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Home My WebLink About211805 08/14/2012 CITY OF CARMEL, INDIANA VENDOR: 362435 Page 1 of 1 0 ONE CIVIC SQUARE INDIANA SECTION AWWA CHECK AMOUNT: $350.00 CARMEL, INDIANA 46032 PO BOX 534 ATTN: ALAN WISEMAN CHECK NUMBER: 211805 NASHVILLE IN 47448 CHECK DATE: 8/14/2012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 5795-C 350 . 00 EMPLOYEE PEN & BENEFI Invoice Indiana Section, AWWA Date Invoice# PO Box 534 Nashville, IN 47448 8/7/2012 5795 TELEPHONE: 866-213-2796 Terms FAX: 866-215-5966 Due on receipt Bill To City of Carmel 3450 W. 131 st St. Carmel, IN. 46074 V` P.O. No. Description Amount Indiana Section Operator School 2012 - Indianapolis - J Rayle 350.00 8/7/2012 E-mail to kloveall @carmel.in.gov CREDIT CARD:Visa MC Discover American Express # Exp.: - NAME ON CARD: Security: SIGNATURE _Billing Zip Code: Total $350.00 PUBLIC WATER SUPPLY APPLICATION FOR . ..FOR OFFICE °� WS number: WATER TREATMENT PLANT AND WATER s; DISTRIBUTION SYSTEM OPERATOR � Receipt number: CERTIFICATION State Form 12094 (R6 12-06) Approved by State Board of Accounts 2006 Approved: 327 IAC 8-12-1 INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT DRINKING WATER BRANCH Denied/Reason: NOTE: A$30 fee must be submitted with each application for certification. Applications must be signed by the individual,and his/her supervisor. Failure to file a properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade:(check one-One application per grade checked): Water Distribution System ❑ ❑ 11 PWS ID#: ZZ 00 Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator El, , 2 ® 3 4 5 06 [0]1. El Northwest CK Central ❑ ❑Northeast Southwest Southeast 9 By examination ❑By reciprocity 1. Name of applicant(last) (first) (middle) ®Mr. ❑Mrs. []Ms. —SAU 2. Mailing address(number and street): •] 231090 Duds e- QD. 7 City: State: ZIP code: County: AuAwA 1+.1. LI(o030 3. O ice telephone number: 4. Ho a telephone number: 317 57 I- Z WA 311 (ao1 -S4-11) 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) ❑Yes' INNo 'If yes,date(mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? ❑Yes' ®No 'If yes,give certification number and classification: 7. Are you presently a certified water works operator in another slate? []Yes* ®No 'If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes XNo 9. Social Security number:' 31 O _ Q yn_ 'q 'Your Social Security number is being requested by this state agency in order to expedite O processing of your application. Disclosure is voluntary and you will not be penalized for refusal. • • •• • • •- 10. Check the highest grade completed. Grade School: High School: College(years): ❑1 02❑3❑4❑5❑6❑7❑8 09❑10 Ell 912 ❑1 02❑3❑4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': W�.SIFIEI MYes ❑No ❑GED OS , - 1p190 \41ESTPIE11-D H16NSCHDOL I�• 12. College Graduate? Degree: Major: ❑Yes [$No Date granted(mm/dd/yyyy): Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 13. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: ► List your current assignment first. Show all experience in the Drinking Water field. Attach additional sheets,if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME/ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: 2o 1a, I 1MAMIN 0.1.7. CAEM6L. WR7GQ. UTILITIES Specific duties performed in day-to-day operation: Address:(number and street) �AC_Y_\,1'15}F 12.01.1 F�IL_T�,S, SoF7��S. 34 SO `�•l.131 sT. NIL-1 l'e0�- ME>A_T VACILrnl , LABS City,state,ZIP code:( (;e,7% -me- SArn�J F—� -rm—riW JES?Fi b 11j. LK7!f A1W&j Q'Xe AND REIQS an! _TQURT M EST FAc1 u-111 FROM: TO: Position title: Name of previous employer: I 14 )Z008 srm&rrio4 LA&e- NertrlEL WATM OTILITIE5 Specific duties performed in day-to-day operation: Address:(number and street) 'j?sPAQS 70 WP,rM ft1AW S,SEQ.I IC-E UaES. PWZ HJUArns, 34SO N4 1311 :T- I Pi ve 5. l ImS7A 7I� �� mA1NS� SIEQJ ICF 3&5, r'e-F- City,state,ZIP code: V4LdES, r+t1e-mkS. 1n/cs-rFiesL_f_) )1J, HW_114 FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) City,state,ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) City,state,ZIP code: (Continued on page 3) Page 2 of 3 A&VAL02:3 . _ .- I hereby certify the information contained in this section of this application is true and correct to the best of my knowledge. I have supervised this individual for A 13 years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): ,7 A ,e-I /ova w-Tcig7D 19 Signat re of Certified Operator 05 O a q Printed name and signature of applicant's supervisor:(if different than above) Applicant's supervisor:(if different than above) Name of organization/utility/system: Telephone number:(include area code) G i - ,eft �e_ ( 3 i - 73 - 8 Address:(number and street) I L4 a tom• l r► City: State: ZIP code: I,the undersigned,certify that I am the above applicant;that all statements made and information contained in the above application are true and correct to the best of my knowledge and belief;that I understand that any omissions or misrepresentations may result in ineligibility for the examination applied for,or revocation of any certificate granted. I also consent to verification of my qualifications for the certificate for which I have applied. 0810, 1 Zo,z Sign ure of applicant: Date(mmlddlyyyy): The completed application,along with all required fees and attachments should be mailed to: Indiana Department of Environmental Management Cashier's Office,Mail Code 50-10C 100 North Senate Avenue Indianapolis,IN 46204-2251 Please make all checks payable to the Indiana Department of Environmental Management (3240-4114-00-140000) DO NOT SEND CASH. Page 3 of 3 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 351668 AWWA-IN SECTION-OPERATOR TRAIN Purchase Order No. P.O. BOX 534 Terms NASHVILLE, IN 47448 Due Date 8/9/2012 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 8/9/2012 5795-C $350.00 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 5-11-110-1.6 Date Officer VOUCHER # 121822 WARRANT # ALLOWED 351668 IN SUM OF $ AWWA-IN SECTION-OPERATOR TRAII P.O. BOX 534 NASHVILLE, IN 47448 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO # INV# ACCT# AMOUNT Audit Trail Code 5795-C 01-6040-03 $350.00 Voucher Total $350.00 Cost distribution ledger classification if claim paid under vehicle highway fund