HomeMy WebLinkAbout194362 02/03/2011 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
0 CHECK AMOUNT: $36.92
.�.J' CARMEL, INDIANA 46032 3601E 9TH ST
INDPLS IN 46201 -2511 CHECK NUMBER: 194362
CHECK DATE: 2/3/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 218846 36.92 OTHER CONT SERVICES
I111111IIIIIVIIIVIIIIIIIVIIIIIIIIIII
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Date Invoice
(3 17) 634 -0801 12/31/2010 218846
r� Invoice Due: 1/30/2011
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I�I,�I�Ildoll,��„II�„I�II 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: _321,0 1 P.O_ Number: I Terms: Net 30. 1
Date Description Manifest Department: Qty Lbs Rate Amount
12/31/2010 Regulated Medical Waste 2.25 Cu. Ft. 285814 1 Containers $32.50 $32.50
Box
12/31/2010 Energy Surcharge 285814 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
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SIOHAZARDOUS WASTE MANIFEST
285814 Hazardous Materials Bill of Lading
SPILL EMERGENCIES ONLY: 800- 535 -5053
Manilst Number
Gener RECREATI N Transporter of Waste:
Name MGNO CT-NT E
123 5 eENTRAL PARK EL;. �U TA 5 Medical Services Darob, Inc.
3601 East 9th Street 1801 Research Drive
Address Indianapolis, IN 46201 Louisville, KY 40269
0—"A *M (317) 634 -0801 (502) 491 -1535
City �e_s c CIA- nnrr ter. a t#aiersr U.S. D.O.T. 725204
46032 =34 s v ffmy
Zip Conta
Account Number County
Telephone Weekly
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG It Customer P/U Hours:
Container Size Quantity R eived Weight Monday:
2.25 Cu. Ft. Box 1
Tuesday:
Wednesday:
Thursday:
Friday:
Generator (Shipper) Certification: Transporter (Consignee) Certification:
This is to certify that t here -in -named materials are properly This is to certify that the here -in -named materials are properly
classified, des i cl -'p ckaged, marked, labeled, and are in classified, described, packaged, marked, labeled, and are in
roper con f
d' io ansportation according to applicable proper condition for transportation according to applicable
regulations f t U S De artment of Transportatio regulations of the U.S. Department of Transportation. Materials
will be destroyed in accordance with all applicable local, state
By Date! J(! and federal regulations.
Sign tire of uth razed r ntative of waste generator.
int Name E Transport
IND -A 1210312010
Route Last P/U Print Name
ElMonth Fri Nem Pidatp: 1128!
Notes: By Date
Transporter 2
Print Name
Type Of'DeAmctio By Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services Darob, Inc.
r 3601 East 9th Street 1801 Research Drive
Arrive C Indianapolis, IN 46201 Louisville, KY 40269
Depa r f Service Time: 1=1
PAM PFA"INGHR (317) 634 0801 (502) 491 1535
U.S.D.O.T. 725204
.Certificate of Destruction: Cer ificati o receipt and de i f RMW mater'als covered by this mani e umb
Signature Date 1
Original: Statewide Medical S ices 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
12/31/10 218846 Regulated Medical Waste 36.92
Total 36.92
1 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
36.92
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1094 218846 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
27 -Jan 2011
WOAM&L
Signature
36.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund