A001 CDRL CoC-MQ-4C-TSAS ANR-GNR_Troubleshoot Cable Set - PN 4106AS0481_0485.doc

DD FORM 1423-1, JUN 09 PREVIOUS EDITIONS ARE OBSOLETE PAGE (1) OF (1) 10 June 2009

Public reporting burden for this collection of information is estimated to average 110 hours per response, including the time for reviewing 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 HWY, Suite 1204, Arlington VA, 22202-4302, and to the Office of Management and Budget, Paperwork Reduction Project (0704-01880, Washington, DC 20503. Please Do Not Return your form to either of these addresses. send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in block E.

A. Contract Line Item No.

TBD

B. Exhibit

A C. Category: TDP ( ) TM( ) Other ( XX )

D. System/Item

MQ-4C-TSAS, ANR-GNR & Troubleshoot Cable Set, PN 4106AS0481-1 & 4106AS0485-1 E. Contract/PR No.

TBD

F. Contractor

TBD

1. Data Item No.

A001

2. Title of Data Item

Test/Inspection Report

3. Subtitle

Certificate of Conformance (CoC)

4. Authority (Data ID No.)

DI-NDTI-80809B See Block 16

5. Contract Reference

SOW Para. 2.4

6. Requiring Office

NAVAIR LKE, UAS SE BR, BL24100

7. DD 250 REQ

LT

9. Dist. Statement Req.

N/A

10. Frequency

AS REQ

See Block 16

12. Date of first submission

As Req

14. Distribution

See Block 16

8. APPCODE

N/A See Block 16

11. As of Date

N/A

13. Date of Subsequent Submission

As Req

michael.a.moncayo.civ@us.navy.mil

Block 10: The Contractor shall provide a Certificate of Conformance (COC) with each shipment certifying that each item within the lot conforms to the government drawing package, this SOW, and the requirements of the contract. The COC shall be on company letterhead and signed by management. Each COC shall identify the part numbers and quantities delivered with each shipment.

Block 14: Delivery Media: Distribution of data shall conform to Electronic Media

Compatible with MS Word or MS-Excel or PDF. Certificate of Conformance (COC)

Certificates shall also be delivered to:

Roger Ding at roger.ding.civ@us.navy.mil

Jeffery Glines at Jeffery.a.glines.civ@us.navy.mil

Mike Moncayo at michael.a.moncayo.civ@us.navy.mil

TOTAL

G. Prepared By

Jennifer M. Etri H. Date

I. Approved By

Adam M. Smiga J. Date