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ORDER FOR SUPPLI�., OR SERVICES Form approved <br />L <br />31, 193 <br />Contractor must submit four copies of invoice. zLx �Expires Dec31, 1993 <br />p CMB No. Dec <br />>t� l�E' <br />� <br />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 <br />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 inf n, including <br />suggestions for reducing this burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operations Reports, 1215 Jefferson Davis Hi� 1204, 2001 <br />and y$uite <br />Arlington, VA, 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project(0704-0187), Washington, DC 20503. <br />PLEASE DO NOT RETURN YOUR FORM TO EITHER OF THESE ADDRESSESSANJUAUUINCOUNTY <br />SEND YOUR COMPLETED FORM TO THE PROCUREMENT OFFICAL IDENTIFIED IN ITr�`EMEFGENCYSERW <br />1. CONTRACT/PURCH ORDER NO. <br />2. DELIVERY ORDER NO. <br />3. DATE OF ORDER 4. <br />REQUISITION/PURCH REQUEST NO. <br />5. PRIORITY <br />SP310001PO852 <br />101DO) <br />�T05 <br />11293054 <br />6. ISSUED BY CODE SP3100 7. <br />ADMINISSTTEE�IRED BY (if other than 6) CODE <br />DEFENSE DISTRIBUTION CENTER <br />B. DELIVERY FOB <br />PROCUREMENT OFFICE DDC -JI -A <br />]{ DEST <br />2001 MISSION DR BLDG 81 <br />OTHER <br />NEW CUMBERLAND PA 17070-5001 <br />See Schedule if Other <br />9. CONTRACTOR CODE F0 0 0 6 5 FACILITY CODE <br />10. DELIVER TO FOB POINT BY (Dale) <br />11. MARK IF BUSINESS IS <br />. • <br />(-...DD) 01 JUN 11 <br />X SMALL <br />OFFICE OF EMERGENCY SERVICES <br />SMALLDISAD- <br />12. DISCOUNT TERMS <br />NAME AND ROOM 610, COURTHOUSE <br />VANTAGED <br />WOMEN -OWNED <br />ADDRESS 222 E. WEBER AVE. <br />13. MAIL INVOICES TO <br />STOCKTON CA 95202 <br />• <br />SEE BLOCK 15 <br />14. SHIP TO CODE SB3 2 0 0 15. <br />PAYMENT WILL BE MADE BY CODE BELOW <br />MARK ALL <br />DEF DIST CENTER SAN JOAQUIN <br />SEE BLOCK 19 <br />PACKAGES AND <br />PAPERS WITH <br />SUPPLY BRANCH <br />SUPPLIES/SERVICES <br />CONTRACTOR <br />WHSE 3 TRACY SITE (SB3200) <br />ORDER NUMBER <br />TRACY CA 95376-5000 <br />16. <br />DELIVER This delivery order is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract. <br />TYPE <br />OF Reference your furnish the following on terms specified herein. <br />ORDE PURCHASE X <br />ACCEPTANCE. THE CONTRACTOR HEREBY ACCEPTS THE OFFER REPRESENTED BY THE NUMBERED PURCHASE ORDER AS IT MAY PREVIOUSLY HAVE <br />BEEN OR IS NOW MODIFIED, SUBJECT TO ALL OF THE TERMS AND CONDITIONS SET FORTH, AND AGREES TO PERFORM THE SAME. <br />NAME OF CONTRACTOR SIGNATURE TYPED NAME AND TITLE DATE SIGNED <br />If this box is marked, supplier must sign Acceptance and return the following number of copies: (YYMMDD) <br />17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE <br />01 97X4930.5BE0 00193 P900 25 533181 $701.73 <br />8' ITEM NO. <br />19. SCHEDULE OF SUPPLIES/SERVICE <br />20. QUANTITY <br />ORDERED/ <br />21. <br />UNIT <br />22. <br />UNIT PRICE <br />23. <br />AMOUNT <br />DOCUMENT NOUN NSN/MFG-PART-NUM ACC <br />0001 <br />11293054 PAYMENT 99990OT340378 01 <br />1 <br />EA <br />$690.0000 <br />$690.00 <br />FEES PAYMENT TO OFFICE OF EMERGENCY SERVICES, <br />HAZARDOUS MATERIALS PROGRAM/HEALTH AND SAFETY <br />CODE CHAPTER 6.95. ACCO NO. 7711 (TRACY SITE) <br />PAID BY GOVERNMENT IMPAC CHECK. <br />MISC. CHARGE 0 <br />$11.73 <br />PROMPT PAYMENT (JUN 1997)FAR 52.232-25 <br />- If quantity accepted by the government is same as <br />24. UNITED STATES OF AMERICA <br />25. TOTAL <br />$701.73 <br />quantity ordered, indicate by X. If different, enter <br />29' <br />actual quantity accepted below quantity ordered and <br />DIFFERENCES <br />encircle <br />BY: LINDA L KLINEDINST CONTRACTING/ORDERING OFFICER <br />26. QUANTITY IN COLUMN 20 HAS BEEN <br />27. SHIP. NO. <br />28. D.O. VOUCHER NO. <br />30. <br />❑ INSPECTED ❑ RECEIVED ❑ ACCEPTED AND CONFORMS TO <br />INITIALS <br />THE CONTRACT EXCEPT AS NOTED <br />PARTIAL <br />32. PAID BY <br />33. AMOUNT VERIFIED CORRECT FOR <br />FINAL <br />DATE SIGNATURE OF AUTHORIZED GOVERNMENT OFFICIAL <br />31, PAYMENT <br />COMPLETE <br />34. CHECK NUMBER <br />36. 1 certify this account is correct and proper for payment. <br />❑ PARTIAL <br />NO. <br />DATE SIGNATURE AND TITLE OF CERTIFYING OFFICER <br />FINAL <br />35. BILL OF LADING <br />37. RECEIVED AT <br />38. RECEIVED BY (Print) <br />39. DATE RECEIVED <br />40. TOTAL CONTAINERS <br />41. S/R ACCOUNT NUMBER <br />42. S/R VOUCHER NO. <br />1 <br />WMMMDD) <br />DD FORM 1155, APR 93 (EF) PREVIOUS EDITION MAY BE USED 460/361 <br />