168042 01/21/2009 CITY OF CARMEL, INDIANA VENDOR: 00351805 Page 1 of 1
is ONE CIVIC SQUARE INDIANA DEPT OF ENVIR MGT CHECK AMOUNT: $130.00
CARMEL, INDIANA 46032 100 N SENATE AVE, PO BOX 6015
PO BOX 6015 CHECK NUMBER: 168042
INDIANAPOLIS IN 46206 -6015
CHECK DATE: 1121/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AM DESCRIPTION
1125 4340600 100773 100.00 RECORDING FEES
601 5023990 10909 30.00 OTHER EXPENSES
INDIANA DEPARTMENT OF ENVIRONMENTAL M ANAGEMENT
We Protect Hoosiers and Our Environment.
Mitchell E. Daniels Jr. 100 North Senate Avenue
6 Governor
Indianapolis, Indiana 46204
(31 7) 232 -8603
Thomas W. Easterly Toll Free (800) 451 -6027
Commissioner
www.idem.IN.gov
December 08, 2008
66 -34
Kris C. Anthis
11955 Cable Dr.
Indianapolis,. IN 46236
Re: Water Works Operator Certification Examination
Dear Mr. Anthis:
This is to notify you that you have either failed to attend or received an unsatisfactory grade for the Grade WT3 Water
Works Operator Certification Examination held on November 6, 2008. D 0D
Should you wish to apply for the May 7, 2009, 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 March 23, 2009. There is also an exam tentatively scheduled for November 5, 2009, with an application
postmark deadline of September 21, 2009, if you would like'to retake your exam at that time.
You may review your examination papers in this office prior to February 6, 2009, by appointment only via a written
request.
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.
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 of your petition to Mary E Hollingsworth, Section Chief,
Permit, Certification and Capacity Section, 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 issues, with particularity, proposed for consideration at the hearing, and
Kris C. Anthis
Page Two
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 of the type granted or
denied.
If you have any questions, please do not hesitate to contact Ms. Ruby Keslar at 3171308 -3305.
Sincerely,
Mary E. Hollingsworth, Section Chief
Permit, Certification and Capacity Section
Drinking Water Branch
Office of Water Quality
I would like to be scheduled for the May 7, 2009 November 5, 2009 Grade w-T
waterworks operator certification examination.
AA A
Applicant (printed name) Applicant (signature)
IDEMi Drinking Water: Certification Application Instructions Page 1 of 2
Drinking Water: Certification Application
Instructions
Instructions for Completing the Application for Water
Treatment Plant and Distribution System Operator Certification
Note: Incomplete Applications Will Be Returned
1. Check one (1) grade of water distribution system or one (1) grade of water treatment plant
exam you wish to take. There is a $30 nonrefundable fee for each grade of certification for
which you apply.
2. Check "by examination" or "by reciprocity"
3. Indicate in the upper right side of the application, the PWSID# of the public water supply
where you are currently employed.
Section I. General Information
a. Type or print clearly the applicant's name (last, first, middle). Indicate Mr., Mrs., or Ms.
b. Enter mailing address, include county and zip code. Enter both an office phone number and a
home phone number.
c. Check whether applicant has applied for Water Works Certification in Indiana before and
indicate the date.
d. Check whether applicant is presently a certified operator in Indiana and, if yes, enter
certification number and grade.
e., Check whether applicant is a certified operator in another state. If yes, give certification
number and grade (attach a copy of certificate or card, if possible).
f. Check whether applicant has ever had a suspended or revoked certification.
g. Enter social security number (Please note the disclosure statement on application.)
Section II. Education and Training
Note; All applicants must have a high school diploma or GED
a. Check the highest grade completed in Grade School, High School, and College, if applicable.
b. Check whether applicant is a high school graduate or a GED equivalent. Indicate date of
graduation or GED completion. (MONTH YEAR NEEDED AT LEAST)
c. Check whether applicant is a college graduate and enter Degree and Major, Date granted,
Name and Location of College. (Attach college transcript if substituting education for
experience.)
d. Indicate training courses attended, include short courses and other courses in the water field.
Section III. Experience History
Note: Experience Must Be Obtained Under The Direction Of A Certified Operator
Indicate applicant's current employment first (show dates of employment and position title). List
specific duties performed (incomplete applications will be returned) in the day to day operation of
water treatment plant or water distribution system. Show percent of time spent in the performance
of duties directly related to treatment or distribution if your primary duties are other than direct
operation.
Note to Applicant's Supervisor
http /www.in.gov /idem /5102.htm 1/9/2009
IDEM: Drinking Water: Certification Application Instructions Page 2 of 2
a. Make sure that name and signature of the "certified operator under whose direction
experience is obtained" is entered.
b. Please read the application being submitted completely to verify that the information
submitted is true and correct to the best of your knowledge and indicate the number of years
you have supervised this individual.
c. Sign your name and print your name on the application in the appropriate box, as well as
your title, along with your certification number (if not certified, enter the name and
certification number of operator under whose direction applicant obtained experience in the
box indicated).
d. Indicate the name of the public water supply, or organization represented, along with the
address and telephone number.
Section IV. Signature of Applicant
Note: Incomplete Applications Will Be Returned
Applicant shall read the statement at the bottom of the application attesting to the accuracy of the
information being submitted before signing. Enter the date signed.
NOTE: The application, along with the required fees and attachments should be mailed to:
Cashier
Drinking Water Branch
Indiana Department of Environmental Management
100 N. Senate Ave., Mail Code. 66 -34
Indianapolis, IN 46204
Please make all checks payable to the Indiana Department of Environmental Management. (Please
indicate who and what the check is for DO NOT SEND CASH)
http://www.in.gov/idem/5102.htm 1/9/2009
VOUCHER 084113 WARR T ALLOWED
7
TIDEM I:� +'t c IN SUM OF
D E M
100 N SENATE AVENUE,`��
INDIANAPOLIS, IN 46204 -2251 50 ..0
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
10909 01- 6040 -03 $30.00
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
TIDEM
IDEM Purchase Order No.
100 N SENATE AVENUE Terms
INDIANAPOLIS, IN 45204 -2251 Due Date 1/9/2009
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1/9/2009 10909 $30.00
�i
I hereby certify that the attached invoice(s), or bills) is (are) true and
correct and I have audited same in accordance with IC 5- 11- 10 -1.5
Date Officer
INVOICE
Please Remit To: Page: 1
INDIANA DEPT OF ENVIRONMENTAL MGMT Invoice No: 000100773
CASHIER OFFICE MAIL CODE 50 -10C Invoice Date: 01/02/2009
100 NORTH SENATE AVENUE Customer Number: CST100026885
INDIANAPOLIS IN 46204 Bill Type: 062
Payment Terms: NET 60
Due Date: 0310312009
Bill To:
CARMEL CLAY PARKS RECREATION
MS AUDREY KOSTRZE LL AMOUNT DUE: 100.00 USD
1411 EAST 116TH STRE
CARMEL IN 46032
Amount Remitted
Note Address Change
For bifiing questions, p lease cail 3 17 -23 4
Line Adj Identifier Description Quantity UOM Unit Amt Net Amount
1 09- IN229080IT -0 PWS Fee GW 1.00 100.00 100.00
This annual fee billing is required for active Public Water Systems (to defray the costs of
administering activities of the federal Safe Drinking Water Act) under Indiana Code: 1C 13 -18 -20.5.
To view via the internet, visit:
http: /www.IN.gov /legislative /ic /code /titlel3 /arl8 /ch2O.S.html
Fees are based on the activity status as of December 31 of the previous year.
Fees on Transient Non Community Water System will be based on the type of water system on record
by December 31 of the prior year.
Fees are not pro rated. If a system is sold or inactivated during the billing year, the amount of
the assessed fee remains due and payable-
If payment of the assessed fee amount imposes an undue burden on the public water system, the
facility may notify this Agency within forty -five (45) days of this invoice date to pay in four
equal installments within a year.
Payments not received or received after the DUE date are subject to a delinquency charge equal to
10% of the assessed fee.
If several invoices are to be paid by one check, you MUST INCLUDE A COPY OF EACH BILLING INVOICE
in order to ensure proper credit for each fee assessment.
For questions regarding your assessed fee amount, please contact Deborah Glover in the Operations
Section, Office of Water Quality at 317 -232 -6472.
ATTENTION: The due date shown in the upper right hand corner of this invoice reflects the
standard 60 days past the invoice print date.
TOTAL AMOUNT DUE 100.00
A copy of your invoice must be included with payment.
n
Purchase 14►'�ooa� parn'4 tr W,
�lQIi'L
Description _wat Ebw l,Y o
P.O. P or F
Budget
Line Descr
Purchaser Date
Approval
495 -IDEM Prin[ed on Recycled Paper Original
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
Indiana Department of Environmental Mgmt Terms
100 North Senate Ave
Indianapolis, IN 46204
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
1/2109 100773 annual permit for public water flowing well 100.00
Total 100.00
I hereby certify that the attached invoice(s), or bills) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20_
Clerk- Treasurer
Voucher No. Warrant No.
Indiana Department of Environmental Mgmt Allowed 20
100 North Senate Ave
Indianapolis, IN 46204
In Sum of
100.00
ON ACCOUNT OF APPROPRIATION FOR
101 General Fund
PO# or INVOICE NO. ACCT #/TTLE AMOUNT Board Members
Dept
1125 100773 4340600 100.00 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
6 -Jan 2009
Signature
100.00 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund