214829 11/20/2012 CITY OF CARMEL, INDIANA VENDOR: 363840 Page 1 of 1
h 10J� ONE CIVIC SQUARE STATE SAFETY&COMPLIANCE LLC CHECK AMOUNT: $147.30
CARMEL, INDIANA 46032 5338 VICTORY DRIVE STE A
ti«oM-o. INDIANAPOLIS IN 46203 CHECK NUMBER: 214829
CHECK DATE: 11/20/2012
DEPARTMENT ACCOUNT PO NUMBER INVOICE NUMBER AMOUNT DESCRIPTION
651 5023990 9973629 147 . 30 MATERIALS & SUPPLIES
INVOICE
State Safety & Compliance, LLC.
INVOICE
Branch: 701 Indianapolis 9973629
5338 Victory Dr Invoice Date Page
Suite A 11/8/2012 12:12:55 1 of I
Indianapolis, IN 46203 ORDER NUMBER
3663754
317-423-7724
Bill To: Ship 7W.W.T.P
City of Carmel Utilities City tilities
Wastewater Carm
760 Third Ave. SW, Suite 110 y 9609 Hazel Dell Parkway
Carmel, IN 46032 1, Indianapolis, In 46280 /
Customer ID: 109095
PO Number Tertns Description Net Due Date Disc Dite Date Discount Ainotrnt
S13375 0.5% 10 net 30 12/08/12 11/18/12 0.74
Order Date Pick Ticket No Primary,Salesrep Name Taker
11/8/2012 09:39:15 5979633 Rob Willmann PGENDRON
Quantities Pricing
Item ID UOdI Unit Extended
UOM Item Description Price Price
Ordered Shipped Remaining Unit Size
Unit Size D
Delivery Instructions: CUSTOMER WILL PICKUP TODAY
Carrier: Pick Up Tracking#:customer 2 pick up
30.0000 30.0000 0.0000 DZ J9 DZ 4.9100 147.30
12.0 GLOVES BROWN JERSEY MENS 9 OZ LARGE 12
(25/DZ PER CS.)
Total Lines:I .SUB-TOTAL: 147.30
TAX. 0.00
AMOUNT DUE: 147.30
ORIGINAL
i
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 11/14/2012
Invoice Invoice Description
Date Number (or note attached invoice(s) or bill(s)) Amount
11/14/201: 9973629 $147.30
hereby certify that the attached invoice(s), or bill(s) is (are) true and
-orrect and I have audited same in accordance with IBC 5-11-10-1.6
Date Officer
VOUCHER # 126139 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
9973629 01-7202-06 $147.30
Voucher Total $147.30
Cost distribution ledger classification if
claim paid under vehicle highway fund