HomeMy WebLinkAbout195213 03/02/2011 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: $36.92
INDPLS IN 46201 -2511
CHECK NUMBER: 195213
CHECK DATE: 3/2/2011
DEPARTMENT ACCOUN PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 220325 36.92 OTHER CONT SERVICES
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Invoice Date Invoice
(317) 634 -0801 01/31/2011 220325
Invoice Due: 3/2/2011
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;_ Y Terms:
Date Description Manifest Department: Qty Lbs Rate Amount
01128/2011 Regulated Medical Waste 2.25 Cu. Ft. 287885 1 Containers $32.50 $32.50
Box
01/28/2011 Energy Surcharge 287885 1 $4.42 $4.42
Total $36.92
Sales Tax $0.00
Total Invoice Due $36.92
D Cc��
FEB 0 8 2011
BY
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
Purchase V)
Description I
P.O.# PorF
G.L.# l,1 L13 LO90CZ—
Bud 9
Line Descr
Purchaser Date
Approval Date
BIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
287881 SPILL EMERGENCIES ONLY: 800 -535 -5053
Manifest !Number
19
Generator (Shipper) of Waste: Transporter of Waste:
CAR T-, CLAY PARKS FEC_T ON
Name
{(wJ {Pl l wide Medical Services Darob, Inc.
Address 123 5 CENTRAL PARK EAST 3601 East 9th Street 1801 Research Drive
Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
City
A EZ N I State N U.S.D.O.T. 725204
•zip 3455 Contact CARrdE KEAV
Account Number 32I0 County
Telephone (31 7) 5 7 3 -5250
W- I'f
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
Container Size Quantity Rec d 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
proper lati condition for transportation according to applicable proper condition for transportation according to applicable
reguo s 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 o. authorized representative of waste generator. f
j By Da ��ir
Print Name �V�( 6qU h Tran e 1
Y-NW -A 12/3 1 /2 010 �j
Route Last P/U Print Name r-
FiMointh Fri. Id t Pidum: Y25/2-011 Notes: By Date
Transporter 2
Print Name
Type Of De,, tuctin BY Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services arob, Inc.
3601 East 9th Street 1801 Research Drive
Arriv �j Depart Service Time: Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
i PF&Frr►MGErc U.S.D.O.T. 725204
Certificate of 17 rruct�ion: Certification of receipt and destruction of RMW materials covered by this manifest number:
Signature t/ Date z' Z
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
1131111 220325 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 220325 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
24 -Feb 2011
i
Signature
36.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
1