165964 11/12/2008 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
h CARMEL, INDIANA 46032 3601 E 9TH ST CHECK AMOUNT: $36.92
INDPLS IN 46201 -2511
CHECK NUMBER: 165964
CHECK DATE: 11112/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE N UMBE R AMOUNT DESCRIPTION
1047 4239012 179148 36.92 SAFETY SUPPLIES
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STATEWIDE MEDICAL SERVIC INVOICE
Full Service Medical Waste Disposal �r•.,
3601 East Ninth Street
Indianapolis, Indiana 46201-2511 OCT 1 Invoice Date Invoice
6c�,L,
(317) 634 -0801 B� 10/10/2008 179148
Invoice Due: 11/912008
Service Address:
CARMEL CLAY PARKS RECREATION CARMEL CLAY PARKS RECREATI
ATTN ACCOUNTS PAYABLE 1411 E. 116TH ST.
1411 E. 116TH ST. CARMEL IN 46032 -3455
CARMEL IN 46032
Account Number: 3210 17.0._Num4e,r_- Terms_ Net 30
Date Description Manifest Department: Qty Lbs Rate Amount
10/03/2008 Regulated Medical Waste 2.25 Cu. Ft. 224775 1 Containers $32.50 $32.50
Box
10/03/2008 Energy Surcharge` 224775 1 $4.42 $4.42
Total $36.92
Purchase Sales Tax $0.00
Description 12) 4EI)
P.O. P or F Total Invoice Due $36.92
Y
G•L 0 90 1 2 "Total past due (See below) $0.00
B ud Dew �C V J `Total Current and past due $73.84
Purchaser Date Minimum amount due now $O.DO
Appro Date Amount due 1119/2008 $36.92
Current and outstanding unpaid invoice history:
Invoice Date Current 30 -60 60 -90 90+
177886 9/18/2008 $36.92 $0.00 $0.00 $0.00
179148 10/10/2008 $36.92 $0.00 $0.00 $0.00
Totals $73.84 $0.00 $0.00 $0.00 O 2 7 2008
DESTRUCTION CERTIFIED Wiz,.
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
BIOHAZARDOUS WASTE MANIFEST
Hazardous Materials Bill of Lading
224775
SPILL EMERGENCIES ONLY: 800 -535 -5053
Manifest Number
20
Generator (Shipper) of Waste: Transporter of Waste:
Name
:ARME 131 pAYM_ R.ECTE ON
Statewide Medical Services Darob, Inc.
Address
14 6 S 3601 East 9th Street 1801 Research Drive
Indianapolis, IN 46201 ouisville, KY 40269
(317) 634 -0801 (D A5
CAR= IN
Cit State U.S.D.O.T. 725204 OCr
Z
Y
p Cont,�acct
Account Number County
Telephone
(3 17) 573 5250
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 condition for transportation according to applicable proper condition for transportation according to applicable
79 Aulti, n 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 1 i Date and federal regulations.
Signature of authorized representative of waste generator.
rint Name L' S u� B Date
Tr sporter 1
Route Last P /U 09 /05/2-008 Print Nam `�v
EWeek Fri Nod Pickup: 10/311200
Notes: By Date
Transporter 2
Print Name
Type O Destructio B Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services Darob, Inc.
-2/ 3601 East 9th Street 1801 Research Drive
Arriv Depart: r Service Time: Indianapolis, IN 46201 Louisville, KY 40269
uuROkiv n (317) 634 -0801 (502) 491 -1535
PlrA G U.S.D.O.T. 725204
Certificate of Destr n- erti on a ipt and destruction of RMW materials covered by this manifest number:
ra_ t5p o
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)) Amount
10/10/08 179148 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
104- Program Fund
PO# or INVOICE NO. ACCT #/TlTLE AMOUNT Board Members
Dept
1047 179148 4239012 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
31 -Oct 2008
T
Signature
36.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
i