205608 01/17/2012 CITY OF CARMEL, INDIANA VENDOR: 363840 Page 1 of 1
ONE CIVIC SQUARE STATE SAFETY COMPLIANCE LLC CHECK AMOUNT: $119.20
CARMEL, INDIANA 46032 5338 VICTORY DRIVE STE A
s�,,+•. INDIANAPOLIS IN 46203
CHECK NUMBER: 205608
CHECK DATE: 1/17/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 9875262 119.20 OTHER EXPENSES
INVOICE
State Safety C ompliance, LLC. INVOICE
Branch: 701 Indianapolis 9875262
5338 Victory Dr Invoice Date Page
Suite A 1/5/2 09:21:33 1 of 1
Indianapolis, IN 16203 ORDER NUMBER
I� T� 3601494_
31 7 -423 -7724
Bill To: Ship To:
City of Cannel Utilities City of Carmel Utilities
Wastewater Carmel W.W.T.P
760 Third. Ave. SW, Suite 110 9609 Hazel Dell Parkway
Carmel, IN 46032 Indianapolis, In 46280
Customer D: 109095
PO Number Terms Description Net Due Date Disc Due Date Discount Amount
JEFF COOPER- 01.05.12 0.5% 10 net 30 02/04/12 01/15/12 0.60
Order Date Pick Ticket No Primary Salesrep Name Taker
1/5/2012 09:18:01 5881650 Gary Collins IJOHNSON
Quantities Pricing
Item ID UOM Unit Extended
Ordered. Shi>>ed Renraiuin UOM C Item Description Price Price
t g Unit Size O Unit Size
Delivery Instructions: customer is on his way to pickup
Carrier: Pick Up Tracking CUSTOMER 2 PICK UP
2.0000 2.0000 0.0000 BG SSOWB BG 28.5000 57.00
I.0 PAD OIL /WATER 15X18 GRAY BGM (100 /13G) 1
(36 BALES /PALLET)
2.0000 2.0000 0.0000 BG SSOO BG 31.1000 62.20
1.0 PAD 01 15X18 (M -WH) WHITE (100 /BL) 1
(E100) (30 BALES /PALLET)
Totrti Lines: 2 SUB- TOTAL: 119.20
TAX. 0.00
AMOUNT DUE: 119.20
ORIGINAL
VOUCHER 116601 WARRANT ALLOWED
363840 IN SUM OF
STATE SAFETY COMPLIANCE LLC
5338 VICTORY DRIVE STE A
INDIANAPOLIS, IN 46203
Carmel Wastewater Utility
ON ACCOUNT OF APPROPRIATION FOR
Board members
PO INV ACCT AMOUNT Audit Trail Code
9875262 01- 7202 -06 $119.20
Voucher Total $119.20
Cost distribution ledger classification if
claim paid under vehicle highway fund
Prescribed by State Board of Accounts City Form No. 201 (Rev 1995)
ACCOUNTS PAYABLE VOUCHER
CITY OF CARMEL
An invoice or bill to be properly itemized must show, kind of service, where
performed, dates of service rendered, by whom, rates per day, number of units,
price per unit, etc.
Payee
363840
STATE SAFETY COMPLIANCE LLC Purchase Order No.
5338 VICTORY DRIVE STE A Terms
INDIANAPOLIS, IN 46203 Due Date 1/12/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
i
1112/2012 9875262 $119.20
I hereby certify that the attached invoice(s), or bill(s) is (are) true and
orrect and I have audited same in accordance with IC 5- 11- 10 -1.6
Date Officer