HomeMy WebLinkAbout199690 07/20/2011 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
+1' CHECK AMOUNT: $43.92
CARMEL, INDIANA 46032 3601E 9TH ST
o INDPLS IN 46201 -2511 CHECK NUMBER: 199690
CHECK DATE: 7/20/2011
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1094 4350900 227327 43.92 OTHER CONT SERVICES
111111 IIIII Illll IIIII Illll IIIII IIII IIII
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 Invoice Date Invoice
(3 17) 634 -0801 Pff v D 06/24/2011 227327
JUN 2 9 2011 Invoice Due: 7/24/2011
1R,V
I�I�slell��ll�o���ll���l�ll 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
06/17/2011 Regulated Medical Waste 4.5 Cu. Ft. 298028 1 Containers $38.50 $38.50
Box
06117/2011 Energy Surcharge 298028 1 $5.42 $5.42
Total $43.92
Sales Tax $0.00
Total Invoice Due $43.92
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
Purchase
Description Rew-LA-rEp rnEbal W ere
P.O. P or F
G.L.# 109q- 4
Budget cow svn
Line Descr Cffier
Purchaser Date
Approval Date
SIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading ei
SPILL EMERGENCIES ONLY: 800 535 -5053
Manifes Number
Genera# (Shipper) of Waste: Transporter of Waste:
Name CARS CLAY PARKS RECREATION
MONON CENTER Statewide Medical Services Darob, Inc.
1235 CENTRAL. PARK EAST 3601 East 9th Street 1801 Research Drive
Address Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
CARIVIEL
City State IN U.S.D.O.T. 725204
Zip Contact
Account Number County (317) 573-5M Telephone Weekly
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
Container Size-- Quantity Received Weight Monday:
2.25 Cu. Ft. Box 1
S 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 Transport tion. 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. y
/�G I B Date
rint Name
,L'z� Transpor 1
MY-NV-A 06/1012011
Route Last P/U Print Name
ElWeek Fri NentPidwp: 6/24/2011
Notes: By Date
Transporter 2
Print Name
Type Of Destructio By Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services rob, Inc.
3601 East 9th Street 1801 Research Drive
Arrive Depart: U S ervice Time: Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
PAMPEA"INGER U.S.D.O.T. 725204
Certificate of Destruction: Certification of rece' MW materials covered by this manifest numb r•
�Y :A s
Signature Date
Original: Statewide Medical Services Copy: rat 1 ste 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
6/24/11 227327 Regulated Medical Waste 43.92
Total 43.92
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
43.92
ON ACCOUNT OF APPROPRIATION FOR
109 Monon Center
PO# or INVOICE NO. ACCT #/TITLE AMOUNT Board Members
Dept
1094 227327 4350900 43.92 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
12 -Jul 2011
Signature
43.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund