HomeMy WebLinkAbout189009 08/18/2010 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
CARMEL, INDIANA 46032 3601 E 9TH ST CHECK AMOUNT: $73.84
INDPLS IN 46201 -2511
CHECK NUMBER: 189009
CHECK DATE: 8118/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 210673 36.92 OTHER CONT SERVICES
1094 4350900 210860 36.92 OTHER CONT SERVICES
1 111111 VIII VIII VIII VIII VIII IIII IIII
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Invoice Date Invoice
(317) 634 -0801 07/22/2010 210673
Invoice Due: 8/21/2010
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. Net 30
Date Description Manifest Department: Qty Lbs Rate Amount
0711612010 Regulated Medical Waste 2.25 Cu. Ft. 273314 1 Containers $32.50 $32.50
Box
07116/2010 Energy Surcharge 273314 1 $4.42 $4.42
Total $36.92
Sales Tax $0.00
Total Invoice Due $36.92
7 19 51
JUL 2 2010 DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable BY:
federal, state, and local regulations.
Purchase J n
Description _V"rr�G�LtP�Y Il�r
P.O.# PorF
G.L. q
Budget
Line t?escr D{W,VX CpY S1/CS
Purchaser Date
Approval Date
BIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
273314
SPILL EMERGENCIES ONLY: 800 -535 -5053
Ma1Wst Number
GenereM.WEInf� RECREAMN T of Waste:
Name Y
1 Statewide Medical Services Darob, Inc.
123-1 CENTRAL PARK 3601 East 9th Street 1801 Research Drive
Address Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
Cit
1 U.S.D.O.T. 725204
Zip Contact
Account Number County
Telephone weekly
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
Container Size— Quantity Re ived Weight Monday:
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 and federal regulations.
Signa tu of authorized representative t waste generator.
rint BY Date 7-
Traa s por tt er t
Route Last P/U Print Nam
E!Week'Fri Nod Pickup: 7123/2010
Notes: By Date
Transporter 2
Print Name
Type ;3fDestruetio By Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services *1)801 arob, Inc.
3601 E=ast 9th Street Research Drive
Indianapolis, IN 46201 Louisville, KY 40269
Arriv epart Service Time: (317) 634 -0801 (502) 491 -1535
PAM PFAYMNGER U.S.D.O.T. 725204
Certificate of Destruction: Certifi ion of cei and destruc n of RMW materials covered by this ma Pest num err
Signature Date L°
Original: Statewide Medical Service Copy: n or of Waste Certificate of Destruction to Accompany Invoice
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Invoice Date Invoice
(317) 634 -0801 07/26/2010 210860
Invoice Due: 8/25/2010
JUL 3 0 2010
pp Service Address:
A CARMEL CLAY PARKS RECREATI
CARMEL CLAY PARKS RECREA°fION
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:._ _Net_30r
Date Description Manifest Department: Qty Lbs Rate Amount
07/23/2010 Regulated Medical Waste 2.25 Cu. Ft. 4273814 1 Containers $32.50 $32.50
Box
07/23/2010 Energy Surcharge 273814 1 $4.42 $4.42
Total $36.92
Sales Tax $0.00
Total Invoice Due $36.92
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
Purchase R� a- w
Description
P.O.# PorF
e.L. I 3 5o U
L t
Desrar '1�1' CUh�"Y, c:�
Purchaser Date j
App r► Dated
BIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
273814 SPILL EMERGENCIES ONLY: 800 535 -5053
Manifest Number
Generator (Shipper) of Waste: ;Transp ter of Waste:
Name CARME CLAY PARKS RECREATION
MONON CENTER Statewide Medical Services Darob, Inc.
1� CENTRAL. PAR AST 3601 East 9th Street 1801 Research Drive
'Address Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
City State IN U.S.D.O.T. 725204
Zip 46032 -3455 Contact C AR ME KEAVENEY
Account Number 3210 County
Telephone (317) 573 -5250
Weekly
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
_—.Container. Size Quantity Rec ved Weight Monday:
2 ,2 5 Cu. Ft. 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
roper condition for transportation according to applicable proper condition for transportation according to applicable
egulations 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 and federal regulations.
Signature of authorized representative of waste generator.
Print Name lr BY Date
ra orte 1
Rout Y -NW-A: Last P/U 07/16/2010 Print Name �T s
N ot el -Week Fri Nam Pidw: 7/30/2010 B Date
Transporter 2
Print Name
T ype Of Destructlo By Transporter 3 Date
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services Darob, Inc.
3601 East 9th Street 1801 Research Drive
Arrive Depart Service Time: Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
PAM PFAFFINGFR U.S. D.O.T. 725204
Certificate of Destruction: Cer, i is on of receipt an r on o R W materials covered by this manifest rjUm er:
0
Signature Date Lo
Original: Statewide Medical vices Copy: Generator of Waste 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
7/22/10 210673 Re ulated Medical Waste 36.92
7126110 210860 Regulated Medical Waste 36.92
Total 1 73.84
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
20._
Clerk- Treasurer
Voucher No. Warrant No.
Allowed 20
361011 Statewide Medical Services
3601 E. 9th St.
Indianapolis, IN 46201 -2511 In Sum of
73.84
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #1TITLE AMOUNT Board Members
Dept
1094 210673 4350900 36.92 1 hereby certify that the attached invoice(s), or
1094 210860 4350900 36.92 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
12 -Aug 2010
'�im�
Signature
73.84 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
I