188532 08/03/2010 CITY OF CARMEL, INDIANA VENDORS 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
CARME,., INDIANA 46032 3601 E 9TH ST CHECK AMOUNT: $36.92
INDPLS IN 46201 -2511
CHECK NUMBER: 188532
CHECK DATE: 813/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 210144 36.92 OTHER CONT SERVICES
STATEWIDE MEDICAL SERVICES I
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Invoice Date Invoice
(3 17) 634 -0801 07/14/2010 210144
Invoice Due: 8/13/2010
111011111111 L 1111111111111 Service Address:
CARMEL CLAY PARKS RECREATION CARMEL CLAY PARKS RECREATI
ATTN: ACCOUNTS PAYABLE MONON CENTER
1411 E. 116TH ST. 1235 CENTRAL PARK EAST
CARMEL IN 46032 CARMEL IN 46032 -3455
Account Number: 3210 P.O. Number- _Terms: I Net 30
Date Description Manifest Department: Qty Lbs Rate Amount
07/0212010 Regulated Medical Waste 2.25 Cu. Ft. 272316 1 Containers $32.50 $32.50
Box
07/0212010 Energy Surcharge 272316 1 $4.42 $4.42
Total $36.92
Sales Tax $0.00
Total Invoice Due $36.92
UMMM
p
DESTRUCTION CERTIFIED JUL 2 1 2010
Waste destroyed in accordance with all applicable
federal, state, and local regulations. BY
Description N t
Qescri ti a p ��r,
P.O.# U PorF
G.L. I Oq y- 2)t:z ()n Budget esc I1 c r l XrS
Line r �f l,� I I r
Purchaser Date
Approval Date
BIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
7.7731 SPILL EMERGENCIES ONLY: 800 535 -5053
Manifest Number
Generator (Shipper) of Waste: Transporter of Waste:
Name CARMEL CLAY PARKS RECREATION
MONON CENTER eStatewide Medical Services Darob, Inc.
Address 1235 CR T R AT. PARK FAST 3601 East 9th Street 1801 Research Drive
Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
cit y CARAIRL State IN U.S.D.O.T. 725204
zip 46032 -3455 contact CARRIE KEAVENEY
Account Number 3210 County
Telephone (317)573 -5250
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Weekly Customer P/U Hours:
-Container Size Quantity Receiv Weight Monday:
Box 1 Tuesday:
Wednesday:
Thursday:
Friday:
Generator (Shipper) Certification: Transporter (Consignee) Certification:
This is to certify that the here -in -named materials are properly This is to certify that the here -in -named materials are properly
classified, described, packaged, marked, labeled, and are in classified, described, packaged, marked, labeled, and are in
proper condition for transportation according to applicable proper condition for transportation according to applicable
regulations of the U.S. Department of Transportation. regulations of the U.S. Department of Transportation. Materials
will be destroyed in accordance with all applicable local, state
By Date LJ and federal regulations.
Signature of authorized reprt a of waste generator. Print Name Q ✓✓1 -cf) By Date
Trans orter 1
Rout -NW -A Last P/U
4
5 l .010 Print Name
NoteElWeek Fri xeNl PiduV: 7/9/2010 By Date
Transporter 2
Print Name
By Date
Typ Of Destructio Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services carob, Inc.
3601 East 9th Street 1801 Research Drive
Arriv Depart: rvice Time: Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
U.S.D.O.T. 725204
PAM PFA"MGER
Certificate of Destruction: Certification of ript a destr ction of MW aterials covered by this ma ifest nur r:
Signature Date
Original: Statewide Medical Services Copy: Gee for of W 7 Certificate of Destruction to Accompany Invoice
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice of bill to be properly itemized must show; kind of service, where performed, dates service rendered, by
whom, rates per day, number of hours, rate per hour, number of units, price per unit, etc.
Payee
Purchase Order No.
361011 Statewide Medical Services
3601 E. 9th St. Date Due
Indianapolis, IN 46201 -2511
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) PO Amount
7114110 210144 Regulated Medical Waste 36.92
Total 36.92
I hereby certify that the attached invoice(s), or bil!(s) is (are) true and correct and I have audited same in accordance
with IC 5- 11- 10 -1.6
20_
Clerk- Treasurer
Voucher No. Warrant No.
Allowed 20
361011 Statewide Medical Services
3601 E. 9th St.
Indianapolis, IN 46201 -2511 In Sum of
36.92
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT WTITLE AMOUNT Board Members
Dept
1094 210144 4350900 36.92 1 hereby certify that the attached invoice(s), or
bill(s) is (are) true and correct and that the
materials or services itemized thereon for
which charge is made were ordered and
received except
29 -Jul 2010
Signature
36.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund