COMPLIANCE INFO_1991-2000 - Laserfiche WebLink

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w _4 �~ y ORDER FORS IES OR SERVICES Form Approved PAGE , OF (Contractor must submit four collies of invoice.) LP OMB No. 0704-0187 Expires Aug 31, 1992 4 Publicreporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and mainta rung the data needed, and co leting and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, inc kAing suggestions for reducing this burden, to 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 official identified in item 6. 1. CONTRACT/ PURCH ORDER NO. 2. DELIVERY ORDER NO. 3. DATE OF ORDER 4. REQUISITION / PURCH REQUEST NO. 5. CERTIFIED FOR NA- DLA00891P1883. 12 JUN 91 11233037 TONAL DEFENSE UNDER DMS REG 1 6. ISSUED BY a ♦ A CODE DEFENSE DISTR. REGION WES7 7. ADMINISTERED BY (If other than 6) CODE DO DIRECTORATE OF CONTRACTING 8. DELIVERY FOB n DEST SHARPE SITE B Did S-4 D OTHER LATHROP CA 95331.5100 (See schedule if other) 9. CONTRACTOR CODE FACILITY CODE 10. DELIVER TO FOB POINT BY (Date) 11. MARK IF BUSINESS 15 • • 19 JUL 91 © SMALL INTEGRITY TANK TESTIN412. ❑ SMALLDISAD- DISCOUNT TERMS NAME AND r I ADDRESS SYSTEMS NC '• NET 30 DAYS VANTAGED EJWOMEN-OWNED 166 FRANK WEST CIRCLE 13. MAIL INVOICES TO ISEE BLOCK 15 • STOCKTON CA 96306 14. SHIP TO 91PI883CODE 15. PAYMENT WILL BE MADE BY CODE ENVIRONMENTAL PROGRAM OFF DLA FINANCE CENTER MARK ALL DDRW-SHARPE SITE ATTN : DFC-AETWA PACKAGES AND LATHROP CA 95331 , P.O. BOX 182317 PAPERS WITH CONTRACTOR COLUMBUS OHIO 43218_2317 ORDER NUMBER 16. DELIVERY This delivery order is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract. TYPE Reference our OF PURCHASE Y furnish the following on terms specified herein. ORDER 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 Elff this box is marked, supplier must sign Acceptance and return the following number of copies: 17. ACCOUNTING AND APPROPRIATION DATA/ LOCAL USE 01 9710100 5132 001 900 25 533181 4350.0 18. ITEM NO. 19. 1 SCHEDULE OF SUPPLIES/ SERVICE 20. QUANTITY ORDERED/ 21. UNIT 22. UNIT PRICE 23. AMOUNT ACCEPTED* 0001 1233037"USTTERSTING 76990OT209473 01 1 JO 4350.0000' 4350.00 OB SERVICE NON PERSONAL.: PROVIDE ALL. TERIALA;JEQUIPMENT, LABOR, AND , UPERVISION''TO PERFORM UNDERGROUND TORAOE,TAW INTEGRITY TESTING IN CCORDANCE WITH ATTACHED STATEMENT OF ORK. LOCATION: DDRW SHARPE SITE GAS . TATtONo 'LATHROP CA. TANKSi 4 - 20000 AL C i- VIESEW 3 -GASOLINE) AND 3 12000,GAL (2-DIESELi 1 -GASOLINE). -IPERFORMANCEPERIOD IS,30..CALENDAR If quantity accepted by the Government is same as 'different, 24. UNITED STATES OF AMERICA 25. TOTAL quantity ordered, indicate by X. If enter 29. actual quantity accepted below quantity ordered and f to tt CONTRACTING OFFICER encircle. BY: CONTRACTING/ORDERINGOFFICER DIFFERENCES 26. QUANTITY NJ COLUMN 20 HAS BEEN 27. SHIP. NO. 28. D.O. VOUCHER NO. 30. INSPECTED RECEIVED TAASORMS TO THE ❑ CONTRACT EXCEPT NOTED INITIALS ❑ PARTIAL 32. PAID BY 33. AMOUNT VERIFIED CORRECT FOR ElFINAL DATE SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE 31. PAYMENT El COMPLETE 34. CHECK NUMBER 36.1 certify this account is correct and proper for payment 11 PARTIAL 35. BILL OF LADING NO. DATE SIGNATURE AND TITLE OF CERTIFYING OFFICER FINAL RECEIVED AT 1 F 38. RECEIVED 8Y 39. DATE RECEIVED 40. TOTAL CONTAINERS 41. S/R ACCOUNT NUMBER 42. S/R VOUCHER NO. uu rorm 1 1», MAT tfV Previous editions are obsolete. 459/122