A001 CDRL Proof Load and NDI Certs-MQ-4C-Adjustable Table Top Assembly-PN 4106AS0630-1-27Jun2022.pdf

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

CONTRACT DATA REQUIREMENTS LIST (1 Data Item) FORM APPRVD OMB No. 0704-0188 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 - Adjustable Table Top Assembly - PN

4106AS0630-1

E. Contract/PR No.

F. Contractor

1. Data Item No.

A001

2. Title of Data Item

Test/Inspection Report

3. Subtitle

Proof Load Certificates & Non-Destructive Inspection Certificates

4. Authority (Data ID No.)

DI-NDTI-80809B See Block 16

5. Contract Reference

SOW Para. 2.3

6. Requiring Office

NAVAIR LKE, UAS SE BR, BL24100

7. DD 250 REQ

LT

9. Dist. Statement

Req.

D

10. Frequency

AS REQ

See Block 16

12. Date of first submission

14. Distribution

8. APPCODE

N/A

11. As of

Date

N/A

13. Date of Subsequent

Submission

See Block 16

Address D r a ft

Re g

Repr

16. Remarks Michael.s.horvath.civ@us.navy.m il

Block 4: Contractor Format is acceptable. Use DI-NDTI-80809B for guidance. fred.e.haggar.civ@us.navy.mil 1

Block 9: Use Distribution Statement D. Distribution authorized to DoD and DoD.

Contractors only, (30 January 2007) other U.S. requests shall be referred to Code 13400B

Block 10: A Proof Load Certificate (also need for COTS items) and non-Destructive

Inspection (NDI) Certificate shall be provided for each unit in accordance with applicable drawings, SOW and specifications. Frequency will coincide with actual hardware deliveries.

Block 12: A copy of the Proof Load Certificate and NDI Certificate shall be shipped with each item. They shall be secured to the item using a plastic bag/pouch/envelope or a temporary fastening device such as a zip tie.

Block 13: An electronic copy of each Proof Load and NDI Certificate shall be submitted within 15 days of actual hardware delivery for each production unit.

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

Compatible with MS Word or MS-Excel or PDF. Proof Load Certificates shall be delivered to:

Michael Horvath at Michael.s.horvath.civ@us.navy.mil

Fred Haggar at fred.e.haggar.civ@us.navy.mil

TOTAL 3

G. Prepared By

Cindy Stransky

H. Date

I. Approved By

Nancy McQuillan

J. Date

17. Price Group 18. Estimated Total Price:

mailto:Michael.s.horvath.civ@us.navy.mil mailto:fred.e.haggar.civ@us.navy.mil mailto:fred.e.haggar.civ@us.navy.mil