222037 07/17/2013 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1
ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M T
H
CARMEL, INDIANA 46032 CASHIER OFFICE-MAIL CODE 50-10C ECK AMOUNT: $30.00
+ylvc 100 N SENATE AVE
CHECK NUMBER: 222037
INDIANAPOLIS IN 46204
CHECK DATE: 7/17/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 5129184 30 . 00 OTHER EXPENSES
1DEM Indiana Department of Environmental Management
100 N.Senate Avenue Invoice Number: 5129184
Mail Code 66-34 Renewal Fee: $30,00 s
Indianapolis,IN 46204-2251
Money Receipt#
(Office Only)
May 16,2013
Certificate Number: DS895912
Expiration Date: 06/30/2013
"`JEFFERY L.CARPENTER Grade: DSL
Obtained B Examination
87$'Tyne'Circle y'
'Danville IN 46122 Login ID: DS895912
Password: 580889
INDIANA DEPAI2'TMEN`I?`OF:ENVIRONMENTAL MANAGEMENT'
,
Water- Works Operator Certification Renewal Fee Statement
"` h ; 3O;wrrecords,indicate your Water Works Certificate No. DS895912, Grade DSL for a class DSL Water
{ Distrlbution S' stem expires on 06/30/2013. You are required to obtain 15.00 contact hours of continuing
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<"ed"ucat''ori;for;renewal. Our records indicate that you currently have accumulated 41.50 contact hours
ard's;renewal-. (This may not reflect hours for courses recently attended.
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Note, 'If youfhave not.recently attended an approved course and you do not have the required number of
dal Y�41� Y p ll
�r Y „hours,you ne�eAd+to�attend courses prior to July 1, 2013. After this date you are on expired status and are not
� aa� a valid certrfedoperator You.do have until July 1 2014 to get your continuing education hours and renew
your;certrficatr`on Fallure>'=to renew by July 1, 2014 will result in termination of your certification, and you
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a�u P, nlrne Renewal Online renewal rs available 24 hours a day, 7 days a week at https://mylicense.in.gov.
'CAI�F fo r S t! . 1..
' „ The cost ,`the,onlrne renewal 1s”,$30.00,plus an additional processing fee for each certification renewal.
�The forms,}of�payment accepted o' ine,are Visa, Master Card, & Discover credit and debit cards. Login ID
Passworduaf, listed above
z Ma>II`Renewal"Y' To,renew through the marl :please.fill out the section on the back of•this page and return
"A P 1SteDtllre°'letter:ywith'$ 0_fee". ayment.ta.the-r-emittance..address listed.--Be-sure to sign and date in
spaces provided. Make a photocopy for your records. Please note that renewal through the mail will take
longer than an online renewal.
If you have other drinking water certifications due renewal, you can combine them in one mailing with a
fee payment that covers all of them. For example: (3 renewals x $30/per renewal)_ $90 combined fee.
Remit Payment to: Indiana Department of Environmental Management
Cashier's Office—Mail Code 50-1 OC
100 N. Senate Avenue
Indianapolis, IN 46204-2251
.` SEE FORM ON OTHER SIDE
(1) _
Cancel Certification—If you do not want to renew this certification please write CANCEL on this '
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form, sign and date in spaces provided, and mail to the remittance address listed.
FILL OUT & RETURN ENTIRE LETTER WHEN RENEWING BY MAIL OR CANCELLING
u ` If this certification was obtained by Examination and the facility you are employed at has changed,please x^�
add your new employer in the space provided. NOTE—If this certification is Grandfathered or Site
Specific, it is valid only for the location below.
Operator Number: DS895912 Invoice Number: 5129184
PWS Name PWS ID
" Carmel Water Department 5229004 ,
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2;
Address Change
Horne Phone Number:'`3 � `L�: S "'�S S
Work Phone Number:IPI. :' y� l 1-1 ` (ASa. <S?�
Operator Signature: Date: 3
VOUCHER # 132041 WARRANT # ALLOWED
146900 IN SUM OF $
IN DEPT. OF ENVIRONMENTAL MGT.
P.O. BOX 7060
INDIANAPOLIS, IN 46207-7060
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
5129184 01-6040-05 $30.00
Voucher Total $30.00
Cost distribution ledger classification if
claim paid under vehicle highway fund
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
146900
IN DEPT. OF ENVIRONMENTAL MGT. Purchase Order No.
P.O. BOX 7060 Terms
INDIANAPOLIS, IN 46207-7060 Due Date 7/8/2013
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
7/8/2013 5129184 $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