12024B18R9006_Attachment_6_12-18-2017.pdf

Solicitation No. 12024B18R9006 US Forest Service National Long-Term Fire Retardant National Office

Attachment 6 – Exhibit J-4 Cumulative Retardant Use/Payment Summary

J4 - 1

1. FOREST/UNIT

2. BASE 4. CONTRACT NO., BID

ITEM

5. CONTRACTOR

6. INCLUSIVE DATES THIS

PERIOD

PAYMENT NO.

7. GALLONS USED THIS PERIOD (from attached worksheet)

CATEGORY A GALS @ $ /GALS = $

CATEGORY B GALS @ $ /GALS = $

CATEGORY C GALS @ $ /GALS = $

CATEGORY D GALS @ $ /GALS = $

TOTAL $

8. MISCELLANEOUS SERVICES

A OFF-LOAD @ $ 40.00 = $

B RELOAD @ $ 20.00 = $

C LOAD WATER @ $ 20.00 = $

D EXTENDED HOURLY @ $ 20.00 = $

*E CALL-UP GUARANTEE @ $ 250.00 = $

*F MOBILIZATION/DEMOBILIZATION Actual cost, attach itemization)= $ G. OTHER SERVICES Mixed Prices $

*Applicable during pre, post, and optional periods TOTAL $

9. DEDUCTIONS/CREDITS THIS PERIOD

CORRECTION FOR GAL @ $ = $

RETARDANT OUT GAL @ $ = $

OF SPECIFIC GAL @ $ = $

GRAVITY GAL @ $ = $

10. TOTAL PAYMENT THIS INVOICE

TOTAL $

11. RETARDANT AND PAYMENT SUMMARY

PREVIOUS TOTAL THIS PAYMENT TOTAL TO DATE

GALLONS AMOUNT GALLONS AMOUNT GALLONS

AMOUNT

RETARDANT $ $ $

MISC SERVICES $ $ $

TOTALS $ $ $

12. GROSS TOTAL PAID TO DATE

13. APPROVED FOR THE UNITED STATES OF

AMERICA

COR Signature and Date

14. APPROVED FOR THE CONTRACTOR

Signature and Date (Optional)