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Home My WebLink About213058 09/25/2012 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M T CARMEL, INDIANA 46032 CASHIER OFFICE-MAIL CODE 50-10C HECK AMOUNT: $30.00 100 N SENATE AVE CHECK NUMBER: 213058 INDIANAPOLIS IN 46204 CHECK DATE: 9/2512012 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 RAYLE 30 . 00 OTHER EXPENSES PUBLIC WATER SUPPLY APPLICATION FOR FOR OFFICE'USE 77 WATER TREATMENT PLANT AND WATER � '5 Ws number: L DISTRIBUTION SYSTEM ((-�� OPERATOR �f�V CERTIFICATION Receipt number: 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 ❑ ❑ ❑ PWS ID#: ZZ qQO4 Operator DSS DSM DSL PLEASE CHECK-EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ® ❑ 0 ❑ ❑ WT1 W72 WT3 WT4 WI-5 WT6 0.1'T ❑Northwest CR Central ❑Southeast 9 By examination ❑By reciprocity ❑Northeast ❑Southwest 1. Name of applicant(last) (first) (middle) ®Mr. ❑Mrs. ❑Ms. 2. Mailing address(number and street): 231090 ®VrIs e- QD. City: State: ZIP code: County: AecAprA )*a. Wbo3o NA+h 1 L-r oil 3. O ice telephone number: 4. Ho a telephone number: 317 S71- Z WA 311 1001-S(o-IO 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) []Yes* ®No *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 state? ❑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:* *Your Social Security number is being requested b this state agency So Y 9 9 Y g cY in order to expedite 310 — $Lp— A o processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 10. Check the highest grade completed. Grade School: High School: College(years): ❑l ❑2❑3❑4❑5❑6 07 08 ❑9❑10❑11 912 ❑l ❑2 03❑4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': WIE57. V1 Yes ❑No ❑GED 0S . • 1gC10 \4E5?FIELtD 1+14HISCHDOL 1►J. 12. College Graduate? Degree: Major: ❑Yes ®No Date granted(mm/dd/yyyy): Name and location of college: (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 13. Training courses,short courses,or other courses attended applicable to water industry: a. Name of course: Name of school: Dates: College units or class hours: b. Name of course: Name of school: Dates: College units or class hours: •- yj i V ATI Eel 914 • ► List your current assignment first. Show all experience in the Drinking Water field. Attach additional sheets,if necessary. DATE POSITION TITLE (Month and Year) AND EMPLOYER NAME/ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: 1 J zs J zcl 1 81-71 Zola, 0.i.-r. CAEmEL W070- OTILITIE.s Specific duties performed in day-to-day operation: Address:(number and street BAC_Y_%, 4st} %iZC J F'1L-r�.S, 50C70EES. 3ySO x../.131�� s-r: ,,a NIt.-y TeOrMeM r' FALILrriy, LA 65 (;"ME2 \\JA'irM SAS PAS Foe- -TmrI� city,state,ZIP code: MAIftn J�C AND REAg12S afJ -MMT rlE►.ST FAclu- IC-5 ��FiFi� I�). �f[�7�{ FROM: TO: Position title: Name of previous employer: I 14 J Z00$ I i )z4 J Zol I bl!ae1&YT104 LAezz C+4emEiL VlATQZ UTILITIES Specific duties performed in day-to-day operation: Address:(number and street) '&PFWa_5 TO 1, 676 MAV45,SE¢v IC-E LIaES, PaE K NAWS, 3450 WXSI 1 :YT. VAI.vE 5. OP � IY9r� ee r las-rAL �i WS. M1 l L,,J City,state,ZIP code: %44wES, rnC'- r~QS. Wrs-rFmL f) 14. HW14 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 y. 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 J years. Name of Certified Operator under whose supervision experience obtained Certification Number(s): /ov/) Signal re of Certified Operator 105 D 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) Address:(n mber and street) 1? �lJ0 Uj. l 1r City: 3State: ZIP code: C ' 607 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. og 1 01 !ZOIZ Signbfure of applicant: Date(mm/dd/yyyy): 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 TIDEM IDEM Purchase Order No. 100 N SENATE AVENUE Terms INDIANAPOLIS, IN 46204-2251 Due Date 9/18/2012 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 9/18/2012 RAYLE $30.00 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 5-11-10-1.6 Date Officer VOUCHER # 122152 WARRANT # ALLOWED TIDEM IN SUM OF $ IDEM 100 N SENATE AVENUE INDIANAPOLIS, IN 46204-2251 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR Board members PO# INV# ACCT# AMOUNT Audit Trail Code RAYLE 01-6040-03 $30.00 Voucher Total $30.00 Cost distribution ledger classification if claim paid under vehicle highway fund