207228 03/13/2012 CITY OF CARMEL, INDIANA VENDOR: 363840 Page 1 of 1
ONE CIVIC SQUARE STATE SAFETY COMPLIANCE LLC CHECK AMOUNT: $107.52
CARMEL, INDIANA 46032 5338 VICTORY DRIVE STE A
INDIANAPOLIS IN 46203 CHECK NUMBER: 207228
CHECK DATE: 3/13/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 9892801 107.52 MATERIALS SUPPLIES
INVOICE
State Safety Compliance, LLC.
FINVOICE
Br-anch: 701 Indianapolis
9892801
5338 Victory Dr
Invoice Date Page
Suite A 2/27/2012
frnfiamipo!ls. IN J16203 ORDER NUMBER
1 _______3611327
717-423-7724
hill To: Ship To:
City of Carmel Utilities City of Cannel Utilities
Wastewater Carmel W.W.T,P (JEFF COOPER 2-22-12)
760 "Third Ave. SW, Suite 110 9609 Hazel Dell Parkway
Carmel, 1.\46032 Indianapolis, In 46280
Ctistomer ID: 109095
PO Number Terms Description Net Due Date I Disc Due Date l Discount Amount
L JEFF COOPER 2-22-12 0.5% 10 net 30 03/28/12 03/08/12 0.50
Order Date Pick Ticket No Primary Salesrep Name Taker
",Q.1/2012 15:57:15 5899221 Rob Willmann JCHANEY
Mummies Pricing
U041
I tem Old Extended
It Descriptio Price Price
onfe, Remaining unit Siz E� em escr e
,it Size
Delivery Instructions: UPS GROUND PREPAY ADD
Carrier: UPS Ground PPA Tracking I Z203YOA0353591517
8.0000 5.0000 0.0000 EA GU-G1540BA EA 12.4400 99.52
1.0 EYEWASH SOZ ADDITIVE BACTERIOSTATIC I
GUARDIAN
Tom/ Lines: I SUB-TOTAL: 99.52
Total FIviglif In: 0. 00 Total Frcighl Out. 8, 00 TOTAL FREIGHT: 8,00
TAX: 0-00
AMOUNT DUE: 107.52
n
T
ORIGINAL
VOUCHER 116944 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
9892801 01- 7202 -05 $107.52
Voucher Total $107.52
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 3/6/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
3/6/2012 9892801 $107.52
I 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
Date Officer