examination. Applicant (printed name) AVplicant (signature) VOUCHER 112190 WARRANT ALLOWED TIDEM IN SUM OF IDEM 100 N SENATE AVENUE ppERAT14NS NDIANAPOLIS, I r\1 46204 -2251 (;TWA A Vie- �blbC Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO INV ACCT AMOUNT Audit Trail Code PLANT 01- 6040 -03 $60.00 t is ck .6ft b 5 156CO Voucher Total 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 TIDEM IDEM Purchase Order No. 100 N SENATE AVENUE Terms INDIANAPOLIS, IN 46204 -2251 Due Date 8/2312011 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 8/23/2011 PLANT $60.00 I 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- 11- 10 -1.6 Date Officer