Attachment_1_DLA_Energy_Form_4.23_Authorization_and_Mine_Description_SPE600-17-R-0400.pdf

SPE600-17-R-0400

PROCUREMENT SENSITIVE - SOURCE SELECTION INFORMATION – SEE FAR 2.101 AND 3.104

ATTACHMENT 1

AUTHORIZATION AND MINE DESCRIPTION SOLICITATION: SPE600-17-R-0400

(To be completed by authorized representative at proposed mine. Please submit one form for each mine offered)

1. THIS WILL AUTHORIZE THE FOLLOWING COMPANY TO SELL COAL FROM THE MINE LISTED IN BLOCK 3 TO THE DEFENSE LOGISTICS AGENCY (DLA) ENERGY’S COAL DIVISION UNDER THE ABOVE SOLICITATION NUMBER.

2. I HEREBY AGREE TO FURNISH ____________________________(NET TONS (NTS))

MEETING OR EXCEEDING THE MINIMUM SPECIFICATIONS FOR LINE ITEM(S):_____________

TO (COMPANY NAME AND ADDRESS):

(Insert above, name of company, agent, broker, or individual authorized to sell your coal to DLA ENERGY)

COMPANY POINT OF CONTACT:________________________________________________________________

TELEPHONE NUMBER ____________________________/E-MAIL:______________________________________

3. MINE NAME ________________________________ STATE PERMIT NUMBER ___________________ (Insert current and previous names, if known) (May be continued in Para. 6., Remarks)

LOCATION __________________ COUNTY ____________________ STATE ______________

SEAM NAME _________________ SEAM NUMBER _______________ TYPE _____________

(Deep, Slope, Strip, Shaft, Auger)

MINE BUSINESS SIZE: ( ) Large Business(500 employees or more) ( ) Small Business (Fewer than 500 employees)

4. TIPPLE NAME ____________________________ STATE PERMIT NUMBER _____________

(Insert current and previous names, if known)

LOCATION ___________________ COUNTY _________________ STATE _________________

5. SHIPPING POINT ___________________________ CAR SIDING CAPACITY ____________

LOCATION _____________________________ RAILROAD(S) ___________________________

6. REMARKS: ______________________________________________________________________________

7. OPERATING COMPANY: _______________________________________________________

(Insert name of the company which is operating the MINE described above)

ADDRESS: _________________________________________________________________

8. ______________________________________________________________________________________ NAME AND TITLE OF AUTHORIZED OFFICIAL OF OPERATING COMPANY (Type or Print)

_________________________________________________________________ DATE ______________

SIGNATURE OF AUTHORIZED OFFICIAL OF OPERATING COMPANY

TELEPHONE NUMBER ____________________________/E-MAIL:______________________________________ DLA Energy Form 4.23 Revised JUNE 2012