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Home My WebLink About174368 07/08/2009 a CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 s,� ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M' �HECK AMOUNT: $30.00 a CARMEL, INDIANA 46032 MAIL CODE 65-42 100 N SENATE AVE CHECK NUMBER: 174368 INDIANAPOLIS IN 46204 -2251 CHECK DATE: 718/2009 DEPARTM ACCOUNT P O NUMBER INVOICE NUMBER AMOUNT DES 651 5023990 17025 30.00 OTHER EXPENSES Indiana Department of Envitonmental Management 100 N. Senate Avenue Mail Code 65-42 Indianapolis, IN 46204 -2251 EST 1986 April 30, 2009 Peter R. Brennan 2414 S Market St Yorktown IN 47396 WASTEWATER TREATMENT PLANT OPERATOR RENEWAL APPLICATION Certification WWO17025 Expiration Date: 06/30/2009 Renewal Fee: $30.00 Login Id: WWO17025 Password: 494756 Current Continuing Education Hours Earned: General 0.00 Technical 7.00 Total 7.00 1 am the responsible char 2e o erator of: Hours/Week Permit Cit N N Address Change: Current Phone 3 17``13.7-03 -3° Operator Signature: Date: Your wastewater treatment plant operator certification expires 06/3012009. After this date, you cannot be the operator in responsible charge of a wastewater treatment plant until your certification is renewed. You must meet the continuing education requirement as shown below: Classes I -SP, A -SO 5 hours earned between 7/1/2007 6/30/2009 from IDEM approved codme with at leas; 3.5 of those hours from courses designated as "technical." Gasses 1, 11, A, B 10 hours earned between 7/1/2007 6/30/2009 from IDEM approved course with at least 7 of those hours from courses designated as "technical." Classes Ili, IV, C, D 20 hours earned between 7/1/2007 6/30/2009 from IDEM approved course with at least 14 of those hours from courses designated as "technical." Online Renewal Online renewal is available 24 hours a day, 7 days a week between May 1, 2009 and July 1, 2009 at httos /lextra net. in.00v /myl ice nse The cost for the online renewal is $30.00 plus an additional $4.17 in processing fees. The forms of payment accepted online are Visa, Mastercard, Discover credit and debit cards. Login ID and Password are listed above. Mail Renewal If you wish to renew by mail, fill out the responsible charge information, and send this form with your $30 renewal Fee to: Cashier— Mail Code 50 -10C Indiana Dept. of Environmental Management, 100 N. Senate Avenue, Indianapolis, IN 46204 -2251 Should you have any questions or concerns about the renewal process, please contact Tonja Fuller -White at (317) 233 -0479 or by e -mail at tfullerw(b)idem.in.gov Certificate of Completion Approved Environment, Inc. Page 1 of 1 Approved Environme Inc. P.O. Box 47805 Indianapolis, I N 46247 -0895 1- 877 241 -9858 Emiail: info�)rovedce.com Certificate of Completion Courses are approved in the following states: Indiana, Illinois, Ohio, Alabama, Delaware, South Carolina, North Carolina, Maryla -nd, Kentucky and Ontario, Canada. Name: Peter R Brennan Address: 9609 HazelDell Parkway, Indianapolis, IN 46280 Course Title: Wastewater Preliminary Treatment Course Value: 1 Contact Hour Approval Number: IN WWT09 5904 TO I -G00, OH OEPA- 5296782 -OM, NC CEO 1140415, MD 3463 -05 -06 Date: 6/29/09 Approximate Time Spent Taking the Course: 60 minutes. Operator Certification License Number: WWO17025 Operator Class Level: 1I License Expiration Date: 06/30/2009 Operator Signature: Training Provider Signature: Ann Bersbach, Approved Environment, Inc. Copyright 2002, Approved Environment, Inc., Indianapolis, Indiana http:// www. approvedce. com/ onlineCEUs /ccuCertificateOfCornpletion.asp 6/29/2009 WASTEWATER OPERATOR /APPRENTICE CONTINUING To ensure proper credit, the wastewater approval number EDUCATION CREDIT REPORT MUST be provided. State Form 51139 (R3 14 Training Course Approval Number: 916 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT X Operator ❑Apprentice Technical 1 H OUR ours Earned: General Contact Hours Earned: 0 In accordance with 327 IAC 5- 22- 17(c), the training provider must submit this form within ninety (90) days of the conclusion of the wastewater treatment continuing education course. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Dept. of Environmental Management 100 N. Senate Ave Mail Code 65 -42 Indianapolis, IN 46204 -2251 Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM. Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete wastewater treatment continuing education course. The training provider must retain a copy of this form for their records for a three (3) year period following the presentation of each wastewater treatment continuing education course. Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified operator/apprentice attendin the entire wastewater operator continuing education course. 1 1-Kila CI~RaTIFIp OPRi41Q[ CIA" PA 1. NAME: if r Bre ti.ti a 2. ADDRESS (number and street): rlyrke—+ 5+ City: r State: l ZIP code:: Tlephone number: 1 1 LU vj� __T& Q W� Y 3 V U rk: Rf 317 7 7 q Check here if this is an address change 0 E -mail Address: GO RSE O° t W. M 1IN, RN7ATION d,�a+�w- ,._<..��.�`+e�i�^��.y. -a 3. NAME OF TRAINING COURSE: �JQ LA)0,+C r Fr .rn 11'k�� 4. NAME OF TRAINING COURSE PROVIDER: S. NAME OF OR ANIZATION SPONSORING COURSE: APPROVED ENVIRONMENT INC SAME 6. DATE(S) ATTENDED (month, day, year): q 7. LOCATION ATTENDED: VWVIN.APPROVEDCE.COM 8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATOR/APPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours: 1 HOUR 0 9. CERTIFICATE OF COMPLETION IS REQUIRED FOR ALL ON -LINE COURSES. 1, the undersigned, certify under penalty of law that this document (and any attachments) were prepared under my direction or supervision and that the information submitted is, to the best of my knowledge and belief, true, accurate, and correct. I also understand that any omissions or misrepresentation may result in the denial of continuing education credit for this course. 10. SIGNATURE OF INSTRUCTOR: 11. PRINTED NAME OF INSTRUCTOR: Ann Bersbach 12. SIG URE IFIED OPERATORIAPPRENTICE: 13. PRINTED NAME OF CERTIFIED 0PERATOR/APPRENTICE: 14. CONTINUING EDUC TION CREDIT HOURS ARE TO BE APPLIED TO: Operator certification /apprentice number: Class: Expiration date: U'�`,J 0) 70� N-,.30 -_-2 Operator certification /apprentice number: Class: Expiration date: Certificate of Completion Approved Environment, Inc. Page 1 of 1 Approved nvironment, Inc. P.O. Box 47895 Indianapolis, IN 46247 -0895 1- 877 241 -9858 Email: info (dJapprovedee.coin Certificate of Completi ®n Courses are approved in the following states: Indiana. Illinois, Ohio, Alal Delaware, South Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada. Name: Peter R Brennan Address: 2414 S Market ST, Yorktown, IN 47396 Course Title: Primary Treatment Course Value: 1 Contact Hour Approval Number: IN WWT09 -5905 T01-GOO,, OH OEPA- S296785 -OM, NC CEO 1140414, NM 3464 -05 -06 Date: 6/29/09 Approximate Time Spent Taking the Course: 60 minutes. Operator Certification License Number: WWO17025 Operator Class Level: It License Expiration Date: 06/30/2009 Operator Signature: SL R Training Provider Signature: t A". Ann Bersbach, Approved Environment, Inc. Copyright 2002, ,Approved Environment, Inc., Indianapolis, Indiana http:// www. ai)provedee. com/ onlineCEUs /ceuCertificateOfCompletion.asp 6/29/2009 WASTEWATER OPERATOR /APPRENTICE CONTINUING a ensure proper credit, the wastewater approval number EDUCATION CREDIT REPORT MUST be provided. i' State Form 51139 (R3 1 4 -08) Training Course Approval Number: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT �t� TfJ /�o �aa 4� `kill v Operator CApprentice Technical 1 H OUR ours Earned: General Contact Hours Earned: a r'.SS- �x �ror�� In accordance with 327 IAC 5- 22- 17(c), the training provider must submit this form within ninety (90) days of the conclusion of the wastewater treatment continuing education course. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Dept. of Environmental Management 100 N. Senate Ave Mail Code 65 -42 Indianapolis, IN 46204 -2251 Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM. Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete wastewater treatment continuing education course. The training provider must retain a copy of this form for their records for a three (3) year period following the presentation of each wastewater treatment continuing education course. Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified op attendin the entire wastewater operator continuing education course. TIFID` O; y PERATORIARPREIVTIGEINFORIIAATION 1. NAME: P t✓� -t� r c Q9� 2. ADDRESS (number and street): City: State: ZIP code, Telephone number: C l 7 3 Work: C 31 7-71 Home/Cell: B -Y.3.� -0 3J� Check here if this is an address change 17 E -mail Address: iF&�� t !�2e ,r E 4,. >d w t� t a a 1 ,ak aa �,:,1 ,COURSE 1Nf= 0RMATfON Y. A :..s a .S a s ..,�z .Lf .'"s d ..u' `r ..t m e..<c$'r,..a. a`'�.«'a..� .caro".v,e 3. NAME OF TRAINING COURSE: –7— 0 f M I t �'r3 1 r� 4. NAME OF TRAINING COURSE PROVIDER: 5. NAME OF ORGANIZATION SPONSORING COURSE: APPROVED ENVIRONMENT INC SAME 6. DATE(S) ATTENDED (month, day, year): 7. LOCATION ATTENDED: -a� j)� 1nlIhNV.APPROVEDCE.COM 8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATORIAPPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours: 1 HOUR 0 9. CERTIFICATE OF COMPLETION IS REQUIRED FOR ALL ON -LINE COURSES. I, the undersigned, certify under penalty of law that this document (and any attachments) were prepared under my direction or supervision and that the information submitted is, to the best of my knowledge and belief, true, accurate, and correct. I also understand that any omissions or misrepresentation may result in the denial of continuing education credit for this course. 10. SIGNATURE OF INSTRUCTOR: 11. PRINTED NAME OF INSTRUCTOR: n Ann Bersbach 12. SIGNATU F CERTIFI PER ATOP/APPRENTICE: 13. PRINTED NAME OF CERTIFIED OPERATORIAPPRENTICE: if F64 e r rC-_0N0. 14. CONTINUING EDUCATION CIIEDIT HOURS ARE TO BE APPLIED TO: Operator certification /apprentice number: Class: Expiration date: W JA/ 0 J '7 v a 30 Operator certification /apprentice number: Class: Expiration date: Certificate of Completion Approved Enviromrent, Inc. Page I of 1 Approved Environment, Inc. P.O. Box 47895 hidianapolis, IN 46247 -0895 1- 877 241 -9858 Email: info(aJ,approvedce.corn Certificate of Completion. Courses are approved in the following states, Indiana, Illinois, Ohio, Alabama., Delaware, South C'.arolina, North Ca- rolina, Maryland, l- entucky and Ontario, Canada. Name: Peter R Brennan Address: 9609 HazelDell Parkway, Indianapolis, IN 46280 Course Title: Final Effluent I Course Value: 1 Contact Hour Approval Number: IN WWT09- 5913 -TO I -GOO, OH OEPA- 5296736 -OM, NC CEO 1140408, MD 3472 -05 -06 Date: 6/29/09 Approximate Time Spent Taking the Course: 60 minutes. Operator Certification License Number: WWO17025 Operator Class Level: I1 License Expiration Date: 06/30/2009 Operator Signature: Training Provider Signature: Ann Bersbach, Approved Environment, Inc. Copyright ?002, Approved Em irontnent, lnc., Indianapolis, Indiana http:// www. approvedee .com/oiilineCEUs /ceuCertif cateOfCompletion.asp 6/29/2009 To ensure proper credit, the WASTEWATER OPERATOR /APPRENTICE CONTINUING wastewater number EDUCATION CREDIT REPORT MUST be provided. State Form 51139 (R3 4 -08) Training Course Approval Number: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT —1615113`0 1.. Goa Operator DApprentice Technical 1 HOUR ours Earned: General Contact Hours Earned: 0 2 INSTRt1 G_ TIQNS' In accordance with 327 IAC 5- 22- 17(c), the training provider must submit this form within ninety (90) days of the conclusion of the wastewater treatment continuing education course. Mail the completed form to: Wastewater Continuing Education Coordinator Indiana Dept. of Environmental Management 100 N. Senate Ave Mail Code 65 -42 Indianapolis, IN 46204 -2251 Incomplete forms will be returned to the training course provider for completion and resubmittal to IDEM. Partial course credit shall not be given to instructors, speakers, or students participating in less than a complete wastewater treatment continuing education course. The training provider must retain a copy of this form for their records for a three (3) year period following the presentation of each wastewater treatment continuing education course. Training providers are encouraged to provide a copy of the completed and signed credit reporting form to the certified operator/apprentice attendin the entire wastewater operator continuing education course. OP�ER/AT�OR/APP�RE'NTIG,E INFU,RMATtO,N" 2 1 W I MU o N R,_ 1. NAME: 2. ADDRESS (number and street): City: State: S ZIP code: Telephone number: Work: 13 377''N�- ]Home/Cell: 1 317- Y3,� l Check here if this is an address change E -mail Address: Stae QIJd L L CQURSEIFORMAT!I(3N T,;:r �3x.�g. k. 3. NAME OF TRAINING COURSE: r7 4. NAME OF TRAINING COURSE PROVIDER: 5. NAME OF ORGANIZATION SPONSORING COURSE: APPROVED ENVIRONMENT INC SAME 6. DATE(S) ATTENDED (month, day, year): ca C> 7. LOCATION ATTENDED: f 1 WVVW.APPROVEDCE.COM 8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATORIAPPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours: 1 HOUR 0 9. CERTIFICATE OF COMPLETION IS REQUIRED FOR ALL ON -LINE COURSES. I, the undersigned, certify under penalty of law that this document (and any attachments) were prepared under my direction or supervision and that the information submitted is, to the best of my knowledge and belief, true, accurate, and correct. I also understand that any omissions or misrepresentations may result in the denial of continuing education credit for this course. 10. SIGNATURE OF INSTRUCTOR: 11. PRINTED NAME OF INSTRUCTOR: Ann Bersbach 12. SIGN RE OF CERTIFtED OPERATORIAPPRENTICE: 13. PRINTED NAME OF CERTIFIED OPERATOR/APPRENTICE: 14. CONTINUING EDUCATION CREDIT HOURS ARE TO BE APPLIED TO: Operator certification /apprentice number: Class: Expiration date: Operator certification /apprentice number: Class: Expiration date: VOUCHER 095956 WARRANT ALLOWED 146900 IN SUM OF IDEM 100 N. Senate Avenue Indianapolis, IN 46207 -7060 Carmel Wastewater Utility ON- ACCOUNT OF APPROPRIATION FOR Board members PO INV ACCT AMOUNT Audit Trail Code 17025 01- 7042 -06 $30.00 f 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 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 7/1/2009 r \f Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 7/1/2009 17025 $30.00 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 OfAerf