Attachment 3 - Site Visit Request Form (Camp Fuji).xlsx

XLSX spreadsheet 56 KB Posted Oct 25, 2021

Attached to: WASTEWATER TREATMENT SYSTEM CLEANING AND KITCHEN EXHAUST VENTILATION SYSTEMS CLEANING SERVICES AT THE U. S. NAVAL AIR FACILITY, ATSUGI AND COMBINED ARMS TRAINING CENTER (CATC) FUJI, JAPAN
Solicitation number: N4008422R8000
Issued by: Department of the Navy Naval Facilities Engineering Command

View the file

Other files

File	Type	Posted
N40084-22-R-8000-0004.pdf	PDF	Nov 14, 2021
N40084-22-R-8000-0003.pdf	PDF	Nov 5, 2021
N40084-22-R-8000-0002.pdf	PDF	Oct 25, 2021
Attachment 2 - 10-Exhibit J-0200000-08.xlsx	XLSX spreadsheet	Oct 25, 2021
Attachment 4 - Site Visit Request Form (NAF Atsugi).xlsx	XLSX spreadsheet	Oct 25, 2021
Attachment 5 - Pre-Proposal Inquiry (PPI) Form.xlsx	XLSX spreadsheet	Oct 25, 2021
N40084-22-R-8000-0001.pdf	PDF	Oct 22, 2021
N40084-22-R-8000 - Wastewater and Kitchen Exhaust Services.pdf	PDF	Oct 14, 2021

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PAGE1

ONE TIME / MULTIPLE ACCESS ROSTER Page 1 of 1 Pages DATE OF REQUEST

DATA REQUIRED BY THE PRIVACY ACT OF 1974
AUTHORITY:		Title 10, U.S. Code, Section 3013.
PRINCIPAL PURPOSE:		To provide information to officials of the Army responsible for monitoring.controlling visitor's status.
ROUTINE USES:		Information is used to record and assign authorized pass numbers to allow authorized visitors onto U.S. Marine Corps installations.
DISCLOSURE:		Voluntary. Failure to disclose the required information wull result in authorized pass numbers not being issued;
		therefore, causing the applicants to have to meet and escort on and off the installation their visitors.
1. INSTRUCTION
a.	A "One Time/Multiple Access Roster" is valid for a single group visit for a specific date and time. It is the sole responsibility of the individual sponsor to
	include all information listed. Processing time can be reduced if each sponsor will take the time to legibly list the required information in both English and
	Kanji. This roster must be submitted to the Provost marshal, MCIPAC, within one week of the proposed visit.
b.	The sponsor's signature serves as an acknowledgment the sponsor is aware of his/her individual responsibilities to exercise total control over his/her
	non-SOFA guests in accordance with the provisions contained in MCIPACO 5512.2 CH1
2. SPONSOR INFORMATION & ACCESS DESCRIPTION
a. TYPED NAME (Last, First MI)			b. RANK	c. DUTY TELEPHONE NO.	d. TELEPHONE NO.
Carabeo, Chito Bong F.			GS-12	315-264-3143	0467-63-3143

e. DESTINATION / INSTALLATION

f. PURPOSE

g. TYPE OF REQUEST

Camp Fuji, Japan

Site Visit

ONE TIME

MULTIPLE

h. MULTIPLE ACCESS

i. MULTIPLE ACCESS

j. SPONSOR'S SIGNATURE

EFFECTIVE DATE

EXPIRATION DATE

2-Nov-2021

3. VISITORS INFORMATION

a. VISIT DAY

b. VISIT TIME

c. TOTAL (PERSONAL)

d. TOTAL (VEHICLE)

e. GATE NO.

15-Jul-2021

FROM

930

1030

NATIONALITY

NAME (Last, First MI)

ADDRESS & TELEPHONE NO.

PASSPORT NO. &

DRIVER'S LICENSE NO.

VEHICLE

PLATE NO.

ENGLISH	ADDRESS	PASSPORT NO.
		0

JAPANESE TEL DRIVER'S LICENSE NO.

ENGLISH ADDRESS PASSPORT NO.

JAPANESE TEL DRIVER'S LICENSE NO.

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

CATC FUJI PMO FORM , MAR 2014 PREVIOUS EDITIONS ARE OBSOLETE. V2.70 PM

&"ＭＳＰゴシック,Bold"&9CUI//FEDCON [When filled in] Source Selection Information--See FAR 2.101 and 3.104 [When filled in]&"ＭＳＰゴシック,Regular"&11

Source Selection Information--See FAR 2.101 and 3.104 [When filled in]

ONE TIME / MULTIPLE ACCESS ROSTER	Page	2	of	4	Pages	DATE OF REQUEST
						31-Dec-1899

	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.	PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

ACCESS ROSTER CONTINUED: SPONSOR'S TYPED NAME SPONSOR'S SIGNATURE

CATC FUJI PMO FORM PREVIOUS EDITIONS ARE OBSOLETE. V2.70 PM

Source Selection Information--See FAR 2.101 and 3.104 [When filled in]

ONE TIME / MULTIPLE ACCESS ROSTER	Page	3	of	4	Pages	DATE OF REQUEST
						31-Dec-1899

	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.	PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

ACCESS ROSTER CONTINUED: SPONSOR'S TYPED NAME SPONSOR'S SIGNATURE

CATC FORM , MAR 2014 PREVIOUS EDITIONS ARE OBSOLETE. V2.70 PM

Source Selection Information--See FAR 2.101 and 3.104 [When filled in]

ONE TIME / MULTIPLE ACCESS ROSTER	Page	4	of	4	Pages	DATE OF REQUEST
						31-Dec-1899

	NATIONALITY	NAME (Last, First MI)		ADDRESS & TELEPHONE NO.	PASSPORT NO. &
DRIVER'S LICENSE NO.			VEHICLE

PLATE NO.

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

0	ENGLISH	ADDRESS	PASSPORT NO.
	0	0	0

JAPANESE	TEL	DRIVER'S LICENSE NO.
0	0	0

ACCESS ROSTER CONTINUED: SPONSOR'S TYPED NAME SPONSOR'S SIGNATURE

CATC FUJI PMO FORM PREVIOUS EDITIONS ARE OBSOLETE. V2.70 PM

Source Selection Information--See FAR 2.101 and 3.104 [When filled in]

ｽﾎﾟﾝｻ-情報入力

スポンサー情報入力 Sponsor's Information

作成日 Date request

依頼者氏名 Name of Sponsor

身分 Job tiltle

職場電話番号 Work Phone

自宅電話番号（携帯電話番号等）

訪問先 Destination of visit

目的 Purpos

訪問者情報 Visitor's Information
訪問日 Date of visit
訪問時間 Time visit	ＦＲＯＭ		ＴＯ
		～
入出門ゲートGate Entry

上記の二重枠内へ各種情報を入力すること

ゲスト情報入力

No	国名 (Nationality)	名前（漢字） Name in Kanji	名前（英文） Name in English	NAME2（カタカナ） Name in Katakana	住所 Address	電話番号（携帯電話） Cell Phone No.	PASSPORT NO.	DRIVER'S LICENSE NO.	車両番号 License Plate No.	所属等 Company
1	Japan	熊坂清二クマサカセイジ	Kumasaka, Seiji	クマサカセイジ
2	Japan	佐藤弘規サトウヒロシキ	Sato, Hiroki	サトウヒロキ
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File details come from the government source that posted it. Updated Oct 25, 2021.