160084 05/28/2008 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
I CHECK AMOUNT: $36.45
CARMEL, INDIANA 46032 3601E 9TH ST
INDPLS IN 46201 -2511 CHECK NUMBER: 160084
CHECK DATE: 5/28/2008
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1047 4239012 170798 36.45 SAFETY SUPPLIES
i
I
STATEWIDE MEDICAL SERVICES INVOICE
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201 -2511 Invoice Date Invoice
(317) 634 -0801 04/30/2008 170798
Invoice Due: 5/30/2008
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 P.O. Number: Terms: Net 30
Date Description Manifest Department Qty Lbs Rate Amount
04/25/2008 Regulated Medical Waste 2.25 Cu. Ft. 212629 1 Containers $32.50 $32.50
Box
04/25/2008 Energy Surcharge 212629 1 $3.95 $3.95
Total $36.45
Sales Tax $0.00
Total Invoice Due $36.45
'Total past due (See below) $35.50
'Total Current and past due $108.40
Minimum amount due now $35.50
Amount due 5/30/2008 $36.45
Current and outstanding unpaid invoice history:
Invoice Date Current 30 -60 60 -90 90+ �n I
169230 3131/2008 $0.00 $35.50 $0.00 $0.00 �ll
170118 4/17/2008 $36.45 $0.00 $0.00 $0.00
170798 4/30/2008 $36.45 $0.00 $0.00 $0.00
Totals $72.90 $35.50 $0.00 $0.00
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
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MAY 0 2 2008
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I MAY I C 2008
BY:
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BIOHAZARD ®US WASTE MANIFEST
Hazardous Materials Bill of Lading
2126,29 SPILL EMERGENCIES ONLY: 800 -535 -5053
Manifest Number
Generator (Shipper) of Waste: Transpo er of Waste:
Statewide Medical Services Darob, Inc.
AddresJ E. 116TH ST. 3601 East 9th Street 1801 Research Drive
Indianapolis, IN 46201 Louisville, KY 40269
(317) 634 -0801 (502) 491 -1535
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StatSN1 U.S.D.O.T. 725204
zt 0 Contact T N. A, R0'�
Account Number county
Telephone (31 573-
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
Container Size Quantity eceived Weight Monday:
9 Tuesday:
P1l1� 0 21 20Q8 Wednesday:
r 1,r.
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 Transportation. regulations of the U.S. Department of Transportation. Materials
it will be destro ed in accordance with all applicable local, state
y ate and fede gelation
i gna tu r eC of authorized represe tative of waste generator.
Print Nam By Date
orter 1,
Ro &D Y ik j "A Last P/U 0 4 11 2009 Print Name �`r -s
No Feek Fri rdext Piclom: 519/2008 By Date
Transporter 2
Print Name
Typ Of Destructio By Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH Statewide Medical Services 2 Inc.
3601 East 9th Street 1801 Research Drive
Arrive: Depart: D S Vic e: Indianapolis, IN 46201 Louisville, KY 40269
si�eeltl� (317) 634 -0801 (502) 491 -1535
U.S. .T. 725204
F:ru�I PTr yFPi.� ?G�ri
Certificate of Destruction: Certification of receipt and str tion f R aterials covered by this mar est number:
Signature Date 0
1
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.
Statewide Medical Services
3601 East Ninth Street Date Due
Indianapolis, IN 46201 -2511
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
4130108 170798 Regulated Medical Waste 36.45
Total 36.45
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.
(o 1 C) 1 Allowed 20
Statewide Medical Services
3601 East Ninth Street
Indianapolis, IN 46201 -2511 In Sum of
36.45
ON ACCOUNT OF APPROPRIATION FOR
404- Program fund
PO# or INVOICE NO. ACCT #!TITLE AMOUNT Board Members
Dept
1047 170798 4239012 36.45 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
23 -May 2008
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a re
36.45 Business Se ces Manager
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
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