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Home My WebLink About209958 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