HomeMy WebLinkAbout189518 08/31/2010 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
s ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
CARMEL, INDIANA 46032 3601 E 9TH ST CHECK AMOUNT: $34.42
IN�PLS IN 46261 -2511
o CHECK NUMBER: 1$9518
CHECK DATE: 8/31/2010
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 211337 34.42 OTHER CONT SERVICES
1 111111 IIIII IIIII IIIII IIIII IIIII 11111111
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East. Ninth Street
Indianapolis, Indiana 46201 -2511 Invoice Date Invoice
(317)634 -0801 07/31/2010 211 337
Invoice Due: 8/30/2010
I I I I I II III 1BI. 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-30-1
Date Description Manifest Department: Qty Lbs Rate Amount
07/30/2010 No Waste Wasted Trip Charge 274365 1 $30.00 $30.00
07/3012010 Energy Surcharge 274365 1 $4.42 $4.42
Total $34.42
Sales Tax $0.00
Total Invoice Due $34.42
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
Purchase
Descriptions �l
P.O. P or F w
G.L. U X13 50 00
une Descr 0
Purchaser Date -�7
Approval Date
SIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
274365 SPILL EMERGENCIES ONLY: 800 535 -5053
Manifest Number
Generator (Shipper) of Waste: Transporter of Waste:
Name CARNE.. CLAY PARKS RECRFATTON
MONON CEN TER Statewide Medical Services Darob, Inc.
Address 1.235 CF-AI PARK EAST 3601 East 9th Street 1801 Research Drive
Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
City R1VIn State IN U.S.D.O.T. 725204
Zip 46032 -3455 contact CARRIE KEAEY
Account Numbe County
Telephone (11 7) 5 73-57 0
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Waeltlp Customer P/U Hours:
Container Size Quantity Re ved Weight Monday:
2.25 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
oper condition for transportation according to applicable proper condition for transportation according to applicable
fregulations of the U.S. Department of Tran on. regulations of the U.S. Department of Transportation. Materials
will be destroyed in accordance with all applicable local, state
Date L/ and federal regulations.
Signature of authorized representative o waste generator. /�a. By nt Name v Tra i
Oporter 1
Routj -NW-A Last P/U 07/23/2010 Print Name
Note 1Week Fri NmPickup: 9/6/2010 By Date
Transporter 2
Print Name
Type Of Destmetio By Date
r Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: El Statewide Medical Services Ll Darob, Inc.
C
3601 East 9th Street 1801 Research Drive
Loce Arrive r' epart: Time: Indianapolis, IN 46201 Louisville, KY 40269 El-- (317) 634 -0801 (502) 491 -1535
PAM GEIt U.S.D.O.T. 725204
Certificate of Destruction: Certificati n of r e' t anal destruc 'o IA m terials covered by this manifest ler-
Signature Date
Original: Statewide Medical Services 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
7131110 211337 Regulated Medical Waste
34.42
Total 34.42
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
1 20
Clerk- Treasurer
s
Voucher No. Warrant No.
Allowed 20
361011 Statewide Medical Services
3601 E. 9th St.
Indianapolis, IN 46201 -2511 In Sum of
34.42
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #MTt_E AMOUNT Board Members
Dept
1094 211337 4350900 34.42 I 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
26 -Aug 2010
Signature
34.42 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund