221595 07/02/2013 i
a *f CITY OF CARMEL, INDIANA VENDOR: 00352774 Page 1 of 1
ONE CIVIC SQUARE JORDAN KLEINSMITH CHECK AMOUNT: $30.00
CARMEL, INDIANA 46032 C/O WASTEWATER
C/O WASTEWATER CHECK NUMBER: 221595
CHECK DATE: 7/2/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 WWO15515 30 . 00 OTHER EXPENSES
Indiana Department of Environmental Management
100 N. Senate Avenue IDEM
Mail Code 65-42
Indianapolis, IN 46204-2251
Jordan J. Kleinsmith
338 Orland Overlook
Westfield IN 460748111
WASTEWATER TREATMENT PLANT OPERATOR RENEWAL APPLICATION
License Class Wastewater Operator Class IV May 9, 2013
Certification#: WW015515
Expiration Date: 06/30/2013
Renewal Fee: $30.00
Login Id: WW015515
Password: 493920
Current Continuing Education Hours Earned: General-0.50 Technical-21.50 Total-22.00
1 am currently the responsible charge operator who signs the monthly reports(MRO/MMR)at the following facilities:
Facility Name Hours/Week Permit# City
etryapemwej W
Address Change:
Home
Current Phone#5711 76.3y_,,_a-Work Operator Signature: �i: (� Date: ��'�
Your wastewater treatment plant operator certification expires 06130/2013. After this date,you cannot be the operator
in responsible charge of a.wastewater treatment plant un".1 your ccirti ication is renewed.
You must meet the continuing education requirement as shown below:
• Classes I-SP,A-SO—5 hours earned between 711/2011 —6/30/2013 from IDEM approved course with at least 3.5 of
those hours from courses designated as"technical."
• Classes I, II,A, B—10 hours earned between 7/1/2011 —6/30/2013 from IDEM approved course with at least 7 of
those hours from courses designated as"technical."
• Classes III, IV, C, D—20 hours earned between 7/1/2011 —6/30/2013 from IDEM approved course with at least 14 of
those hours from courses designated as"technical."
Online Renewal: Online renewal is available 24 hours a day,7 days a week between May 10, 2013 and July 1, 2013 at
https://mylicense.in.gov. The cost for the online renewal is$30.00 plus an additional$4.17 in processing fees. The forms of
payment accepted online are Visa, Mastercard, & Discover credit and debit cards. Login ID and Password are above.
Mail Renewal: If you wish to renew by mail,fill out the responsible charge information, and send this form with your$30
renewal fee to: Cashier—Mail Code 50-10C, Indiana Dept.of Environmental Management, 100 N.Senate Avenue,
Indianapolis, IN 46204-2251. Make checks payable to IDEM.
Should you have any questions or concerns about the renewal process, please contact Tonja Fuller-White at(317)233-0479
or by e-mail at tfullerweidem.in.00v.
I'\ Department of Environryiental-Ma6agement
lz+ Off ice of Water.Qu a]1tv-:�.,M ail Code'654-7."
100 N.Senate Ave.",
Indianapolis, al
Indi 'ia-`4024 2251''
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w ate r p" e 0'
-,ator,�Qa`ss
WWO 15515 07/01/2013.t: :
Gordan fleinsth
Certificate of COMP etency
This-certifies that I lie person,.-nanled<" bo 'e]ias�1'611-1 lied the:�zl V
requirements 16 rcertilica tion,,s Wast6watertreat neit':p a
nt,
Or
operator `in aCC'ordanye'.with--SIC- A 3`1 8-,l I. aiid"..is. Iier
EasterlY,
ew, ator C.ass"IV
cerlified-as a':Wast iter'0'1*' r, I"'
ImIss
STATE FORM 49122(9-98)
I
JORDAN J. KLEINSMITH
338 ORLA.VD OVEALOOK
WESTFIEID, W 46074 ��
CID
pOlUAS
CHASE
1►1bry-n Qhaw 4nit,
v.r.Clu"./crdn
1:071.0000101: 19 5 1846 50«' 5 6 18 -"pyppap 30001'.
002670539260 MAY 30 #0000005618 $30.00
s
VOUCHER # 135803 WARRANT # ALLOWED
T9971 IN SUM OF $
KLEINSMITH, JORDAN
WASTEWATER
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR f'
i
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
WWO15515 01-7042-05 $30.00 /
i
I
i
i
Voucher Total $30.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
i
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
T9971
KLEINSMITH, JORDAN Purchase Order No.
WASTEWATER Terms
Due Date 6/25/2013
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
6/25/2013 WW015515 $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
r
Date J Ofocer