MIRR.pdf

PDF 120 KB Posted Mar 8, 2012

Attached to: Cutter Boat Pooling Program Federal contract opportunity
Solicitation number: HSCG40-12-R-50008
Issued by: Department of Homeland Security US Coast Guard

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ATTAHMENT J.4 - MATERIAL INSPECTION RECEIVING REPORT

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DEPARTMENT OF HOMELAND SECURITY

MATERIAL INSPECTION AND RECEIVING REPORT

DATE

1. CONTRACT NO. 2. ORDER NO. 3. REPORT NO.

4. MATERIAL AND/OR SERVICES INSPECTED

5. CONTRACTOR

6. MANUFACTURER

7. PLACE OF INSPECTION

INSPECTION DATES QUANTITYCONTRACT LINE

ITEM NO(S)

(If applicable)

10. RECEIVED 10. READY 11. STARTED 12. COMPLETED 13. REJECTED 14. ACCEPTED

REPORTS

THIS

REPORT

TOTAL TO

DATE

15.

16.

17.

18.

ORDER

19.

DATE

20. BALANCE

REMAINING

SUBMITTED

REJECTED

ACCEPTED

QUANTITY ON

ACCEPTED TO

21. REMARKS (Use Continuation Sheet for Additional Entries)

22. INSPECTED BY 23. TITLE

The materials and/or serices listed herein have been iinspected or certified test data has been examined, by me or under my supervision. The materials and/or services listed above as accepted conform to contract requirements. Those listed as rejected do not conform and may not be delivered, except as authorized under "Remarks."

24. 25. TITLE 26. DATE SIGNATURE OR NAME

DHS Form 700-21 (12-03)

DEPARTMENT OF HOMELAND SECURITY

MATERIAL INSPECTION AND RECEIVING REPORT (Cont'd )

3. REPORT NO.

INSPECTION DATES QUANTITYCONTRACT LINE

ITEM NO(S)

(If applicable)

10. RECEIVED 10. READY 11. STARTED 12. COMPLETED 13. REJECTED 14. ACCEPTED

DHS Form 700-21 (12-03) Page 2

DATE:

CONTRACT_NO:

ORDER_NO:

REPORT_NO:

MATERIAL:

CONTRACTOR:

MANUFACTURER:

PLACE_INSPECTION:

LINE1:

REC_DATE1:

READY1:

START1:

COMPLETED1:

REJECTED1:

ACCEPTED1:

LINE2:

RECEIVE2:

READY2:

START2:

COMPLETED2:

REJECTED2:

ACCEPTED2:

LINE3:

RECEIVE3:

READY3:

START3:

COMPLETED3:

REJECTED3:

ACCEPTED3:

LINE4:

RECEIVE4:

READY4:

START4:

COMPLETED4:

REJECTED4:

ACCEPTED4:

LINE5:

RECEIVE5:

READY5:

START5:

COMPLETED5:

REJECTED5:

ACCEPTED5:

PREVIOUS1:

THIS1:

TOTAL1:

PREVOUS2:

THIS2:

TOTAL2:

PREVIOUS3:

THIS3:

TOTAL3:

QUANT_ORDER:

ACCEPTED_DATE:

BAL_REMAINING:

REMARKS:

INSPECTED_BY:

TITLE:

TITLE2:

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File details come from the government source that posted it. Updated Nov 14, 2017.