L0WC17 CDRL A004 DI-MISC-81356A Cert of Compliance signed.pdf

CONTRACT DATA REQUIREMENTS LIST

(1 Data Item)

Form Approved OMB No. 0704-0188

The 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 the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT C. CATEGORY:

TDP TM OTHER __ENGR__

D. SYSTEM/ITEM E. CONTRACT/PR NO. F. CONTRACTOR

1. DATA ITEM NO. 2. TITLE OF DATA ITEM 3. SUBTITLE

4. AUTHORITY (Data Acquisition Document No.)

DI-MISC-81356A/T

5. CONTRACT REFERENCE

PD para 5.4.3

6. REQUIRING OFFICE

402 CMXG/MXDQBE

7. DD 250 REQ

NO

9. DIST

STATEMENT

REQUIRED

A

10. FREQUENCY

SEE BLK 16

12. DATE OF 1ST SUBMISSION

ASREQ

14. DISTRIBUTION

a. ADDRESSEE

b. COPIES

8. APP CODE

N/A

11. AS OF DATE

N/A

13. DATE OF SUBSEQUENT

SUBMISSION

ASREQ

Draft

Final

Reg Repro

15. TOTAL 0 2 0

I. APPROVED BY J. DATE

DD Form 1423-1, FEB 2001 PREVIOUS EDITION MAY BE USED Page _ _ of __Pages

18. ESTIMATED

TOTAL PRICE

17. PRICE

GROUP

L0WC17

1 1

G. PREPARED B H. DATE

A004 CERTIFICATE OF COMPLIANCE

16. REMARKS

Block 4: Contractor's format is acceptable. DID paragraph 2 (g), NSN, is not applicable; substitute model/part number and serial number. DID paragraph 2(i): include a statement by third-party test facility certifying that the breathing air quality is Grade D.

Block 10: Submit breathing air quality certificate within thirty (30) days of on-site verification testing.

Addressees:

Taylor Bozard, 402 CMXG/MXDQBE, stephen.bozard@us.af.mil Scott Swartz, 402 CMXG/MXDQBE, scott.swartz@us.af.mil

SEE BLK 16

ELECTRONIC 0 2 0

12 Feb 20 13 Feb 20Laura Faith