Attachment 1_PWS.pdf

ATTACHMENT 1

Performance Work Statement

U.S. DEPARTMENT OF ENERGY

WESTERN AREA POWER ADMINISTRATION

PERFORMANCE WORK STATEMENT

EMERGENCY GENERATOR MAINTENANCE

1. General

1.1. Scope of Work

The Western Area Power Administration (WAPA), Sierra Nevada Region (SN), requires a Contractor to perform generator maintenance, in accordance with manufacturer’s recommendations, at various locations within the SN services territory to ensure that the emergency generators are always available. There are nine (9) units distributed at seven (7) locations that need annual maintenance.

WAPA, SN and the Government are used interchangeably in this document, and all have the same meaning.

1.2. Background

WAPA, part of the U.S. Department of Energy (DOE), is a Federal power marketing administration that markets and delivers reliable, cost-based hydroelectric power and related services. SN region serves customers in California and Nevada. SN’s mission includes maintenance and operation of the high-voltage transmission system, including substations and high-voltage power transmission lines that deliver power to its customers. It is critical that the WAPA emergency generators used at various places are maintained in optimal condition.

1.3. Location

SN (headquartered at 114 Parkshore Drive, Folsom, California, 95630) is responsible for a geographic service territory that includes central and northern California and parts of Nevada.

Although most services will be provided within 75 miles of Redding and Sacramento, CA, the contract requires performance and travel throughout all SN’s service territory. Work at project sites may require traveling through steep, uneven terrain. See PWS Exhibit 1, Generator Inventory.

Verify location of the mobile generators with the Technical Point of Contact (POC) before scheduling service and service on current location.

1.4. Government Personnel

1.4.1. The Contracting Officer (CO) is the individual executing this contract on behalf of the

Government and is responsible for the overall administration of the contract. He/she is the only person authorized to make any changes in the prices, terms, or other conditions of the contract.

1.4.2. The CO or Technical POC are responsible for giving the Contractor any special technical instructions or guidance necessary to ensure contract execution. The Technical POC has no authority to alter the terms of conditions of the contract.

1.5. Contractor Personnel

1.5.1. The Contractor shall furnish adequate supervision at the site to ensure that work is performed in a satisfactory manner. It is the responsibility of the Contractor to maintain close surveillance over personnel employed to perform work on the contract.

1.5.2. The Contractor shall have a competent on-site representative authorized to act on behalf of the Contractor, available to the CO or Technical POC to receive instructions or information regarding work under the contract. The on-site representative must be able to fluently speak, write and understand English.

1.5.3. No unauthorized personnel are permitted on the premises.

1.6. Period of Performance

The contract period of performance is April 1, 2022 through December 31, 2022 for the base year and January 1 to December 31 for each option year. There will be a total of four optional years available.

1.7. Hours of Work

1.7.1. SN normal business hours are 7:30 a.m. to 4:30 p.m., Tuesday through Friday, excluding Federal holidays. Contractor work may be authorized outside normal business hours on a case-by-case basis with prior approval from the CO.

1.7.2. Contractor is responsible for coordinating with the Technical POC for all site visits necessary to perform the work of the contract.

1.7.3. Federal Holidays: Unless specifically negotiated, the Contractor is not required to provide service on New Year’s Day (1 January), the birthday of Martin Luther King Jr. (3rd Monday in January), Washington’s Birthday (3rd Monday in February), Memorial Day (last Monday in May), Independence Day (4 July), Labor Day1st Monday in September), Columbus Day (2nd Monday in October), Veterans Day (11 November), Thanksgiving Day (4th Thursday in November), or Christmas Day (25 December). If the holiday falls on Saturday, it is observed the preceding Friday. If the holiday falls on a Sunday, it is observed on the subsequent Monday.

1.7.4. The Contractor may be called out 24/7 during non-business hours, nights, weekends, or holidays to repair or service emergency generator systems. Contractor must be capable of responding within two (2) to four (4) hours of a service call.

1.8. Deliverables / Submittals.

1.8.1. All deliverables and submittals shall be provided via electronic means to the Technical

POC for review and approval. The Government requires ten (10) business days for review of each deliverable/submittal.

1.8.2. Safety Plan. The Contractor must submit a Safety Plan to the Government CO and Technical POC no later than 10 calendar days after contract award. WAPA’s approval of the plan is required prior to work commencement. The safety plan shall meet California OSHA and industry standards.

1.8.3. List of Employees. Contractor shall furnish names of all personnel performing work on this contract no later than 10 calendar days after contract award. No unidentified or unauthorized personnel shall be allowed or permitted on the work site.

1.8.4. Work Schedule. This contract is a base year plus four option years. For the base year and each subsequent option year the Contractor shall submit a proposed work schedule to the Technical POC no later than 10 calendar days after contract or option year award. WAPA’s approval of the work schedule is required prior to work commencement. Changes in the proposed schedule shall be coordinated and approved by the Technical POC.

1.8.5. Safety Data Sheets. Prior to beginning work, the Contractor shall provide WAPA with a list of all Chemicals and a Safety Data Sheet (SDS) for chemicals that will be used. WAPA shall reserve the right to refuse the Contractor use of a specific chemical if it poses an excess risk or would require additional training of WAPA employees.

1.8.6. Pollutant Spill Prevention Notification and Clean-up Plan. The Contractor must submit a Pollutant Spill Prevention Notification and Clean-up Plan to the Government CO and Technical POC no later than 10 calendar days after contract award. WAPA’s approval of the plan is required prior to work commencement.

1.8.7. Service Log. Maintain a written service log for each location, by facility, building/unit number that documents date of Preventive Maintenance (PM) service and corrections/repairs made. At the conclusion of annual PM services, provide a report to the Technical POC of all PM performed.

1.8.8. Include in the proposal, a resume or other documentation, not to exceed two pages in length, indicating the Contractor/on-the job technicians have:

1.8.8.1. A minimum five (5) year experience servicing a wide variety of emergency generator systems.

1.9. Pre-Performance Meeting

The Technical POC will schedule a meeting with the Contractor within 2 weeks following the contract award to discuss the requirements of the contract, prior to start of work. The attendees could include Safety and Environment.

1.10. Quality Control and Quality Assurance

1.10.1. The Contractor is responsible for quality control and shall utilize its own internal quality control processes in the performance of this contract. The Contractor shall develop and maintain a Quality Control Plan (QCP) to ensure all services are performed in accordance with the Government’s PWS, including the performance standards outlined in the Performance Requirements Summary (PRS) section of this PWS.

1.10.2. Performance Standards. See Exhibit 2. The PRS is a listing of significant performance objectives with associated performance standards that will be monitored and inspected by Government personnel. Each performance objective represents a critical function as identified by the Government at the time of contract award. The performance standard represents the minimum acceptable level of Contractor performance. The performance objectives and standards represent only the critical components of this Contract, and do not excuse the Contractor from performance of other responsibilities identified in the PWS. All services described in this PWS are subject to inspection/surveillance by the Government.

1.10.3. Government Surveillance of Contractor Performance. To supplement the Contractor’s

QCP, WAPA personnel will verify Contractor compliance with essential performance requirements. The Government may use various methods to perform surveillance of Contractor performance, including customer input, random sampling, periodic inspection, Contractor reporting, etc.

1.10.4. Contract Discrepancy Report (CDR). A CDR (PWS Exhibit 3) will be initiated by the

CO or Technical POC if, at any time during the performance, the results of WAPA’s surveillance show the number of observations of unacceptable performance during the period exceeds the threshold specified in the PRS, and the CO/Technical POC determines that the unacceptable performance was not caused by the Government. Instructions for completing the CDR are as follows:

1.10.4.1. The Technical POC completes Blocks 1 through 6 and sends the form to the CO.

Block 6 must include the PRS number corresponding to the discrepancy, the threshold of that PRS item, the number of discrepancies documented, and the PWS paragraph reference describing the Government’s expectations for that PRS item.

1.10.4.2. The CO evaluates the CDR, and if appropriate, signs it and sends it to the

Contractor with a cover letter requesting a response within a specified number of days.

1.10.4.3. The Contractor must complete Blocks 7 through 10 and return the CDR to the CO within the specified time on the cover letter.

1.10.4.4. Upon receipt of the Contractor’s response, the CO, in consultation with the Technical POC, will evaluate the Contractor’s response and take appropriate action.

The CO will document the evaluation in Block 11 and action taken in Block 12.

1.10.4.5. In most cases, the preferred action is re-performance by the Contractor at no additional cost to the Government. If deduction from payment is the appropriate action, the Technical POC and CO will calculate the payment deduction based on the performance period in which the discrepancy occurred. The deduction is taken from the Contractor’s payment as close as possible to the month in which the discrepancy occurred, but not necessarily the same month. The Government should not withhold payment of an invoice while calculating the deduction.

1.10.4.6. The Technical POC will complete Blocks 13a and 13b. The CO signs the CDR in

Block 13c. These signatures indicate concurrence with the actions taken.

1.10.4.7. In the event the CO determines that issuance of a CDR is not appropriate; the CO shall document the contract file indicating why such action is not appropriate.

1.11. Compliance with Regulations

In performing the work required by this Contract, the Contractor shall comply with all applicable Federal, State, and local laws and regulations.

1.12. Licenses and Permits

The Contractor shall obtain and maintain, at its sole expense, all necessary licenses and permits required to meet the requirements of the contract.

1.13. Materials, Equipment and Storage

1.13.1. The Contractor shall furnish all materials, supplies and incidentals required for the performance of work under this contract.

1.13.2. The Contractor shall determine and furnish all tools and equipment required for the performance of the work under this contract. All equipment shall comply with applicable OSHA guidelines and shall be in good operating condition. The Contractor shall operate the equipment in accordance with the original manufacturer’s recommendation and applicable laws and regulations.

1.13.3. The Contractor shall provide off-site storage space for its materials and equipment.

Materials and equipment shall not be stored on WAPA property.

1.14. Interference with Business

The Government may undertake or award other contracts for additional work, and the Contractor shall fully cooperate with such other Contractors and Government employees and carefully schedule its own work to such additional work as may be directed by the Technical POC. The Contractor shall not commit or permit any act that will interfere with the performance of work by any other Contractor or by Government employees.

The services under this contract shall be performed in such a way that there will be no interruption to or interference with the normal operation of Government business on the premises. Persons employed by the Contractor shall, while on the premises, comply with all applicable regulations.

1.15. Government Furnished Property, Equipment, Materials and Utilities

1.15.1. The Government will not furnish any property, equipment, or materials for use under this

1.15.2. The Government will provide electrical power at sites with existing power outlets for the operation of equipment as necessary to perform services. Contractor shall furnish and provide power for those sites without electrical power.

1.15.3. The Government will provide water at sites where it is available from an existing outdoor source. Contractor shall furnish and provide water for those sites without existing water.

1.15.4. Sanitation facilities are available at some sites.

1.16. Security of Facilities

Security of Government facilities is a shared responsibility of all employees, both Federal and Contractor.

1.16.1. No Contractor or Subcontractor employee shall be allowed to work under this contract without prior approval being obtained from WAPA. This includes management personnel visiting sites.

1.16.2. Prior to being granted access to information such as technical system or architectural drawings, Contractor employees may be required to execute a Confidentiality and Nondisclosure Agreement with WAPA. Failure to execute this agreement shall be grounds for requesting removal from performance on this contract.

1.16.3. All information related to this contract is property of the Government and as such, must be safeguarded. This information may only be disclosed to Contractor personnel directly involved in the program management, administration, servicing, or installation and shall not be released to anyone without the express written consent of WAPA or the originator of the information.

1.16.4. Contract personnel will conform to Federal requirements to ensure that workers are US citizens. If a foreign national is required to be at the work site, the Contractor (to include any subcontractors) will have advance approval from WAPA’s Personnel Security Office.

A Foreign National Data Card request will be submitted 45 days prior to the start date of the individual and access will only be granted after final approval of this request.

1.16.5. Contractor personnel shall notify the CO, Technical POC and SN Safety/Security Office, or on-duty Contractor security staff after hours, if they have any security issues or concerns.

1.16.6. The Government may require immediate removal of the employee from the contract and the job site for conduct issues deemed by the Government to be serious (for example, violent behavior or comments, theft, misuse of Government equipment, unsafe work practices, fraudulent activity, etc.).

1.17. Safety and Safety Plan

1.17.1. The Contractor shall comply with the latest effective standards promulgated by the

Department of Labor, Occupational Safety and Health Administration, Safety and Health Standards, 29 CFR 1910 and 29 CFR 1925, and shall comply with all applicable safety and health regulations and requirements, including DOE and WAPA requirements.

1.17.2. The Contractor shall take all reasonable precautions in the performance of the work under this contract to protect the safety and health of employees and members of the public and shall comply with all applicable safety and health regulations and requirements, including DOE and WAPA requirements.

1.17.3. The Contractor shall maintain an accurate record of and shall immediately report to the

CO and the Technical POC, all cases of death, occupational disease, or traumatic injury to employees or the public, and any property damage because of performance under this

1.17.4. The Contractor shall report all near misses to the CO and Technical POC within 24 hours of the occurrence. These near-miss reports, identifying the nature of the hazard and the corrective actions which have been implemented to prevent a reoccurrence in the future, may be generic, with no mention of individual employees involved in the incident. Near-miss reports are used as an information tool and are distributed regionally.

1.17.5. The Contractor shall ensure that its employees are provided with personal protective equipment (PPE) as necessary in accordance with established regulations and procedures.

This equipment includes, but is not limited to, occupational foot protection and eye and face protection as required by OSHA Standards, 29 CFR 1910 and as required by WAPA safety standards and directives.

1.17.6. The Contractor shall ensure that its employees have been appropriately instructed and trained in the proper use of any equipment, vehicles, and/or personal PPE needed for the performance of their duties. The Contractor shall ensure that its employees comply with all applicable Federal, State, and/or local safety rules and regulations.

1.17.7. The Contractor is required to establish a Safety Plan/Program that includes, in addition to other requirements, an onsite pre-work safety meeting. The plan standard is available to the public at: https://www.wapa.gov/DoingBusiness/SellingToWestern/Pages/what-western-buys.aspx and the safety plan is under Section 1.4.1 of the Construction Standards. The plan shall address the relevant sections, the potential hazards and mitigation of the work being performed.

1.17.8. If a subcontractor is utilized, the subcontractor will be aware of the prime Contractor’s safety plan and adhere to those safety precautions.

1.18. Environmental Requirements

1.18.1. Recycling. All materials generated from the project that can be recycled, shall be recycled. Quantities of recycled and waste materials shall be reported to the Technical POC. The Contractor shall dispose of or recycle hazardous, universal, and non-hazardous waste material in accordance with all applicable Federal, State, and local laws, regulations and ordinances and current policies and procedures identified by WAPA. Wastes shall be reduced by recycling, reusing, or reprocessing to the maximum extent practicable.

1.18.2. Hazardous, Universal, and Non-Hazardous Wastes. The Contractor will manage hazardous, universal, and non-hazardous wastes in accordance with all applicable State, Federal and Local regulations. Hazardous wastes anticipated under this contract include used oil, coolant, and filters. Facilities exist for disposal of these items at Elverta Maintenance Facility and Redding Maintenance Facility. Disposals of all hazardous waste will be coordinated through the Technical POC and the WAPA Environmental office. In the event of a spill, the Contractor shall pay for the services of the hazardous waste disposal contractor of WAPA’s choosing.

1.18.3. Contractor’s Liability for Regulated Material Incidents. All significant (>10 gallon or any amount to surface water) spills shall be reported to the Technical POC and WAPA Environmental. Disposal of waste generated from spill response activities shall be managed according to section 1.17.2. The Contractor is solely liable for all expenses related to spills, mishandling, or incidents of regulated material (such as, but not limited to petroleum products and corrosive materials) attributable to its employees’ actions or the actions of its Subcontractors. In the event of a spill, the Contractor shall pay for the spill contractor, laboratory (and associated turnaround times), and waste disposal contractor of WAPA Environmental choosing. Spill reporting to environmental regulatory agencies, if required, would be performed by WAPA Environmental.

1.18.4. Bird Nests. If active bird nests (i.e., containing chicks or eggs) are found during the replacement process, removal of the nest and any replacement must not occur without approval from WAPA Environmental. In the event active nests are discovered work will stop and the Technical POC will be immediately notified.

1.19. PWS Exhibits

The exhibits listed below are attached to and incorporated into this PWS.

Exhibit 1 Generator Inventory

Exhibit 2 Performance Requirements Summary (PRS). The purpose of the PRS is to communicate the Government’s quality expectations and the process to evaluate the Contractor’s performance.

Exhibit 3 Contract Discrepancy Report (CDR)

2. Scope of Work

Contractor shall provide qualified, trained, skilled personnel for:

2.1. General Requirements

2.1.1. Maintain all emergency generator equipment/systems in working order with Contractor continuously available for repair. For each emergency generator system, the Contractor shall perform annual Preventive Maintenance (PM) inspections and services that include all the tasks identified in PWS section 2.2, 2.3, 2.4, 2.5, and 2.6 designating Preventive Maintenance Checklists for SNR’s regional reliability centered maintenance program (RCM), and other tasks required by manufacturers’ recommended maintenance plans.

2.1.2. Provide continuous availability for unscheduled and emergency repairs of generator systems when requested and approved by the Technical POC.

2.1.3. If minor repairs are identified during the PM, the Contractor must advise the Technical POC of the recommended repair. If approved by the CO and Technical POC, repairs may be made during the PM site visits.

2.1.4. The Contractor should provide recommendations for repair action(s). Recommendations must include site/facility location, building number, inspection date, recommended repairs, and estimated price.

2.1.5. The Contractor must obtain verbal approval from the CO for any repair, replacement, upgrade, or installation estimated to be less than $2,500.00. The Contractor must obtain written approval from the CO for any repair, replacement, upgrade, or installation estimated to be $2,500.00 or more.

2.2. Air Induction and Exhaust System

2.2.1. Air Service Indicator – Inspection and notation of the reading on service indicator (if applicable).

2.2.2. Air Filter – Visual inspection (replace when required and as needed).

2.2.3. Air Inlet System – Inspection of piping/ducting for damage, loose connections and inspect for proper louver or inlet air fan operation (if applicable).

2.2.4. Turbocharger – Visual inspection for signs of wet stacking, exhaust leakage or external damage.

2.2.5. Exhaust Manifold – Inspection for damage, lose or missing hardware and evidence of wet stacking and exhaust leaks.

2.2.6. Exhaust Silencer/After treatment – Visual inspection of overall condition, wet stacking, exhaust leaks, loose, broken, and missing fasteners, and after treatment high back pressure alarms (if applicable). Check for proper rain cap operation or exhaust fan operation.

2.3. Cooling System

2.3.1. Radiator/Heat Exchanger – Visual inspection for leaks, damage, and debris. Inspect louvers for proper operation (if applicable).

2.3.2. Coolant – Inspect for proper level, conditioner level, proper freeze point, and visual inspection for color quality. Inspect radiator cap for signs of leaking, damage, and deteriorating sealing gasket.

2.3.3. Hoses and Connections – Visually inspect hoses and connections for leaks, bulging, collapsing and damaged clamps.

2.3.4. Fan Drive Assembly – Check for proper operation (no slipping) while engine is running and check for signs of slipping on adjacent components. Inspect fan belt for proper tightness and for any wear cracks.

2.3.5. Jacket Water Heater – Check and record temperature and check upper hose for hardening.

Ensure circulation is adequate throughout the engine.

2.3.6. Water Pump – Visual inspection for coolant leaks out of flanges and weep holes.

2.3.7. Temperature Thermostats (regulators) – Infrared analysis before and after the regulators prior to starting engine to check for signs of open thermostats. Run engine and record engine coolant temperature after cooling system has stabilized.

2.3.8. Coolant – Drain coolant, and flush with fresh water (or chemicals if applicable). Replenish cooling system with a new NGEC coolant and purge system of air when full. The Contractor shall coordinate disposal of waste coolants with SNR Environmental.

2.3.9. Hoses and Connections – Replace, as needed, all cooling system hoses including jacket water heater hoses; for all connections using worm-gear clamps replace clamps as needed.

2.3.10. Fan Belts – Replace engine fan belts as needed; after final operational check, check the unit to verify belt tension.

2.4. Fuel System

2.4.1. Filters – Replace engine fuel filters (if applicable).

2.4.2. Laboratory Analysis of Fuel Sample – Diesel fuel analysis shall be performed by a qualified lab to verify that the stored fuel is as clean and dry as practicable and that water, sediment, or microbial growth on the tank bottom is minimized. Any needed corrections shall be performed to ensure the system is within accepted norms. Results of the lab test shall be included in the Service Log.

2.5. Lube Oil System

2.5.1. Oil Level – Check for proper oil level and contamination of oil on level gauge. Check for external oil leaks

2.5.2. Oil Pressure – Check and record engine oil pressure while engine is running if an external gauge exists.

2.5.3. Crankcase Breather – Visual inspection for damage leaks and excessive blow-by while the engine is running.

2.5.4. Oil – Replace engine oil and record level after engine testing (unless approved for extended intervals). The Contractor shall dispose of used oil in accordance with California hazardous waste regulations. The simplest way will generally be to utilize the existing used oil tanks at Elverta Maintenance Facility and Redding Maintenance Facility.

2.5.5. Filters – Replace engine oil filters.

2.6. Resistive - Resistive/Reactive Load Bank Testing

2.6.1. Connect load bank to generator output

2.6.2. Start engine and record baseline readings (Engine: Oil Pres, Water temp, Fuel pressure, RPM, D.C. Voltage, & Exhaust temp.; Generator: A.C. Voltages across all phases, Amperage @ each phase, Frequency, Power, Power Factor, & Ambient temp.)

2.6.3. Apply load to generator at required levels and at required intervals. Monitor unit and recording readings at required intervals for duration of load bank test.

2.6.4. Complete Load Bank Data Sheet and provide copy to Technical POC.

2.7. Air Quality Permit Compliance

2.7.1. The Contractor shall operate the generators in accordance with all permit conditions.

2.7.2. The Contractor shall maintain current copies of the air permits for all equipment at each generator location.

2.7.3. The Contractor shall attend inspections performed by the air district inspectors and shall start the generators for air district inspectors upon request.

2.7.4. The Contractor shall be responsible to report breakdowns or upsets to WAPA

Environmental within 12 hours of the knowledge of such breakdown.

Exhibit 2

PERFORMANCE REQUIREMENTS SUMMARY

Performance Objective PWS Section Performance Standard

General Requirements Contractor will maintain all emergency generator equipment/systems in working order.

2.1.

All emergency generator equipment/systems in working order and verified by Government inspection.

Air Induction and Exhaust Contractor will provide services to inspect for issues and correct all issues. The inspection will include recording service indicator and inspecting air filter, inlet, turbocharger, exhaust, and silencer.

2.2

Air Induction and Exhaust system in excellent condition including air filter, inlet, turbocharger, exhaust, and silencer.

Report including service indicator reading is delivered to Technical POC in report.

Cooling System Contractor will provide services to inspect for issues and correct all issues. The inspection will include radiator/heat exchanger, coolant, hoses & connections, fan drive assembly, jacket water heater water pump, temperature thermostats, and coolant.

Record temperatures for jacket water heater test and temperature thermostat test.

Replace hoses, connections, and fan belts, as needed.

2.3.

Cooling system in excellent condition including radiator/heat exchanger, coolant, hoses & connections, fan drive assembly, jacket water heater water pump, temperature thermostats, and coolant.

Recorded temperatures for jacket water heater test and temperature thermostat test given to Technical POC in report.

Hoses, connections, and fan belts are in excellent condition.

Fuel System Contractor will provide services to inspect for issues and correct all issues. The inspection will include engine fuel filters.

2.4.

Fuel system in excellent condition including engine fuel filters.

Lube Oil System Contractor will provide services to inspect for issues and correct all issues. The inspection will include oil level, oil pressure, and crankcase breather.

Replace engine oil and engine oil filters.

2.5.

Lube oil system in excellent condition including oil level, oil pressure, and crankcase breather.

Replaced engine oil and engine oil filters.

Resistive - Resistive/Reactive Load Bank Testing Contractor will conduct the resistive – resistive/reactive load bank testing and complete load bank data sheet & analysis.

2.6.

Resistive/reactive load bank testing results are excellent. Complete load bank data sheet and summary analysis given to Technical POC.

Air Quality Permit Compliance The Contractor will maintain generators in accordance with the permit conditions.

2.7

Air permits shall be posted on 100% of generators, and generators shall be operated in accordance with permit conditions.

The Contractor shall be in attendance at 100% of air district inspections.

The Contractor shall report 100% upsets or shutdowns to WAPA Environment within 12 hours of the knowledge of the upset or shutdown.

Exhibit 3 Contract Discrepancy Report

Contract No. 1. Report No. for this Discrepancy:

Contractor’s Name:

2. From: (Name of Contracting Officer representative)

Dates

3. Prepared:

4. Returned by Contractor:

5. Action Complete:

6. Discrepancy or Problem: (Describe in detail; include reference to PWS directive; attach continuation sheet, if necessary):

Signature of CO:

7. To: (Contracting Officer)

8. From: (Contractor)

9. Contractor Response as to Cause, Corrective Action and Actions to Prevent Recurrence (Attach Continuation Sheet if Necessary)

10. Signature of Contractor Representative:

Date:

11. Government Evaluation:

12. Government Actions:

13 Close Out Name Title Signature Date

(13a) Contractor Notified

(13b) Technical

POC

(13c) CO