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Form Approved PAGE 1 OF ORDER FOR SUF,i OR SERVICES OMB No. 0 187 31, Expires Aug 31, 1992 � * • ;1 submit four copies of invoice.) L P (Contractor must indudin Ne time for reviewing instructions, searching existing data sources, athOring and or any other aspect this collection o information, burden far this collection of information is as ad to average 1 hour per response, 9 a Davis Hi hway, State 1204, Arlington, VA gof Public reporting 1215 Person mblic reporting the data needed, and completing and reviewing the collection of informUirecrosate fo�rinfor atio9aOpe9a6ons and Reports, 1215 including suggestions for reducing this burden. to Washington Peaerwork rReductions 'Project (0704-0187), Washington, DC 20503. Please DO NOT RETURN your form to either of these addresser 22202-4302, and to the Office of Management and Budge; ap Send your completed form to the procurement offioa' iden4fied in It 6. 4. REQUISIHON/ pURCH REQUEST NO. 5. CERTIFIED FOR NA - TIONAL DEFENSE 2. DELIVERY ORDER NO. 3. DATE OF ORDER 1. CONTRACT/ PURCH ORDER NO. UNDER DMS REG 1 19 FEB 91 1 453018 DLA00591P1107 Do CODE DLA 0 0 S 7, ADMINISTERED BY Qf other than 6) A1JD5 F08 g_ DELIVERY 6. LSSUED 8Y DEFENSE DISTR. REGION WEST DEs DIRECTORATE OF CONTRACTING OTHER SHARPE SITE BLDG S-4 09- (se, Schedule if other) LATHROP CA 95331-5108 O. DELIVER TO FOB POINT By (Date% MARK IF BUSINESS CODE TP0383 FACILITY CODE ■ SMALL 9. CONTRACTOR 19 FEB 91 • SMALL DISAD- ❑ • VANTAGE PUBLIC: HEALTH SERVICES 12, DISCOUNTTERMSAa4A3*dfj � WOMEN -OWNED NAME AND ADDRESS ENVIRONMENTAL HEALTH PERMIT/ 13. MAIL INVOICES TO P O BOX 2009 • SEE BLOCK 15 • STOCKTON CA 95201 CODE S 3 3181 CODE S B 3 2 0 1 15. PAYMENT WILL BE MADE BY MARK ALL 14. SHIP TO PACKAGES AND DLA FINANCE CENTER SUPPLY BRANCH PAPERS WITH ATTN DFC-AETWA M/F WHSE. 7-2 S63200 CONTRAR 00. DDRW - TRACY SITE P.O. BOX 182317 ORDER NUMBER TRACY CA 95370+-5000 COLUMBUS OHIO 43218-2317 act 16. DELIVERY This delivery order is Issued on another Government agency or in accordance with and subject ro terms and conditions furnish thea following on ove nbc,,d r terms specified herein TYPE Reference your OF PURCHAS ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE BEEN OR 15 NOW ACCEPTANCE. THE CONTRACTOR HEREBY ORDER MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME. SIGNATURE TYPED NAME AND TITLE DATE SIGNED F CONTRACTOR NAME on Off this bon is marked, supplier must sign Acceptance and return the following number of copies: 17. ACCOUNTING AND APPROPRIATION DATA/ LOCAL USE 510.00 01 9710100 5132 001 900 2S S33181 w 18. ITEM NO. 19. SCHEDULE OF SUPPLIES /SERVICE 20. QUANTITY ORDERED/ 21. UNIT 22. UNIT PRICE 23. AMOUNT ACCEPTED OCUMENT NOUN NSN/MFG-PART-MUM ACL' 0001 0453018 JFEE 76990OT205559 01 1 0 510.00000 510.00 ILLING STATEMENT FOR 1991 PERMIT. NDERGROUND TANK FACILITY FEE FOR HREE (3) UNDERGROUND TANKS AT EFENSE DISTRIBUTION REGION WEST, RACY. LAUSES/PROVISIONS INCORPORATED BY EFERENCE (JUN 1988) (FAR 52,252-1 8 _ GTMIM HIS CONTRACT INCORPORATES THE _ _ If quantity accepted by the Government is same as 1 24. NITED STATES OF AMERICA 25. TOTAL 1 quantity ordered, indicate by X. If different, enter T�� YY �' 9/ 29. actual quantity accepted below quantity ordered and encircle. ' Ow T OFFICER BY,CONTRACTING CONTRACTING/ORDERINGOFFICER DIFFERENCES 26. QUANTITY IN COLUMN 20 HAS BEEN 27. SHIP, NO. 28. D.O. VOUCHER NO, 30. AND CONFORMS O THE INSPECTED ❑RECEIVED Ej ACCECONTRACT EXCEPT AS NOTED INITIALS ❑ PARTIAL 32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR E] FINAL DATE SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 31. PAYMENT COMPLETE 34. CHECK NUMBER 36.1 cer5fy this account is correct and proper for payment ❑ PARTIAL 35. BILL OF LADING NO, DATE SIGNATURE AND TITLE OF CERTIFYING OFFICER 1:1 FINAL 37. RECENED AT 1 38. RECEIVED BY 39. DATE RECEIVED 40. TOTAL CONTAINERS 41. S/R ACCOUNT NUMBER 42 5/R VOUCHER NO. DD Form 1155, MAY 90 Previous editions are obsolete. 459/122