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Form approved PAGE 1of ORDER FOR SUPPL M OR SERVICES CMB No.0704-0187 **** 1 (Contractor must submit four copies of invoice.) LLK Expires Dec 31,1993 Public reporting burden for this collection of information is estimated to average 1 hour per response,including the time for reveiwing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to Department of Defense,Washington Headquarters Services,Directorate for Information Operations and Reports,1215 Jefferson Davis Highway,Suite 1204, Arlington,VA,22202.4302,and to the Office of Management and Budget,Paperwork Reduction Project(0704-0187),Washington,DC 20503. PLEASE DO NOT RETURN YOUR FORM TO EITHER OF THESE ADDRESSES SEND YOUR COMPLETED FORM TO THE PROCUREMENT OFFICAL IDENTIFIED IN ITEM 6. 1.CONTRACT/PURCH ORDER NO. 2.DELIVERY ORDER NO. 3.DATE OF ORDER 4.REQUISITION/PURCH REQUEST NO. 5.PRIORITY (YYMMMDD) SP310001PO450 101 FEB 12 10393076 6.ISSUED BY CODE SP310 0 7.ADMINISTERED BY(if other than 6) CODE DEFENSE DISTRIBUTION CENTER 8.DELIVERY FOB PROCUREMENT OFFICE DDC-J1-A X DEST 2001 MISSION DR BLDG 81 OTHER NEW CUMBERLAND PA 17070-5001 See Schedule if other 9. CONTRACTOR CODE FO 0 0 0$ FACILITY CODE 10.DELIVER TO FOB POINT BY (Date) 11.MARK IF BUSINESS IS O • (YYMMMDD) 01 FEB 28 }( SMALL SMALL PHS/EHR - SAN JOAQUIN CTY VANTAGI 12.DISCOUNT TERMS VANTAGSAD- ED NAMEAND ENVIRONMENTAL HEALTH DIV WOMEN-OWNED ADDRESS 304 E. WEBER AVE, 3RD FL 13.MAIL INVOICES TO STOCKTON CA 95202 SEE BLOCK 15 14. SHIP TO CODE SB320 0 15.PAYMENT WILL BE MADE BY CODE I BELOW MARK ALL DEF DIST CENTER SAN JOAQUIN SEE BLOCK 19 PPAPERS AND WITH SUPPLY BRANCH SUPPLIES/SERVICES CONTRACTOR WHSE 3 TRACY SITE (SB3200) ORDER NUMBER TRACY CA 95376-5000 16. DELIVER This delivery order is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract. TYPE furnish the following on terms specified herein. OF Reference your ORDE PURCHASE X ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE BEEN OR IS NOW MODIFIED,SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH,AND AGREES TO PERFORM THE SAME. NAME OF CONTRACTOR SIGNATURE TYPED NAME AND TITLE DATE SIGNED ❑ If this box is marked,supplier must sign Acceptance and return the following number of copies: (YYMMDD) 17 ACCOUNTING AND APPROPRIATION DATA/LOCAL USE 01 97X4930.5BEO 00193 P900 25 S33181 $651.00 20. QUANTITY 21. 22. 23. B. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICE ORDERED/ UNIT UNIT PRICE AMOUNT DOCUMENT NOUN NSN/MFG-PART-NUM ACC 0001 10393076 PAYMENTS 99990OT330978 01 1 EA $651.0000 $651.00 UNDERGROUND STORAGE TANK FEES, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ACCOUNT ID AR0003584, FACILITY ID FA0003966 (SHARPE SITE) , INVOICE #IN0079236. WILL BE PAID BY GOVERNMENT IMPAC CHECK. PROMPT PAYMENT (JUN 1997)FAR 52.232 I - A I I - If quantity accepted by the government is same as r24 ;ErDATE'ROF AMERICA 25.TOTAL $651.00 quantity ordered,indicate by X. If different,enter Ye,actual quantity accepted below quantity ordered and DIFFERENCESencircle CONTRACTING/ORDERING OFFICER 26.QUANTITY IN COLUMN 20 HAS BEEN 27. SHIP.NO. 28. D.O.VOUCHER NO. 30. ® INSPECTED ®RECEIVED ❑TACCEPTED AND HE CONTRACT EXCEPT TAS NOTED NFORMS TO INITIALS ®PARTIAL 32. PAID BY 33.AMOUNT VERIFIED CORRECT FOR ®FINAL DATE SIGNATURE OF AUTHORIZED GOVERNMENT OFFICIAL 31. PAYMENT 34.CHECK NUMBER 36.1 certify this account is correct and proper for payment. ®COMPLETE ®PARTIAL 35.BILL OF LADING NO. s DATE SIGNATURE AND TITLE OF CERTIFYING OFFICER ®FINAL 37. RECEIVED AT 1 38.RECEIVED BY (Print) 39.DATE RECEIVED 40.TOTAL CONTAINERS 141. S/R ACCOUNT NUMBER 42.S/R VOUCHER NO. (YYMMMDO) 7 FORM 1155,APR 93(EF) PREVIOUS EDITION MAY BE USED 460/361