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222442 07/30/2013 CITY OF CARMEL, INDIANA VENDOR: 146900 Page 1 of 1 ` ONE CIVIC SQUARE INDIANA DEPT OF ENVIRONMENTAL M&ECK AMOUNT: $330.00 CARMEL, INDIANA 46032 CASHIER OFFICE-MAIL CODE 50-10C o� 100 N SENATE AVE CHECK NUMBER: 222442 INDIANAPOLIS IN 46204 CHECK DATE: 7/30/2013 DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION 601 5023990 WT5 330 . 00 OTHER EXPENSES ME - I hereby certify the informat n contained in this section of this application is true and correct to the best of my knowle e. I have supervised this individual r years. Name of Certified Operator under who supervision experience obtained Certification Nu er(s): Signature of Certified Operator: Printed name and signature of applicant's supervisor: (if different n abo ) Applicant's supervisor: (if different than above) Name of organization/utility/system: Telephone number:(include area code) Address:(number and street) City: State: ZIP code: • I,the undersigned,certify that I am th above applicant;that all statements made and information contained in�above application are true and correct to the best of my knowledge and beli ,that I understand that any omissions or misrepresentations may result in for the examinati on applied for,or revocation of any certificate gra d. I also consent to verification of my qualifications for the certificate for whpplied. g ture f appli nt: 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 PUBLIC WATER SUPPLY APPLICATION FOR o- o number: WATER TREATMENT PLANT AND WATER f DISTRIBUTION SYSTEM OPERATOR 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 property 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#:yI Z 900 Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ ❑ WT1 WT2 WT3 WT4 WT5 WT6 O.I.T ❑Northwest Central ❑Northeast ❑ Southwest El Southeast By examination ❑By reciprocity e- a •- 1. Name of applicant(last) (first) (middle) 5�Mr. ❑Mrs. ❑Ms. Zs8 NBc>26r,� IgMT- dNy . 2. Mailing address(number and street): 6212— BUT-TCNW006 Dk• City: State: ZIP code: County: Noac.�suz`« sN V606G- 14AMrl7-01Y 3. Office telephone number: 4. Home telephone number: (30) 733-2-8:5S (30),�'Tz9-583 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) M O Vyes' ❑No `If yes,date(mm/dd/yyyy): III IO:;11 1 6. Are you presently a certified water works operator in Indiana? ( Yes* ❑No 'If yes,give certification number and classification: D512- 0002— p Se- 7. Are you presently a certified water works operator in another state? ❑Yes' QNo "If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes [O/No 9. Social Security number:' 'Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is'voluntary and you will not be penalized for refusal. e 1 s• • •- 10. Check the highest grade completed. Grade School: High School: Co ge(years): ❑1 ❑2❑3 04❑5❑6❑7� ❑9❑10❑11 12 �❑2 03❑4❑5❑6❑More than 6 years 11. HigVSchool Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': es ❑No ❑GED OSA6.a' CoMMoN iT 05 z4 1998 r scHwoL. 05A6L= zA- 12. College GGr�ate? Degree: Major: ❑Yes R 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 ..: PUBLIC WATER SUPPLY APPLICATION FOR ° ° WATER TREATMENT PLANT AND WATER WS number: ,., DISTRIBUTION SYSTEM OPERATOR Receipt number: CERTIFICATION State Form 12094 (R6/2-06) . . 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 ❑ ❑ ❑ PS ID#: Operator DSS DSM DS] PLE SE H K E AM LO ATI N Water Treatment Plant Operator 1 W❑T2 W❑T3 E] WTS W❑T6 O❑I.T ❑Northwest Central ❑Northeast El Southwest ❑Southeast "examination ❑By reciprocity e- • o- 1. N e of applicant(last) (first) (middle)) r. ❑Mrs. ❑Ms. I 0/� �/Ir% JJr� 1 A 2. Mailing address(number and street): City: n flt;,n �� State: ZIP code: County: f� I n 1 ' &&03 3. Office telephone number: 4. Home telephone number: 3 )J -01 - 9343 7&5-- 4i3.1- Yti7�, 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) 9tes* 4o *If yes,date(mm/dd/yyyy): 6. Are you presently a certified w ate r works ope r ato r in Indiana. 9Yes* ❑No *If yes,give certification number and classification: To� �`j i . T 2 7. Are you presently a certified water works operator in another state? V� 1 J ❑Yes* P(No *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes pNo 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. e e o •• � • e- o 10. Check the highest grade completed. Grade School: High School: College(years): [--11 E12 E13 E]4 E15 E)6[37[:)8 [19 E110 1:111 B 2 ❑l ❑2❑3 04❑5❑6❑More than 6 years 11. Hi h School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': 19-yes ❑No ❑GED (D rev � ;10D'J T;'t3t©n �n 12. College Gt�r duate? 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: LLIA « 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 I ADDRESS JOB DUTIES FROM: TO: Position tiittle: L lName of current employer: / NOV Specific duties performed in day-to-day operation: Address:(number and street) •!i r 111J,j�''ru' City,state,ZIP code: GNL�v i/;•11S irv�lti•'„9 G� � 5� 3' Ly13 C..u.f'/�c, , 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: 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 PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER ws number: 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 ❑ ❑ ❑ PWS ID#: j 22`10©l Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ E] ,�/ WT1 WT2 WT WT4 WT5 WT6 O.I.T E)Northwest t.7t entral ❑Southeast ❑Northeast El Southwest go'By examination E]By reciprocity OEMe- o o- 1. Name of applicant(last)/ _ (first) (middle) Mr. ❑Mrs. ❑Ms. I 60clf 2. Mailing address(number and str' t): City: --� State: ZIP code: County: //P J Tyli 1 LW 7 L -7 /71✓+ 3. Offi a telephone number: 4. Home telephone number: Cc I I 20 - 733- 29,55 '7(,-5-&-7 S X70 7&T-q 32 let{ 7 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) E�yes* ❑No *If yes,date(mm/dd/yyyy): 6.//Are you presently a certified water works operator in Indiana? MYes* ❑No *If yes,give certification number and classification: W 9r!!7 /,X15 7. Are you presently a certified water works operator in another state? ❑Yes* LyNo *If yes,give certification number and classification (attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes ZNo 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. o • e oe e • o- e 10. Check the highest grade completed. Grade School: High School: Collegge1years): ❑l ❑2❑3❑4❑5❑6❑7 EE(8 09 E31❑11 EY<2 ❑l 22❑3 04 05❑6 Elmore than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school : [ Yes ❑No ❑GED 12. College Graduate? Degree: Major: [ es ❑No p�SUC_i u k s ,ter- lq7 C, ���►zl<< Date granted(mm/dd/yyyy): Name and location of college: oo.2 ? 7 v �x,61 14/t-'; (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: r_ a. Name of course: Name of school: Dates: College units or class hours: AOL6A Lbd �� b. Name of course: Name of school: Dates: College units or class hours: a- • o 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"Gkhu� �Gi^� C'w rQ�.E— �1)7� 1( �t Tr��.l wt.� •r ' Specific duties performed i-4--to-day operation: ��} ,r W T 3 } P��N(– Address:(number and street) ��� e� t`,,,�I+�1 - lt�tar�iw� w,F1. CIO,, w� S�5 cy� a�..� , k00m;w\ 31.4 6� LIV Clk f.�k .tti�� NyclroF�w�S�)�t A-cicj, ' E�Icww�� lrx (Akr's. M�i�vt�a�ncwy. �ch1 1=l<<�c� tc �,A,_t%Aj t?�'Ui)�tuE��. lA� n}�+ve [ co, City,state,ZIP code: Nc�.c.� tkr�aa< and �p1�1 c<�t P'VIN J�:n��rnct� 17���c�, j / V , rJ L1 -7 Cct('✓14G r fV _l ��% 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: 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 PUBLIC WATER SUPPLY APPLICATION FOR •' • WATER TREATMENT PLANT AND WATER WS number. DISTRIBUTION SYSTEM OPERATOR •• CERTIFICATION Receipt number: .' State Form 12094 (R6/2-06) 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#: Operator DSS DSM DSL PLEASE C EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ 14 ❑ ❑ WT1 WT2 WT3 WT4 WT5 WT6 O.I.T ❑Northwest '�dentral El Southeast (LBy examination [I By reciprocity El Northeast Southwest • o • 1. Name of applicant(last) pp (first) (middle) 19Mr. ❑Mrs. ❑Ms. Tt 2. Mailing address(number and street): I I ASS C.�.blc DQ, City: State: ZIP code: County: I#Jbp TP! !-16-436 Atriuw 3. Office telephone number: 4. Home telephone number: 31 - -I 11- ZKSS 31,7- M-,11egs 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) [KYes* ❑No *If yes,date(mm/dd/yyyy): //A A l� 6. Are you presently a certified water works operator in Indiana? 5•Yes* ❑No *If yes,give certification number and classification: W T i U L/6 W T3 7. Are you presently a certified water works operator in another state? ❑Yes* K,No *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes 04No 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. • o • o• e e •• o 10. Check the highest grade completed. Grade School: High School: College(years): ❑l 02❑3❑4❑5❑6❑7❑8 ❑9 F-1 10 El 11 592 El ❑2❑3❑4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school : ®.Yes ❑No ❑GED Mct -Z00,1 L a-✓i'evhc o. No.A 12. College Graduate? Degree: Major: [--]Yes ®,No /y/A 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: _x. 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: 9 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 1 ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: Suns ZOa PCt%te"C I Water 0 4ro.Tor C 41 04- Cc«xo' Specific duties performed in day-to-day operation: �„�:nS 145 w+ 4t1 Vw�v Pre.tT Address:(number and street) kai.,, Git Ft. #4%rk4.ri'' TQow, PN C6.cclr.,'4'4 P pkf wetrft•r r v� ro 0 t a0.okkft4_ris 1(Co.. �.fFei-r, ° 4C'CIC dk:wJ Znn �¢XCtv.�e, $o�dc��s� 1ZrC`.:IJ;gS GA tlwlvtj cL^ Avte af.c S'1�0 b✓ 131ST terse d'j )-ro ^jr /`?►n.'Fa ' w4tt� To..tr City,state,ZIP code: Vwl��t.ff Cr.c,a,n i�J Ol�.,�� a pct � � Cyr-e fN H6oT�l 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: 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 ��v4rs PUBLIC WATER SUPPLY APPLICATION FOR a :- �•;,¢ A WS number. f„ { a WATER TREATMENT PLANT AND WATER =' f DISTRIBUTION SYSTEM OPERATOR 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#: 03 Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ ❑ ❑ WT1 WT2 WT3 WT4 47T5 WT6 O.I.T ❑Northwest LWCentral ❑ ❑ Northeast Southwest Southeast y examination El By reciprocity ff e e e A 1. Name of applicant(last) (first (middle) �r. []Mrs. ❑Ms. I)Iat 56d r t 44�O r1 I 2. Mailing address(number and street): n City: Stag ZIP code: County: I a'i-OL.Po u 6L mar '0"J 3. Office telephone number: 4. Home telephone number: Liz) 3g5'-80) O 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) es' ❑No *If yes,date(mm/dd/yyyy): /C� V'D /D" � 6. Are you presently a certified water works operator in Indiana? es* ❑No *If yes,give certification number and classification: w-r3 w 9q�z 3(v DS L O9/6 b 7 g 7. Are you presently a certified water works operator in another state? f []Yes* o *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes o 9. Social Security number:* Your Social Security number is being requested by this state agency in order to expedite 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❑7 08 ❑9❑10❑11 ❑12 1 ❑2❑3❑4❑5❑6[--)More than 6 years 11. Hi h School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': _ es ❑No ❑GED S— $Q C4*ti p 12. College Graduate? Degree: Major: h / [--]Yes Nlo Date granted(I 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: A- S hod S � 9- 0- 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 emplo r: Specific duties performed in day-today operation: Address:(number and street) �w✓>¢- d PQ-cam�-b^'s �n�.,.¢ ; �,tlC I( !�5`�`�', City,state,ZIP code: Cur lzz/ �1607� FROM: TO: Position title: Name of pr vious employer: zoQO �L ��,�_ V5 Specific duties performed in day-to-day o ration: Address:(number and street) �(u ink-> t,J h-�-e ,2 Jew !�lu,�.� ;,,J k�� ,2,'✓e—N�h t� Ca'✓1(� 1"`` II �PeQ k-/ alb�r. wc � Pl41�i�l5 City,state,ZIP code: yr qP'q A FROM: TO: Position title: Name of previous employer,/ Specific duties performed in day-to-day operation: 1 Address:( umber and street) i✓J�'`�� �[rc�� ��i rz.-►-I u fl — CU���;5 a� CA 1.L i I y 7h 5�0 0 City,state,ZIP code: 111avJa/V lIy FROM: TO: Position title: Name of previous employer: Specific duties performed in day-today operation: Address:(number and street) City,state,ZIP code: (Continued on page 3) Page 2 of 3 PUBLIC WATER SUPPLY APPLICATION FOR WS number: WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR CERTIFICATION Receipt number: State Form 12094 (R6/2-06) 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#: Operator DSS DSM DSL PLEAS C K EXAM LOCATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ ❑ ❑ WT1 WT2 WT3 WT4 W 5 WT6 O.I.T ❑Northwest VXentral El Northeast El Southwest ❑Southeast y examination El By reciprocity 1. Name f �plicant(last (first) (middle) El Mr. �jt�rs. ❑Ms. ft�fm- 100 � b �ho 2. Mailing address(number and street): City- State: A code: unty:nfru �3. Office telephone number: 4.�Hr�e telephone number: 5. Have you ever applied for Water Works certification in Indiana before?(is this exam a repeat/retake?) []Yes* A o *If yes,date(mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? es* ❑No *If yes,give certification number and classification: "T 7. Are you presently a certified water works operator in another state? J ❑Yes* A o *If yes,give certification number and classification(attach a copy of certificate) B. Have you ever had a certification suspended or revoked? ❑Yes IP o 9. Social Security number:* Your Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. o • � •e e • • e 10. Check the highest grade completed. Grade School: High School: College(years): El El El❑4❑5 ED❑7❑8 09 010 Eli A 2 ❑l ❑2❑3❑4❑5❑6❑More than 6 years 11. Fiiqh School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': es ❑No ❑GED 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 D 0 • 9 0 0 'Sr zl 13. Training ourses,short courses,or other courses attended applicable to water industry: 9 PP ry: fo a. Name of course: Name of school. Dates. College units or class hours: k�w A z0b b. Name of course: Name of school: Dates: College units or class hours: o- e e P� 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 1 ADDRESS JOB DUTIES FROM: TO: Position title: _ ame of curr nt employer: r Specific duties performed in day-to-day operation: Add res :(numberand street) rel ied opff�, lab irk, bmpl� b I Q5s14 46D W. 15( 5f t�4. U I m8j n (� pro Co. Sf f l I City,state,ZIP code: i �C1 '►i��j, �U1« n C�.rW I I� 4bo _ 7FROM: 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: 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 PUBLIC WATER SUPPLY APPLICATION FOR WS number: .;,,. WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR �.�=,f" '•• 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$30 fee must be submitted with each application for certification. Applications must be signed by the individual,and his/her supervisor. Failure to file a properly completed application may result in the application being disapproved. (THE APPLICATION FEE IS NONREFUNDABLE) This is an application for Grade:(check one-One application per grade checked): Water Distribution System ❑ ❑ ❑ PWS ID#: Q(} Operator DSS DSM DSL PLEASE CHECK EXAM L ATION Water Treatment Plant Operator ❑ ❑ ❑ ❑ ❑ ❑ WTI WT2 WT3 WT4 WT5 WT6 O.I.T ❑Northwest Central ❑Northeast 5Southwest ❑Southeast 2-15-y examination ❑By reciprocity • • • 1. Name of applicant(last) (first) (middle) 50Mr. ❑Mrs. Elms. TOL&Q 1UA Ali/ 5 2. Mailing address(number and street): 1001 S . U LiICA4 S r. City: State: ZIP code: County: WCSTGI15LD Ai q&07q 0.$.A. 3. Office telephone number: 4. Home telephone number: 317 7 3 3 R 955 317 Ll 17 50(o 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) 2r�es* ❑No *If yes,date(mm/dd/yyyy): aJ&rQ QGrQK6- - f7A556D L(>T3 6. Are you presently a certified water works operator in Indiana? i es* E]No *If yes,give certification number and classification: /_� 2 . W'i�3 7. Are you presently a certified water works operator in another state? 1 v �J [-]Yes* R<0 *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? []Yes 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. u • • •• e o • e A I 10. Check the highest grade completed. Grade School: High School: College(pars): ❑1 ❑2❑3❑4❑5❑6 07 09❑10[ill 4?�< ❑l QeU3❑4❑5❑6❑More than 6 years 11. Hig chool Graduate? Date of graduation(mm/dd/yyyy): Name and location of chool : es ❑No ❑GED N 0 5- 21-�'>t �E57r=i6L0 ASH lath reAl �k[�f 12. Graduate? Degree: Major: 6R ❑No AAsee- Date granted(mm/dd/yyyy): Name and location of college: a-3•z e- 0 0170 I TTC--c-4 o1AL nc 911VIE� AJD o 4?0LJs /A/ (Continued on page 2) Proof of education must be submitted when used as a substitution for experience. Page 1 of 3 ;; e e e e xit 13. Training courses,short courses,or other courses attended applicable to water industry: r a. Name of course: Name of school: Dates: College units or class hours: QAT64 SUa�� ti aCof WZ6 Hoilli,5 b. Name of course: _ IOGM y( t-(ST bG k(.(r VA1004f Wi/a 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 I ADDRESS JOB DUTIES FROM: / TO: Position title: Name of current employer: O -5� S C UT-106L640145_1- Specific duties performed in day-to-day operation: Address:(nurgber and street) ox 1(s�c SYST��S GprL � 1dlsrST � u y T ,6u A L PL444! � W IRA4• City,state,ZIP code: 96ftl of P"WIPIVA 5 MOMS. Lq.e2M,&-L 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: T0: 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_ f.. _-OFFICE II PUBLIC WATER SUPPLY APPLICATION FOR ws number: • N WATER TREATMENT PLANT AND WATER F, ` �*• DISTRIBUTION SYSTEM OPERATOR Receipt number: CERTIFICATION State Form 12094 (R6/2-06) 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#: 5'47-?004 Operator DSS DSM DSL PLEASE CHECK EXAM L I N Water Treatment Plant Operator �1 El 1:1 El El El ❑ 5 OI.T [3 Northwest Central "Na rtheast ❑Southwest ❑Southeast By examination ❑By reciprocity 1. Name of applicant(last) (first) (middle) %Mr. ❑Mrs. ❑Ms. Qom, 2. Mailing address�(number and street)' , VV D ISK RA City: State: ZIP code: County: 40n -XN 4-6017 Z v S 3. Office telephone number: 4. Home telephone number: C3 11) 33 - ZBSS 301 3Ss -10'74 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: 7'12 On IS �®VV f 77-3 7. Are you presently a certified water works operator in another state? I ❑Yes* iA No *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes lNo 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. � • o se e e •- e 10. Check the highest grade completed. Grade School: High School: College(years): ❑l El❑3❑4 0❑6❑7 E3 ❑9❑10 Ell P912 ❑l 02❑3❑4❑5❑6[]More than 6 years 11. High School Graduate? Date of graduation(mm/ddtyyyy): tNiWe nd location of school Yes ❑ ' sNo ❑GED OS p-k" 1/i9h Ve-h"� 440-72. 12. College Graduate? Degree: Major: ❑Yes �110 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 A Ti ON AND . 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: I ' b. Name of course: Name of school: Dates: College units or class hours: e f 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: o M8 6Vrrd*A4 e►r• 7-fY ►' 1 O coltvlmd Specific duties performed in day-to-day operation: Address:(number and street) City,state,ZIP code: f 4 �1 ro"c t I X.N 4 FROM: TO: Position title: Name of previous employer: ? zqv. 2008 bcrtw \) S Z C, )Specific duties performed in day-to-day operation``: Address:(number and street) C..00a'12 Sl8 C+ City,state,ZIP code: ,Xerv4IIQ ,TA) 0W FROM: TO: Position title: Name of revious emp o er: (('' t �r�• Specific duties performed in day-to-day operation: Address:(number and str et) P1,Oka r /FomOV4Cy cs iir. / n� 4J �" 4-kt v i Cr<•�c r We i riv� City,state,ZIP code: EKI er w4Yr,4.k5 4r .�NIC'IS r.1., j TA) 4,4041 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 PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER WS number: DISTRIBUTION SYSTEM OPERATOR 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#: -,109064 Operator DSS DSM DSL LEASE CHECK EXAM LOCATION Water Treatment Plant Operator 1:1 ❑ V-V] [�I' ED ❑ ED Northwest WT1 WT2 ❑T3 WE3T 4 WT5 WT6 O.I.T ZCentral ❑Southeast By examination ❑By reciprocity ❑Northeast ED Southwest loffi=I 1. Name of applicant(last) (first) (middle) Mmr. ❑Mrs. ❑Ms. LL 2. Mailing address(number and street): State: ZIP code: County: Ae(-AoiA- 4(loo3c, Hai-11 i-TorJ 3. ce,telephone number: 4. Hom)telephone number: .7 '17) 733•- Z-i,-SS 0 (r>C-.7 -S(c" — r b 5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeat/retake?) EKes* ❑No *If yes,date(mmlddlyyyy): iJ u-F A R c V r C - N-ess e---b "I T 3 6. Are you presently a certified water works operator in Indiana? 2(yes* ❑No *if yes,give certification number and classification: \-J'T 120ZaS WT .� 7. Are you presently a certified water works operator in another state? ❑Yes* �o *If yes,give certification number and classification(attach a copy of certificate) 1. Have you ever had a certification suspended or r1voked? E]Yes MI No 9. Social Security number:* *Your Social Security number is being requested by this state agency in order to expedite 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 ED 2 ED 3 ED 4 E-)5[16 ED 7 EJ9 E310 E111 Z12 Ell ❑2❑3❑4❑5❑6❑More than 6 years 11. High School Graduate? Da e of graduation(mmlddlyyyy): Name and location of school': 9Yes ❑No EDGED 'VA�T 12. College Graduate? Degree: Major: ❑Yes ❑No Date granted(mmlddlyyyy): 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: 77 Name of school: Dates: College units or class hours: At,,/1Nj A CtC7 CL.ASS(3 Cif ZC12 - IIiZCIL 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: : Zc-1( nZcS��.�T � LNr T OPEZATC2 . CITy eV C-4 W_.1CI- Specific duties performed in day-to-day operation: Address:(number and street) TcLST VJATL2 Go-'9L17- _&Gt_kJAStf FIL70LS V-50FT-'+=2s A1c��iPc� CHi✓.,<<HL FLE.) 4-ATC—s City,state,ZIP code: CNCC)�_ WCLLS 14 JTce-y ArJD 0eDL2 C}Ftn'ic0S Ct ►2^1f=(_ W. U(LC�7 FROM: TO: Position title: Name of previous employer: i zoo(, I Zola J L.AWR_ C i T CA'Z,-n C L Specific duties performed in day-to-day operation: Address:(number and street) r'7jEPAtP_ LJa icrz 'RoA1� LJATE Stu ice Lt jES 3�i� 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: 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 PUBLIC WATER SUPPLY APPLICATION FOR WATER TREATMENT PLANT AND WATER WS number: 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 ❑ ❑ ❑ PWS ID#: (Xj Operator DSS DSM DSL PLEASE CH E A L OCATION Water Treatment Plant Operator �1 11 WE] WI- WTS a 6 O❑.I.T ❑ orthwest N Central ❑Southeast By examination [I By reciprocity Li Northeast El Southwest s- 1. Name of applicant(last) (first) (middle) 9mr. []Mrs. Elms. xe 2. Mailing address(number and street): s ra w « v City: State: ZIP code: County: 3. Office telephone number: 4. Home telephone number: 30 -T 707 5. Have you ever applied for Water Works certification in Indiana before?(is this exam a repeat/retake?) Q-�"es* []No *If yes,date(mm/dd/yyyy): 6. Are you presently a certified water works operator in Indiana? Or 00 7 %-7 VS-G L]Yfs* []No *If yes,give certification number and classification: J 00 77�J� W j 7. Are you presently a certified water works operator in another state? ❑Yes* [;R6 *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? []Yes [ble- 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite 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❑7❑8 ❑9 Ell❑11 El 12 ❑1 ❑2❑3❑4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mm/dd/yyyy): Name and location of school': ❑Yes ❑No 96tD Lz,Zle 12. College Graduate? Degree: Major: ❑Yes [2iJo 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 I ' • IN 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: ARTIll 'EXPERIENCEIHISTORY s • 0- 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 I ADDRESS JOB DUTIES FROM: TO: Position title: Name of current employer: Specific duties performed in day-to-day operation: Address:(number and street) i _r,-v,e f City,state,ZIP code: 02 t n e e r ti FROM: TO: Position title: Name of previous employer: l�i9q G:JO �iPP�a - t - Tclzu,c_ PP c Specific duties performed in day-to-day operation: Address:(number and street) y'"Pt r "N ettT-41 60L_t 6c-Q S� (�rDC Ccfii;es ,�,✓'i 0� e M F,LT City,state,ZIP code: FROM: TO: Position title: Name of previous employer: Specific duties performed in day-to-day operation: Address:(number and street) C'ie L' T'"�'/c�c( �(/�-_J.�s ,'e S Q I/ /< e P� ` City,state,ZIP code: riGv ic.0 r-r e( �,G 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 I PUBLIC WATER SUPPLY APPLICATION FOR 74F�,�r�k EMOFFIMUSE, WATER TREATMENT PLANT AND WATER DISTRIBUTION SYSTEM OPERATOR 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 D SM❑ � DO � Dll- PWS ID� SS Operator PLEAS CH�Q EA _QQATION Water Treatment Plant Operator ❑WT1 ] WT2 FIVDV7 3 WE]T4 WVT 5 WT6 ODIJ ❑Northwest entral 0 Southeast y examination ❑By reciprocity Northeast /A/ southwest 1. Narpe of applicant(last) (first) (middle) BRfiIlr. ❑Mrs. OMs. 0 J 2. Mailing address(number and street): JIF6 0 UJ 1'AJ 1 411329 0 PA.,44Jd City: State: ZIP code: County: -A)6 Lie 's )I, I 1 71-1) 7V/4.61/i 3. Office telephone number: 4. Home telephone number: 7, ? 3/7 -Vacl c 0-7 9 5. Have you ever applied for Water Works certification in Indiana before?(is this exam a repeat/retake?) 0 es* A=—.0 *If yes,date(mmlddlyyyy): elNIN 6. Are you presently a certified water works operator in Indiana? kyes* ❑No *If yes,give certification number and classification: 7. Are you presently a certified water works operator in another state? ❑Yes* kNo *If yes,give certification number and classification(attach a copy of certificate) 8. Have you ever had a certification suspended or revoked? ❑Yes ANO 9. Social Security number:* our Social Security number is being requested by this state agency in order to expedite processing of your application. Disclosure is voluntary and you will not be penalized for refusal. 0 0 a o- 10. Check the highest grade completed. Grade School: High School: College(years): ❑1 ❑2❑3❑4❑5❑6❑7 N8 [19T Am. O❑11 ❑12 ❑1 ❑2❑3❑4❑5❑6❑More than 6 years 11. High School Graduate? Date of graduation(mmlddlyyyy): Name and location of school': ❑YesANo AGED Mill 11'e- 12. College Graduate? Degree: Major: ❑Yes,,allo Date granted(mmlddlyyyy): 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 i 0 o e e e 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: HISTORY, OU S,EM P L6YER ► 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 I ADDRESS JOB DUTIES FROM: TO: Position title: OIAv Name of current employer: Specific duties performed in day-to-day operation:_ ` Address:(number and street)JfS City,state,ZIP code: FROM: TO: Position title: Name of previous employer: W ,e,!` s� � � sod tv , I•t1 .4 Specific duties performed in day-to-day operation: J Address:(number and street) 41 j 1 lor" City,state,ZIP code: L W� F- �c� rJ '7 FROM: TO: Position title: IVA J i Name of previous employer: r () - -? _ 1--0 ' 4a-,J wee r1-^J 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 VOUCHER # 132237 WARRANT # ALLOWED 146900 IN,SI,JM OF $ IN DEPT. OF ENVIRONMENTAL MGT. \� P.O. BO 0 INDIAN (OCTS, 46207-7060 Carmel Water Utility ON ACCOUNT OF APPROPRIATION FOR i _ I Board members PO# INV# ACCT# AMOUNT Audit Trail Code WT5 01-6040-03 $300.00 WT5 01-6040-05- $30.00 U Voucher Total $330.00 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 7/18/2013 Invoice Invoice Description Date Number (or note attached invoice(s) or bill(s)) Amount 7/18/2013 WT5 $330.00 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 T�Z Lip Gvyv� Date Officer