224550 09/25/2013 CITY OF CARMEL, INDIANA VENDOR: 362124 Page 1 of 1
ONE CIVIC SQUARE ANTHONY ISENBERGER CHECK AMOUNT: $30.00
CARMEL, INDIANA 46032 6212 BUTTONWOOD DRIVE
y,off 6ca NOBLESVILLE IN 46062 CHECK NUMBER: 224550
CHECK DATE: 9/25/2013
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
601 5023990 WT3 30 . 00 OTHER EXPENSES
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https:/lfs85.gmis.in.gov/pse/fs91prd/F-WLOYEE/ERP/c/COLLECT RECFIVABLES.ITEM—N4AINTAIN.... 9116/2013
1 �l
'a PUBLIC WATER SUPPLY APPLICATION FOR
b �
WATER TREATMENT PLANT AND WATER WS number:
• � DISTRIBUTION SYSTEM OPERATOR Receipt number:
CERTIFICATION
State Form 12094 (R612-06)
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
1S NONREFUNDABLE)
This is an application for Grade:(check one-One application per grade checked):
Water Distribution System ❑ ❑ ❑ PINS ID#:SZz 900V
Operator DSS DSM DSL PLEASE CHECK EXAM LOCATION
Water Treatment Plant Operator Cl ❑ U ❑ ❑ ❑ Northwest �/
WT1 WT2 3. WT4 W 15 WT6 O.I.T ❑ LVJ Central
❑Northeast El Southwest
El Southeast
By examination ❑By reciprocity
o- o e-
1. Name of applicant(last) (first) (middle)
IdivIr. ❑Mrs. ❑Ms. Z �F3c` �Fl2 y Nr►�onl y W
2. Mailing address(number and street):
&Z.12— %jUTTONWOo6 0iz-
City: State: ZIP cod/e: County:
1V"C'6:6 ULGLa ZJy. L/600 Z- 11A1gx41--/q
3. Office telephone number: 4. Home telephone number:
(3J'7) 733-2-8:55- �31�)�z9-583
5. Have you ever applied for Water Works certification in Indiana before?(Is this exam a repeatiretake?) 1\I O
Reyes' ❑No 'If yes,date(mm/dd/yyyy): 01103111
6. Are you presently a certified water works operator in Indiana?
[EYes' ❑No 'If yes,give certification number and classification: D5 12—000;2 'D 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/N.
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 s � ee � o e• e
10. Check the highest grade completed.
Grade School: / High School: College(years):
❑l ❑2❑3❑4❑5❑6❑7[y8 ❑9 Ell❑11 12 Erl ❑2 03,❑4❑5❑6❑More than 6 years
11. Hig chool Graduate? Date of graduation(mm/dd/yyyy): Name and location of school
[DYes []No ❑GED 05/2ti�i990 05,g6.4 do/4,o%)Ntry SdN.OL.
06,9 7=
12. College Grouate? Degree: Major:
❑Yes ONo
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
N. J• 'L V I J L. 1 7 1 IN I V Uri J n i 11 ii i 11 V rr n i L IN u n M4 VI I • 1X V• I I J U r L
ra 1 -,_Tsen biro e r ty.�). 4-1'7 u1y 'QXa m CF)pp A
13. Training courses,short courses,or other courses attended applicable to water Industry:
8. Name of course; �k)UJ 4 '5 l- GbwflS
Name of school: Dales: College units or class hours:
b. Name of course;
Name of school: Dates: College units or class hours:
o s
►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 t ADDRESS
JOB DUTIES
FRO TO: Position title: Name of current employer:
07j 16/200 PRF.569-r D).5.Ri13or,nry oPe-ggvoft DSc L 1'ry OF CA�M6G
wPoPM UT)lIT04rS 0)snei S ova
Specific duties performed in day-to-day operation: Address:(number and street)
1 ONO r+312 'sr+MP64 C 14cvRIN6 ANID IPON CAI '3 y50 W. 1:3 1 4 ST:
Basis TNRcTt;6If6•vr TIiS DuTRI1BoTICtl Sy5'rrMy JhohIIY�R
+sir IC-A TZWC-& A•NP PRr:6SvK4f• ./J Srsi r�'aR JZVi
POZ6- P'-19NACO h Al A ;:_: M�RFL�AI6Y 15 K CA V(�rlorvS W ITH I N TH& City,state,ZIP code:
1)157-91 gv7-10 el i-VVZgM- 5GRt11c6/en,91NrF_4ANC-J-- 0-f r1ree11YAe,9,V- •CgRM.FL, rA "400 7q
CVSToM6i; 5�ku1C /!Np SuPPQRT.
FROM: Td: Positon title: Name of previous employer:
081-201 Zoi 3 o.r- bJ/;TEK T�&AT/yi6NT
Specific duties performed In day-to-day operation: Address;(number and street)
,11C14 IT09ISAW)t GHLoR00, JR*+ F4,009 Ip6 , .41,4 A 64 A154 e,
9191i?,NaS.l LGV64S iar'TNNf WATCR tPCANT.
&dk0 4sA 1RoN F14-ropas. R66CrNeR6Tj7 0.9T4FC S0FTNG-Aj City,state,ZIP code:
mOhi-II l2 WC/.(— hZ65soR6S f 6GrN6_g4L
1NA1NT&N4No& 4 C".NlN(y, /}c,c. MOU 7J R&�T
!Sj?ER V►s,o,j o F or c-
FROM: j TO: Posp title; Name of previous employer;
Specific duties performea in day-lo-day operation: Address:(number and street)
City,state,ZIP code:
FROM: TO: Position tide: Name of previous employer:
Specific duties performed In day-to-day operation: Address:(number and street)
City,state,ZIP Code;
(Gonlinued on page 3)
Page 2of3
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_I yezrs-
Nam of Certified O e supervision experience obtained Certification Number(s):
wl q `{701�1
SronaturV Certified Operator:
Pq
Printed name and signature of applicant's supervisor:(if different than above) Applicants supervisor:(if different than above)
Name of organization/utility/system:: Telephone number:(include area code)
!',I 'A /z-- 317-
Address:(number and street)
City: State: ZIP code:
gig111 110
1,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.
Signature of applica Date(mm/ddtyyyy):
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.
i
Page 3 of 3
VOUCHER # 132738 WARRANT # ALLOWED
T1663 IN SUM OF $
ISENBERGER, ANTHONY
CARMEL WATER
Carmel Water Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO# INV# ACCT# AMOUNT Audit Trail Code
WT3 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
T1663
ISENBERGER, ANTHONY Purchase Order No.
CARMEL WATER Terms
Due Date 9/16/2013
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) _ Amount
9/16/2013 WT3 $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
9 41, ��,� `L.._ U�/1,� -ems✓
Date Officer