206287 02/14/2012 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL MGT
GHECK AMOUNT: $16,628.80
CARMEL, INDIANA 46032 CASHIER OFFICE -MAIL CODE 50 -10C
oN 100 N SENATE AVE CHECK NUMBER: 206287
INDIANAPOLIS IN 46204
CHECK DATE: 211412012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 146307 16,628.80 OTHER EXPENSES
INVOICE
Please Remit To: Page: 1
INDIANA DEPT OF ENVIRONMENTAL MGMT Invoice No: 000146307
CASHIER OFFICE MAIL CODE 50 -10C Invoice Date: 01109/2012
100 NORTH SENATE AVENUE Customer Number: CST100010357
INDIANAPOLIS IN 46204 Bill Type: 060
Payment Terms: NET 60
Due Date: 03/09/2012
Bill To:
CITY OF CARMEL
MR JOHN DUFFY -WATER DEPT AMOUNT DUE: 16,628.80 USD
760 3RD AVENUE SOUTHWEST
SUITE 110
CARMEL IN 46032 -2584
Amount Remitted
Note Address Changes Above___
For billing questions, please call 317- 232 -8705
Line Ad' Identifier Description Quantity UOM Unit Amt Net Amount
1 12- IN5229004C -0 PWS Fee SVC:17504 1.00 EA 16,628.80 16,628.80
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: IC 13 -18 -20.5.
To view via the internet, visit:
http: /www.IN.gov/ legislative /ic /code /titlel3 /ar18 /ch2O.5,html
Fees are based on the activity status as of December 31 of the previous year.
Fees on Community water Systems will be based on the number of service connections on record for
the month of December 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 -8472.
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 16,628.80
A copy of your invoice must be included with payment.
495 -I0EM Printed on ReCyCled Paper Original
VOUCHER 113648 WARRANT ALLOWED
146900 IN SUM OF
IN DEPT. OF ENVIRONMENTAL MGT.
n0 !U S&,v41 e Ade
INDIANAPOLIS, IN
Y6� ®y
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
146307 01- 6750 -08 $16,628.80
Voucher Total $16,628.80
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
IN DEPT, OF ENVIRONMENTAL MGT. Purchase Order No.
P.O. BOX 7060 Terms
INDIANAPOLIS, IN 46207 -7060 Due Date 2/7/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
2/7/2012 146307 $16,628.80
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