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HomeMy WebLinkAbout173692 06/22/2009 -�e CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 ONE CIVIC SQUARE IND DEPT ENVIR MGT CARMEL, INDIANA 46032 CASHIER OFFICE -MAIL CODE 50 -10C CHECK AMOUNT: $30.00 100 N SENATE AVE CHECK NUMBER: 173692 INDIANAPOLIS IN 462D4 CHECK DATE: 6122/2009 DEPARTMENT ACCOUNT P O NUM BER INVOIC N UMBER AMOU DESCRIPT ;1 651 5023990 30.00 PERMIT Indiana Department of Environmental Management f 100 N, Senate Avenue Mail Code 65 -42 Indianapolis, IN 46204 -2251 EST April 30, 2009 Lonnie J. Patton 139 North 5th Street Middletown IN 473561438 WASTEWATER TREATMENT PLANT OPERATOR RENEWAL APPLICATION Certification WW018293 Expiration Date: 06130/2009 Renewal Fee: $30.00 Login Id: WW018293 Password: 494261 Current Continuing Education Hours Earned: General 0.00 Technical 13.00 Total 13.00 1 am the responsible charge operator of: Hours/Week Permit Cit Address Change: Current Phone Operator Signature: Date: Your wastewater treatment plant operator certification expires 0613012009. After this date, you cannot be the operator in responsible charge of a wastewater treatment plant untit,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 course with at least 3.5 of those hours from courses designated as "technical." Classes 1, II, A, 8 10 hours earned between 7/112007 6/3012009 from IDEM approved course with at least 7 of those hours from courses designated as "technical." Classes 111, IV, C, D 20 hours earned between 7/1/2007 6130/2009 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 https /YextT /mylicense 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(&demJn.00v 'Certificate of Completion Approved Environment, Inc. Page 1 of 1 Approved Environment, Inc. P.O. Box 47895 Indianapolis, IN 46247 -0895 1 -800 631 -9747 Email: infoAapprovedce.com Certificate of Completion Courses are approved in the following states: Indiana, Illinois, Ohio, Alabama, Delaware, South Carolina, North Carolina, Maryland and Ontario, Canada. Name: lonnie patton Address: 139 north 5th st, middletown, indiana 47356 Course Title: Safety n Course Value: 1 Contact Hour Approval Number: IN WWT09- 5919 -TO1 -GOO, PWSG06 -3073, OR OEPA- B300334- X, NC CEO 1140411, MD 3478 -05 -06 Date: 6/11/09 Approximate Time Spent Taking the Course: 60 minutes. Operator Certification License Number: wwO18293 Operator Class Level: 3 License Expiration Date: 06/30/09 Operator Signature: Training Provider Signature: Ann Bersbach, Approved Environment, Inc. Copyright 2002, Approved Environment, Inc., Indianapolis, Indiana http: /www.approvedce. corn/ onlineCEUs /ceuCerti#icateOfCompletion.asp 6/11/2009 Continuing Education Credit Report Page 1 of 1 WAS t4A( A3ER{ yP15RATURC�IUTiNlJIP1GEDUGATIt7N ?aansurepropsrei adit,ths:wsstewater:approval: CRDtT REPORT 6. ndni*:MUST. be.ijrovidad.: State Form tl m jR ('3 .06). Trpinma Coiuse,Appraval Hpmber INDIANA DEPARTUE'NT OF ENFORONMENTAL MANAGE \DENT. Technical Cont6cl fioEUS tamed: 1.'0 GeneiarCOrited:Houts Eerned_" 0 In' accordance wifh:3271AC 5 22 -17(c) the trairling provider must submit this -to trOvithia thirty (30) deys of the of fhs wasfewatePireatr3ienTcontint ling:edueatibh "urse; tlia #ed Wastewater Continuing Education Coordinator lridlwa DOLof Elvirbnmentai Managefrient 140 N•: Senate Ave Nfaif= CodeE5ri2: IndiAnapoiie. IN 46204-2251 I.riCOnSplefe fb¢ms wijl -btr •returrl@.d tD. tCltl train_irig ¢ourg� provider for cQlnpletior, io IDE Paifal daurse credlt,:sMefLnot be:given.fo fristrilctors.; spaefcers; or sfudenfs: paiticipatirig lii:Iass:tMan a.carnplete Wa06Mrdter; treatment wrtinuing: education Course:' The train. ing ptcvidermustietain a .copy af:thls forrri,for, the records f©ra five (5j year: p:etiod:foliovvitlg the presepfation :of each Wa8taw8tvr treatment. continuing education c ddf%6, Training providersareersc ©urag.a, ta.providaaD 1 9 a, C13rlifiett:tl erator:atfendin ths:entlrr;wastswateto 9r &t47rt~gntinuili educatiancgtirse. :t NAM 2. ADDRE98'(ndrnbe'aend streetJ; A110 /7 OiTp: LL Stataf ZIP coda: Te4ph)ne'ndmbar;. Y ID�1"l =F �i� �1 omeicli ie�. GIF �7 Cho' k.Fi9re if this Is an a4dresss; change N► r.' .00URSE;1Ni= M Tt4N. 3, NAME OF E: 4: AHED :ORGANI2ATION8PON80 IHGCOURSE: Approvers P)viihmelt ;lnc.. S,.DA SrATTEF1U s] E; I.OGATIONATTWDED �i: la"G"� pt�fovedce core 6:707 L,NUMBEJt OF' CONTACT .HOURS ATTENDED. BY.CERTiFIEO' OPERATOR 'AND VERIFIED BY:INSTRUCTOit'AND TRAINING COURSE PR¢ViDER:' Technical Contsa Hnurs: General.COntect Finu s: i undersigned ce t'dy wader penalty of low that this datum f (�nGd lty attachrhenis) w.8re prepared: und'e!my.directloa or s4p'arvis[on and that t", intortt aUOr oubcr` tsd to the }real of:my knoMkga:and behaf; two, accurate; and-mveci. l also understand that any omissions or:misrepresentetions:msy result 3n the denial gftondnuing:eduuttloA b*edh for this cour se_ 8: SIGNATUR.EOF IN5 rR11CT4R ER;NTEb NAME OE:IH6.TRUCTORs. An t;. Bers ac 10.81 ©NA77JRA lFl PEt3ftTOR:. 11: PR1h17EO NAME.QF.GE1�71FECf P "fpR; A� iZ. CONTINUING.p.Ot)CATION CREDrr HOURS ARE:TO EiE APPLIED M Opera cenifcatlon. number; Class: EkPlrationdat Oorator aerbficsf,°on m'jm sn Class: Explretlon date: http:// www.approvedce.com/onliiieCEUS/CEReport.asp 6/11/2009 sr4r To ensure proper credit, the WASTEWATER OPERATOR/APPRENTICE CONTINUING wastewater approval number EDUCATION CREDIT REPORT MUST be provided. State Form 51139 (R3/4 -08) Training Course Approval Number: INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT WWT09 5945 T06 G00 Technical Contact Hours Earned: Operator OApprentice 6.0 General Contact Hours Earned: 0 M S a.c a _.AW 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 attending the entire wastewater operator continuing education course. .u»*+, j,rw N �t�1F1t},PE1 ATORfAP 1. NAME: 2. ADDRESS (number and str6et): 9 N' -:ity: State: ZIP code: Telephone number: M ���f f_'t'd1J /1 ✓u c 7 Work 13!7 S] L `�E�� Check here if this is an address change E -mail Address: U n- .n'x.',.m a 3. NAME OF TRAINING COURSE: Laboratory Procedures for Plant Control 4. NAME OF TRAINING COURSE PROVIDER: 5. NAME OF GANIZATION SPONSORING COURSE: Approved Environment, Inc. Same 6. DATES) ATTENDED (month, da ear 7. LOCATION ATTENDED: June, �L00� Indianapolis, Indiana 8. TOTAL NUMBER OF CONTACT HOURS ATTENDED BY CERTIFIED OPERATORIAPPRENTICE AND VERIFIED BY INSTRUCTOR AND TRAINING COURSE PROVIDER: Technical Contact Hours: General Contact Hours: 6.0 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..SIGNATVRE OF INSTRUCTOR: 11. PRINTED NAME OF INSTRUCTOR: Ann Bersbach 12. SI N RE OF CERTIFIED OPERATORIAPPRENTICE: 13. PRINTED NAME OF CERTIFIED OPERATOR/APPRENTICE: I- 'T �f+T� fl A-J 14. CO TINUING EDUCATION CREDIT HOURS ARE TO BE APPLIED TO: `perator certification /apprentice number: Class: Expiration date: C 4 Operator certifcatioNapprentice number: Class: Expiration date. 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 6/15/2009 �a Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 6/15/2009 18293 $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 Officer VOUCHER 095813 WARRANT ALLOWED 146900 IN SUM OF IDEM 100 N. Senate Avenue Indianapolis, IN 46207 -7060 Carmel Wastewater Utility ON ACCOUNT OF APPROPRIATION FOR i Board members PO INV ACCT AMOUNT Audit Trail Code 18293 01- 7042 -06 $30.00 Voucher Total $30.00 Cost distribution ledger classification if claim paid under vehicle highway fund