A002 CDRL CoC - 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.

A002

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

8. APPCODE

N/A

11. As of

Date

N/A

13. Date of Subsequent

Submission

As Req

Address Draft Reg Repr

16. Remarks fred.e.haggar.civ@us.

navy.mil

Block 4: Contractor Format is acceptable. Use DI-NDTI-80809B for guidance. Jeffery.a.glines.civ@us.nav y.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:

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

Jeffery Glines at Jeffery.a.glines.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:fred.e.haggar.civ@us.navy.mil mailto:Jeffery.a.glines.civ@us.navy.mil mailto:Jeffery.a.glines.civ@us.navy.mil mailto:Jeffery.a.glines.civ@us.navy.mil