175151 07/22/2009 CITY OF CARMEL, INDIANA VENDOR: 361011 Page 1 of 1
ONE CIVIC SQUARE STATEWIDE MEDICAL SERVICES
i 1 0 CHECK AMOUNT: $36.92
CARMEL, INDIANA 46032 3601E 9TH ST
4 0� io INDPLS IN 46201 -2511 CHECK NUMBER: 175151
CHECK DATE: 7/22/2009
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
1047 4341999 191218 36.92 OTHER PROFESSIONAL FE
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STATEWIDE MEDICAL SERVICES INVOIC
Full Service Medical Waste Disposal
3601 East Ninth Street
Indianapolis, Indiana 46201 -2511 Invoice Date Invoice
(317) 634 -080 06/19/2009 191218
i Invoice Due: 7/19/2009
J UN 2
4 2009
BY:
S ice Address:
CARMEL CLAY PARKS RECREATION ARMEL CLAY PARKS RECREATI
ATTN: ACCOUNTS PAYABLE 1411 E. 116TH ST.
1411 E. 116TH ST. CARMEL IN 46032 -3455
CARMEL IN 46032
,account= Dumber: 3210 1 P.O. Number: Terms: Net 30
Date Description Manifest Department: Qty Lbs Rate Amount
06/12/2009 Regulated Medical Waste 2.25 Cu. Ft. 243485 1 Containers $32.50 $32.50
Box
06/12/2009 Energy Surcharge 243485 1 $4.42 $4.42
Total $36.92
Sales Tax $0.00
Total Invoice Due $36.92
*Total past due (see below) $0.00
*Total Current and past due $36.92
Minimum amount due now $0.00
Amount due 7/19/2009 $36.92
Current and outstanding unpaid invoice history:
Invoice Date Current 30 -60 60 -90 90+
191218 6/19/2009 $36.92 $0.00 $0.00 $0.00
Totals $36.92 $0.00 $0.00 $0.00
DESTRUCTION CERTIFIED
Waste destroyed in accordance with all applicable
federal, state, and local regulations.
Purchase MEIN CAL 1n► A '5TE
Description 'b 1 S 12[0814 L
P.O. L. 9s092 Poe
G.L.# y7 hl 00• r1a
Budget
Una DesCr (C 1-j F1't 122nF 3E
Purchaser pate
Approval Date
BIOHAZARD ®US WASTE MANIFEST
24,3485 Hazardous Materials Bill of Lading
SPILL EMERGENCIES ONLY: 800 535 -5053
Mgnifest Number
/--V
Gene4ator� (Shipper)jofjW, IEC'MD' Transporter of Waste:
Name
E les5 tewide Medical Services Darob, Inc.
3601 East 9th Street 1801 Research Drive
Address Indianapolis, IN 46201 Louisville, KY 40269
'{1i1 W (317) 634 -0801 (502) 491 -1535
City All) -111 1 '1T1�11� W(b :T,IG State U.S.D.O.T. 725204
Zip Contadt I A
Account Numbeq; a'71 !Vi l dfN County
Telephone
UN3291, REGULATED MEDICAL WASTE, n.o.s., 6.2, PG II Customer P/U Hours:
Container Size Quantity Rece•ved Weight Monday:
2.2 Cu. Ff. Bo 1
�7— 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
regulations of the U.S. Department of Transportation. regulations of the U.S. Department of Transportation. Materials
f' j])F will be destroyed in accordance with all applicable local, state
By Date and federal regulations
Signature of a uthorized representative of waste generator. o�.�° f *7
Print Narne •„sfi ,a �i t, E+ r 1 �.,1 ,.Y Bye ,�P Date
Transporter 1
Route Last P/U Print Name
F', s e-A Fri NeAplVic!p' 81 "009
Notes: By Date
Transporter 2
Print Name
I ype Of De,:tyuall) By 1 Date
Transporter 3
Print Name
Liners OH:
Designated Facilities:
Containers OH: Statewide Medical Services Darob, Inc.
3601 East 9th Street 1801 Research Drive
Arri Depart: Se
'7 rvile Time: Indianapolis, IN 46201 Louisville, KY 40269
Ai::- (317) 634 -0801 (502) 491 -1535
PAM FAFF1NGER U.S.D.O.T. 725204
Certificate of Destruction: Certification of receipt and destruction of RMW materials covered by this manifest number:
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 property 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
6/19/09 191218 Regulated Medical Waste 22092 F 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 WITLE AMOUNT Board Members
Dept
1047 191218 4341999 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
16 -Jul 2009
r
Signature
36.92 Accounts Payable Coordinator
Cost distribution ledger classification if Title
claim paid motor vehicle highway fund
I