209958 06/20/2012 CITY OF CARMEL, INDIANA VENDOR: 00353019 Page 1 of 1
ONE CIVIC SQUARE ALTON B CHAFIN
CARMEL, INDIANA 46032 C/O WASTEWATER PLANT CHECK AMOUNT: $125.00
CARMEL IN 46032
CHECK NUMBER: 209958
CHECK DATE: 6/20/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 125.00 REIMBURSEMENT
u CITY OF CARMEL Expense Report (required for all travel expenses)
/NDIAN�
2010 mileage reimbursement rate is 50 cents /mile
EMPLOYEE NAME: Alton Bart Chafin DEPARTED na TIME:
DEPARTMENT: Utilities /Sewer RETURN na TIME:
REASON FOR TRAVEL: na DESTINATION CITY: na
EXPENSES ARE FOR (check all that apply): TRAVEL ADVANCE TRAVEL REIMBURSEMENT _X_ TRAVEL PER DIEM
Date Transportation Gas/Tolls/ Lodging Meals Misc. Total
Air -fare Car Rental Other Parking Breakfast I Lunch I Dinner I Snacks Per Diem
5/30/12 Safety $25.00 $25.00
5/31/12 Final Effulent 1 $25.00 $25.00
6/1/12 Trickling Filters RBC's $25.00 $25.00
6/1/12 Wastewater Preliminary Treatment $25.00 $25.00
5/29/12 Odor Control $25.00 $25.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
0.00
Total $0.00 $0.00 $0.001 $0.00 $0.00 $0.001 $0.001 $0.00 $0.001 $0.001 $125.00
DIRECTOR'S STATEMENT: I hereby affirm that all expenses listed conform to the City's travel policy and are within my department's appropriated budget.
Director Signature: Date:
City of Carmel Form ER06 Revision Date 6/4/2012 Page 1
E Sr— WASTEWATER OPERATOR /APPRENTICE CONTINUING a ensure proper credit, the
j
wastewater approval number
EDUCATION CREDIT REPORT MUST be provided.
State Form 51139 (R3 4 -08) Training Course Approval Number:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT \Nwn -59 i5 7o i -coL
Technical Contact Hours Earned:
Operator ❑Apprentice 1 HOUR
General Contact Hours Earned:
0
21 INSTRUCTIONS n !"'0
v
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
CERTIFiEDOPERATOR /APPRENLT, CEINFO- RMATI;QN
1. NAME:
X -Tic> iJ
2. ADDRESS (number and street):
fj1z,
City: State: ZIP code: Telephone number:
Work:
zSHE(u HLGT1 Home /Cell: cesq 71 3 -0 1 3
Check here if this is an address change E-mail Address
3. NAME OF TRAINING COURSE:
SATIETY
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:
1�
.5J -ao 1 WNV.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:
F rr Ann Bersbach
12. SIGNATURE CERTIFIED ERA OR/APPRENTICE: 13. PIRATED NA E OF CER�IFIE�D OPERATOR/APPRENTICE:
14. CONTINUING EDUCATION CREDIT OURS ARE TO BE APPLIED TO: u Z
Operator certification /apprentice number: Class: Expiration date:
W WO! _�9 lir- s o) �v i z
Operator certification /apprentice number: Class: Expiration date:
Certificate of Completion Approved Environment, Inc. Page 1 of 1
Approved. Environment, Inc.
P.O. Box 42744
Indianapolis, IN 46242
1- 877 241 -9858
Email: SupportC&approvedce.com
Certificate of Completion
Courses are approved in the following states: Indiana, Illinois Ohio, Alabama, Delaware, South
Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada.
Name Alton Bart Chafin
Address: 12747 Touchdown Dr., Fishers, In 46037
Course Title: Safety
Course Value: 1 Contact Hour
Approval Number IN WWT11 -5919 TO 1 -GOO, PWSG06 -3073, OH OEPA- B300334-
X, NC CEO 1140411, MD 3478- 05 -06, KY 10282
Date: 5/30/2012
Approximate Time Spent Taking the Course: 60 minutes.
Operator Certification License Number: WWO17998
Operator Class Level: 3
License Expiration Date: 06/30/2012
Operator Signature: I JAk
Training Provider Signature:
Ann Bersbach, Approved Environment, Inc.
Copyright 2002. Approved Environment, Inc., Indianapolis, Indiana
http:// www. approvedce. com/ onlineCEUs /ceuCertificateOfCompletion.asp 5/30/2012
Approved Enviroment Inc Customer Receipt/Purchase Confirmation Page 1 of 1
From: APPROVED ENVIRONMENT <SUPPORT @APPROVEDCE.COM>
To: Alton Chafin <BCroc @aol.com>
Subject: Approved Enviroment Inc Customer Receipt/Purchase Confirmation
Date: Wed, May 30, 2012 9:39 am
Thank you for your order!
Order Information
Merchant: Approved Enviroment Inc
Description: Safety
Invoice Number: 904C
Billing Information Shipping Information
Alton Chafin
City Of Carmel
12747 Touchdown Dr.
Fishers, In 46037
Hamilton
BCroc(a)aol.com
317/773/6923
Total: US $25.00
Visa
Date/Time: 30- May -2012 06:39:44 AM PT
Transaction ID: 4409236004
http://mail.aol.com/36210-1 I I aol- 6 /en- us /mail/PrintMessage.aspx 6/1/2012
WASTEWATER OPERATOR/APPRENTICE CONTINUING To ensure proper credit, the
o� Sg wastewater approval number
EDUCATION CREDIT REPORT MUST be provided.
State Form 51139 (R3 4 -08) Training Course Approval Number:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT 11 —59'6 lo1
X616
Operator ❑Apprentice Technical 1 HOUR ours Earned:
General Contact Hours Earned:
0
IQNS,��', 55
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 continuin education course.
E„RTIFIEP10RERATOR/APPRENTI,CE INFORMit�TIO,N'
a
1. NAME:
2. ADDRESS (number and street):
I aI LC. �jUu J D o,
City: State: ZIP code: Telephone number:
ISt'L� 1,1ov Work:
Home /Cell: 2 3n-7 7 73-01 3
Check here if this is an address change E -mail Address:
d t �3,�
3. NAME OF TRAINING COURSE:
N A L Er_ L 1LkE(JT
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:
t_ ap'� VW WV.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.
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: tar 11. PRINTED NAME OF INSTRUCTOR:
Ann Bersbach
12. SIGNATUIZE OF CERTIFI OPE L TORIAPPRENTICE: 13. PRI TED NAME OF CERTIFIED 0PERATOR/APPRENTICE:
otj 1J, A CM 0"'
14. CONTINUING EDUCATION CRIED HOURS ARE TO BE APPLIED TO:
Operator certification /apprentice number: Class: r Expiration date
WW01 -7Wd J'_ j0
Operator certification /apprentice number: Class: Expiration date:
Certificate of Completion Approved Environment, Inc. Page 1 of 1
Approved. Environment, Inc.
P.O. Box 42744
Indianapolis, IN 46242
1- 877 241 -9858
Email: Support(a).approvedce.com
Certificate of Completion
Courses are approved in the following states: Indiana, Illinois. Ohio, Alabama. Delaware, South
Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada.
Name: Alton Bart Chafin
Address: 12747 Touchdown Dr., Fishers, In 46037
Course Title: Final Effluent I
Course Value: 1 Contact Hour
Approval Number IN WWT11 -5913 TO1 -G00, OH OEPA- S296736 -OM, NC
CEO 1140408, MD 3472- 05 -06, KY 10299
Date: 5/31/2012
Approximate Time Spent Taking the Course: 60 minutes.
Operator Certification License Number: WWO17998
Operator Class Level: 3
License Expiration Date: 06/30/2012
Operator Signature: 4
Training Provider Signature: '4
Ann Bersbach, Approved Environment, Inc.
Copyright 2002, Approved Environment, lne., Indianapolis. Indiana
http: /www. approvedce. com/ onlineCEUs /ceuCertificateOfCompletion. asp 5/31/2012
Approved Enviroment Inc Customer Receipt/Purchase Confirmation Page 1 of 1
From: APPROVED ENVIRONMENT <SUPPORT @APPROVEDCE.COM>
To: Alton Chafin BCroc @aol.com>
Subject: Approved Enviroment Inc Customer Receipt/Purchase Confirmation
Date: Thu, May 31, 2012 10:33 am
Thank you for your order!
Order Information
Merchant: Approved Enviroment Inc
Description: Final Effluent I
Invoice Number: 907C
Billing Information Shipping Information
Alton Chafin
City Of Carmel
12747 Touchdown Dr.
Fishers, In 46037
Hamilton
BCroc aol.com
317 773 -6923
Total: US $25.00
Visa
Date/Time: 31- May -2012 07:33:47 AM PT
Transaction ID: 4411717104
http://mail.aol.com/36210-1 I I /aol- 6 /en- us /mail/PrintMessage. aspx 6/1/2012
e sT sT� To ensure roper credit, the
WASTEWATER OPERATOR /APPRENTICE CONTINUING p
wastewater approval number
EDUCATION CREDIT REPORT MUST be provided.
a i....
State Form 51139 (R3 4 -08) Training Course Approval Number:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT W vN TJ
X616
Operator ❑Apprentice Technical 1 HOUR ours Earned:
General Contact Hours Earned:
0
jig �INST v
u. L ..x... ....xx..
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.
.R-1 _y �CERTIF( ED?OPE_I�i4T, OR/A,P,PRE fit,
1. NAME:
AL-Votj �P, rr-� C
2. ADDRESS (number and street
City: S State: ZIP code: Telephone number:
TasiA ti 2S Work:
Home /Cell: V, 113 0y
Check here if this is an address change E -mail Address:
COURSEINFORMATION r
W E
3. NAME OF TRAINING COURSE:
"ZCKL:�6 LTem �A mo RgG:S
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:
U i VWWV.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.
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:
Ann Bersbach
12. SIGNATURE OF CERTIFIED ERAT R/APPRENTICE: 13. PRI TED NAME O CERTIFIED OPERATOR/APPRENTICE:
L'TOn� D C
14. CONTINUING EDUCATION CREDIT H IRS ARE TO BE APPLIED TO:
Operator certification /apprentice number: Class: Expiration date:
W wo W 1599 I 3o z�IZ
Operator certification /apprentice number: Class: Expiration date:
Certificate of Completion Approved Environment, Inc. Page 1 of 1
Approved Environment, Inc.
P.O. Box 42744
Indianapolis, IN 46242
1 -877- 241 -9858
Email: Support(a)approvedce.com
Certificate of Completion
Courses are approved in the following states: Indiana, Illinois, Ohio, Alabama, Delaware, South
Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada.
Name: Alton Bart Chafin
Address: 12747 Touchdown Dr., Fishers, In 46037
Course Title: Trickling Filters and RBCs
Course Value: 1 Contact Hour
Approval Number: IN WWT11 -5906 TO1 -G00, OH OEPA- 5296733 -OM, NC
CEO 1130405, MD 3465- 05 -06, KY 10306
Date: 6/1/2012
Approximate Time Spent Taking the Course: 60 minutes.
Operator Certification License Number: WWO17998
Operator Class Level: 3
License Expiration Date: 06/30/2012
Operator Signature:
Training Provider Signature: r
Ann Bersbach, Approved Environment, Inc.
Copyright 2002, Approved Environment, Inc., Indianapolis. Indiana
http: /www. approvedce. com/ onlineCEUs /ceuCertificateOfCompletion. asp 6/1/2012
Approved Enviroment Inc Customer Receipt/Purchase Confirmation Page 1 of 1
From: APPROVED ENVIRONMENT <SUPPORT @APPROVEDCE.COM>
To: Alton Chafin <BCroc @aol.com>
Subject: Approved Enviroment Inc Customer Receipt/Purchase Confirmation
Date: Fri, Jun 1, 2012 11:03 am
Thank you for your order!
Order Information
Merchant: Approved Enviroment Inc
Description: Trickling Filters and RBCs
Invoice Number: 910C
Billing Information Shipping Information
Alton Chafin
City Of Carmel
12747 Touchdown Dr.
Fishers, In 46037
Hamilton
BCroc(cDaol.com
317 773 -6923
Total: US $25.00
Visa
Date/Time: 01- Jun -2012 08:03:53 AM PT
Transaction ID: 4415027129
http://mail.aol.com/36210-11 1 /aol- 6 /en- us /mail/PrintMessage. aspx 6/1/2012
6 —''°v, WASTEWATER OPERATOR /APPRENTICE CONTINUING To ensure proper credit, the
wastewater approval number
EDUCATION CREDIT REPORT MUST be provided.
i' State Form 51139 (R3 4 -08) Training Course Approval Number:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT *W T' 1 —S904 701., 4�
perator ❑Apprentice Technical 1oHOUR ours Earned:
General Contact Hours Earned:
0
r �INSTRUCTtIQNS,
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
3 CERTIFIED OPERATIORlAPP IN; FORM „4TIQN h r
H ill A 0,11
1. NAME:
2. ADDRESS (number and street):
\,k LH 0 0
City: State: ZIP code: Telephone number:
Work:
�2S�- 1t�1(LS IN 3 Home /Cell: Iv 3Q 11 1-013
Check here if this is an address change E-mail Address
gp
C®URSE1 INFORMATION a��
k,,. ....7 zL':? al. .xi'N” 3fR..A R a'�+s.':..m� ,kYs' 11 1011
AS
3. NAME OF TRAINING COURSE:
N)AS%tCwt47v. M �12ig LatA }PC/4TM�N
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:
i 2u 12 VWWV.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.
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:
r� Ann Bersbach
12. SIGNA URE OF CERTIF OPE TOR/APPRENTICE: 13. P NTED NAME OF CERTIFIED OPERATOR/APPRENTICE:
14. CONTINUING EDUCATION CREDI HOURS ARE TO BE APPLIED TO:
Operator certification /apprentice number: Class: Expiration a
Operator certification /apprentice number: Class: Expiration date:
Certificate of Completion Approved Environment, Inc. Page 1 of 1
Approved. Environment, Inc.
P.O. Box 42744
Indianapolis, IN 46242
1- 877 241 -9858
Email: Support(aapprovedce.com
Certificate of Completion
Courses are approved in the following states: Indiana, Illinois, Ohio, Alabama, Delaware, South
Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada.
Name: Alton Bart Chafin
Address: 12747 Touchdown Dr., Fishers, In. 46037
Course Title: Wastewater Preliminary Treatment
Course Value: 1 Contact Hour
Approval Number: IN WWT11 -5904 TO1 -GOO, OH OEPA- 5296782 -OM, NC
CEO 1140415, MD 3463- 05 -06, KY 10304
Date: 6/1/2012
Approximate Time Spent Taking the Course: 60 minutes.
Operator Certification License Number: WWO17998
Operator Class Level: 3
License Expiration Date: 06/30/2012
Operator Signature: rLft
Training Provider Signature: 14,r
Ann Bersbach, Approved Environment, Inc.
Copyright 2002, Approved Environment, Inc., Indianapolis, Indiana
http:// www. approvedce. com/ onlineCEUs /ceuCertificateOfCompletion.asp 6/1/2012
Approved Enviroment Inc Customer Receipt /Purchase Confirmation Page 1 of 1
From: APPROVED ENVIRONMENT <SUPPORT @APPROVEDCE.COM>
To: Alton Chafin <BCroc @aol.com>
Subject: Approved Enviroment Inc Customer Receipt/Purchase Confirmation
Date: Fri, Jun 1, 2012 2:17 pm
Thank you for your order!
Order Information
Merchant: Approved Enviroment Inc
Description: Wastewater Preliminary Treatment
Invoice Number: 914C
Billing Information Shipping Information
Alton Chafin
City Of Carmel
12747 Touchdown Dr.
Fishers, In. 46037
Hamilton
BCroc(cDaol.com
317 773 -6923
Total: US $25.00
Visa
Date/Time: 01- Jun -2012 11:17:41 AM PT
Transaction ID: 4415791893
http: /mail.aol.com/36210- 111/ aol- 6 /en- us /mail/PrintMessage.aspx 6/1/2012
WASTEWATER OPERATOR/APPRENTICE CONTINUING To ensure proper credit, the
EDUCATION CREDIT REPORT wastewater approval number
MUST be provided.
State Form 51139 (R3 4 -08) Training Course Approval Number:
INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT w I SG� 10I
ale 1
r perator ❑Apprentice Technical 1 Ht ours Earned:
General Contact Hours Earned:
0
yes �e S s x
UC�TION -,S.,
_�,j Q
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.
sCERTIFIEDO, PERATO „R/APPRENTICEI;N,FORMAtTtIO:N� r..,. TY Xa�,,..,,��n.4
1. NAME:
2. ADDRESS (number and street):
22 1
City: State: ZIP code: Telephone number:
"rnQ�t¢It_S 1 1 Q"3� Work:
rl Home /Cell: 030' 713-1,12 3
Check here if this is an address change E -mail Address:
r5 k COURSE INFORMATION
3. NAME OF TRAINING COURSE:
p COn1 T at' L
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:
WWW.APPROVEDCE.COM
B. 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:
F' s Ann Bersbach
12. SIGNATURE F CERTIF ED OP TOR/ PPRENTICE: 13. PRIN ED NAME OF CERT IED OPERATOR/APPRENTICE:
14. CONTINUING EDUCATION CREDIT HO RS ARE TO BE APPLIED TO:
Operator certification /apprentice number: Class: Expiration date:
W 01 7�1(!�
Operator certification /apprentice number: Class: Expiration date:
Certificate of Completion Approved Environment, Inc. Page 1 of 1
Approved Environment, Inc.
P.O. Box 42744
Indianapolis, IN 46242
1- 877 241 -9858
Email: Support(cU,approvedce.com
Certificate of Completion
Courses are approved in the following states: Indiana, Illinois, Ohio, Alabama, Delaware, South
Carolina, North Carolina, Maryland, Kentucky and Ontario, Canada.
Name: Alton Bart Chafin
Address: 12747 Touchdown Dr., Fishers, In 46037
Course Title: Odor Control
Course Value: 1 Contact Hour
Approval Number: IN WWTI 1 -5930 TO1 -GOO, PWSG06 -3078, OH OEPA- 13376918-
OM, NC CE01040702, MD 3820- 06 -07, KY 8390
Date: 5/29/2012
Approximate Time Spent Taking the Course: 60 minutes.
Operator Certification License Number: WWO17998
Operator Class Level: 3
License Expiration Date: 06/30/2012
Operator Signature: wt Q 'j 6+
Training Provider Signature: ,,4
Ann Bersbach, Approved Environment, Inc.
Copyright 2002, Approved Environment, Inc., Indianapolis, Indiana
http:// www. approvedee. com/ onlineCEUs /ceuCertificateOfCompletion.asp 5/29/2012
Approved Enviroment Inc Customer Receipt/Purchase Confirmation Page 1 of 1
From: APPROVED ENVIRONMENT <SUPPORT @APPROVEDCE.COM>
To: Alton Chafin <BCroc @aol.com>
Subject: Approved Enviroment Inc Customer Receipt/Purchase Confirmation
Date: Tue, May 29, 2012 11:06 am
Thank you for your order!
Order Information
Merchant: Approved Enviroment Inc
Description: Odor Control
Invoice Number: 902C
Billing Information Shipping Information
Alton Chafin
City Of Carmel
12747 Touchdown Dr.
Fishers, In 46037
Hamilton
BCroc(a)aol.com
317/773/6923
Total: US $25.00
Visa
Date/Time: 29- May -2012 08:06:21 AM PT
Transaction ID: 4406887187
http: /mail.aol.com/36210- 111/ aol- 6 /en- us /mail/PrintMessage.aspx 6/1/2012
Prescribed by State Board Accounts ACCOUNTS PAYABLE VOUCHER
Form No. 301 -S (Rev. 1995)
TO
ADDRESS
Invoice Date Invoice Number Item Amount
i
I I
l
I
I
I
I 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
I
1 19
Signature Title
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.
19
Officer Title
Voucher No, Warrant No.
ACCOUNTS PAYABLE DETAILED ACCOUNTS
SANITATION DEPARTMENT ACCT.
CARMEL, INDIANA No.
I n Favor Of
w
1� l r T
Total Amount of Voucher
Deductions
c� 0
s v s
Amount of Warrant
Month of 19
Acct.
VOUCHER RECORD No.
Collection System
Operation
Plant
Commercial
General
Undistributed
Construction
Depreciation Reserve
Stock Accounts Merchandise
Total
Allowed
Board Members
Filed
BOYCE FORMS SYSTEMS 1- 800- 382 -8702 325