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Home My WebLink About176451 08/19/2009 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1 ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES =i CHECK AMOUNT: $101.92 CARMEL, INDIANA 46032 3601E 9TH ST INDPLS IN 46201 -2511 CHECK NUMBER: 176451 CHECK DATE: 8/19/2009 DEPARTMENT ACC OUNT PO NUMB INVOICE NUMBER AMOUNT DESCRIPTION 1047 4341999 192788 101.92 OTHER PROFESSIONAL FE STATEWIDE MEDICAL SERVICES INVOICE Full Service Medical Waste Disposal 3601 East Ninth Street JUL 2 7 2009 Indianapolis, Indiana 46201 -2511 Invoice Date Invoice (317) 634 -0801 BZ': 07/21/2009 192788 Invoice Due: 8/20/2009 Service Address: CARMEL CLAY PARKS RECREATION CARMEL CLAY PARKS RECREATI ATTN: ACCOUNTS PAYABLE 1235 CENTRAL PARK EAST 1411 E. 116TH ST. CARMEL IN 46032 -3455 CARMEL IN 46032 FA ccount.Number 3210 P.O. Number:_ Terms: .Net 30 Date Description Manifest Department: Qty Lbs Rate Amount 07/20/2009 Regulated Medical Waste 2.25 Cu. Ft. 246171 3 Containers $32.50 $97.50 Box 07/20/2009 Energy Surcharge 246171 1 $4.42 $4.42 Total $101.92 Sales Tax $0.00 Total Invoice Due $101.92 'Total past due (See below) $36.92 'Total Current and past due $138.84 Minimum amount due now $36.92 Amount due 8/20/2009 $101.92 Current and outstanding unpaid invoice history: Invoice Date Current 30 -60 60 -90 90+ 191218 6/19/2009 $0.00 $36.92 $0.00 $0.00 192788 7/21/2009 $101.92 $0.00 $0.00 $0.00 Totals $101.92 $36.92 $0.00 $0.00 DESTRUCTION CERTIFIED Waste destroyed in accordance with all applicable federal, state, and local regulations. Pub Ned i CO-1 KIC& -e- Desaiptlorl I S P115 L P.O.# NA P Budget Une Descr �I Pu Date Approval Date BIOHAZARDOUS WASTE MANI Hazardous Materials Bill of Lading J� 246171 SPILL EMERGENCIES ONLY: 800 -535 -5 2 7 2o09 Manifest Number Generator (Shipper) of Waste: Transporter of Waste: Name CA RAM, CI AY PARKS RECREATION �(J Statewide Medical Services Darob, Inc. 3601 East 9th Street 1801 Research Drive Address GT'R P�IRK Indianapolis, IN 46201 Louisville, KY 40269 (317) 634 -0801 (502) 491 -1535 cG Y ARAML State IN U.S.D.O.T. 725204 z§ 6017. "3455 Contact TINA T- TOT/.F Account Number 371 County Telephone UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours: ContainerSize Quantity Received W ht Monday: T i t) 2.2 Cu. Ft. B ox 1 1 0 1 4 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 regulati ns 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 Dat and federal regulations. ignature 01 i authorized representative of waste generator. Print Name I�G17 h tliT /,�lr By Date Transporter 1 T rT 7 \SV 7• a Ro K A L P/U 06/12/7009 Print Name No*§; Fri Y N tPic'tm: R /7JJ(lp By Date Transporter 2 Print Name I pe Of D estmetto By Transporter 3 Date Print Name Liners OH: Designated Facilities: Containers OH: Statewide Medical Services arob, Inc. 3601 East 9th Street 1801 Research Drive Arrive: Depart: Service Time: Indianapolis, IN 46201 Louisville, KY 40269 n (317) 634 -0801 (502) 491 -1535 U.S.D.O.T. 725204 Certificate of Destruction: Certifi i n of re eip a des uction of RMW materials covered by this manifest number: Signature Date V NI Original: Statewide Medical Services C-4 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 7/21/09 192788 Regulated Medical Waste 101.92 Total 101.92 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 101.92 ON ACCOUNT OF APPROPRIATION FOR 104 Program Fund PO# or Board Members Dept INVOICE NO. ACCT #/TITLE AMOUNT -rnn n7n no Q (11 07 1 homh� rartify that the attached invoice(s). or 1 ILL /00 1no W v 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 13 -Aug 2009 Signature 10152 Accounts Payable Coordinator Cost distribution ledger classification if Title claim paid motor vehicle highway fund