9050-2055_CDRLs.pdf

CONTRACT DATA REQUIREMENTS LIST Form Approved

(1 Data Item) 0MB No. 0704�0188

Public reporting burden for this collec1Jon of lnfannallan Is estimated to average 110 hours per response, Including the time for reviewing Instructions, searching existing data souR:es, 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 Department of Defense, Washington Headquarters Services, Directorate for Information Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302.

Please DO NOT RETURN your form to either of these address. Send completed form to the Government Issuing Contrac1Ing Officer for the Contract/PR No. Listed In Block E.

A. CONTRACT LINE ITEM NO. 8.EXHIBIT

I

C. CATEGORY

TDP TM Other MISC

0. SYSTEMnTEM

I

E. CONTRACT/PR NO. F. CONTRACTOR

Paint MiK and Dispense Machine

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

CERTIFICATE OF COMPLIANCE CONFORMANCE

4. AUTHORITY (Data Acquisition Document No.) 15. CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-MISC-81356A PER CONTRACT PURCHASING ACTIVITY

7 00250REQ 9. DIST STATEMENT 10. FREQUENCY 12 DATE OF FIRST 14. DISTRIBUTION

REQUIRED SUBMISSION

DD D* ONE/R SEE BLOCK 16* b. COPIES

8. APPCODE 11 AS OF DATE 13 DATE OF SUBSEQUENT A ADDRESSEE Final SUBMISSION

NIA N/A N/A Dralt Rog Repr

16. REMARKS

Block 9: Distribution Statement D. Distribution authorized to DoD and DoD contractors N4523A 0 1 0 only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow (INAWF) a-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFQACertifications.FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

TOTAL 0 1 0

G. PREPARED av H. PATE I. APPROVED av J. DATE

/s/ Joseph Houck 3/6/2019 /s/ P MEYERS 3/6/2019

DD Fonn 1423-1, FEB 2001

SIN 0102·LF.010·5600

Page 1 of 2 Page{s)

For Document no: 9050-2055

'17 PRICE

GROUP

18. ESTIMATED

TOTAL

rRICE

0002AA A

A001

(1 Data Item) 0MB No. 0704-0188

Public reporting buroen for this collecllon of Information Is estimated 10 average 110 hours per response, Including the time for reviewing Instructions, sean:hlng existing data sources, gathering and maintaining lhe data needed, and completing and reviewing lhe collecllon of Information. Send comments regarlllng this burden esllmale or any other asped of this collection or Information, lncludlnlJ suggestions for reducing the buroen, to Oepanment or Defense, Washington Headquarters Services, Olredorate for lnlormallon Operations and Reports (0704-0188), 1215 Jefferson Davis Highway, Suite 1204, Arllngton VA 22202-4302.

Please DO NOT RETURN your form to either of these address. Send completed form to the Government Issuing Conlracllng Officer lor the Contract/PR No Listed In Block E.

A. CONTRACT LINE ITEM NO. I B.EXHIBIT

I c.

GORY

0. SYSTEM/ITEM I E. CONTRACT/PR NO.

Paint Mix and Dispense Machine

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

COMMERCIAL OFF-THE-SHELF (COTS) MANUALS

AND ASSOCIATED SUPPLEMENTAL DATA

4. AUTHORITY /Data AcQuis�ion Document No.) I 5. CONTRACT REFERENCE nI-TM�.:ui.0257C PER CONTRACT

7 DD250REQ 9. DIST STATEMENT 10 FREOUENCY 12 DATE OF FIRST

REQUIRED SUBMISSION

TU C"ITHFR T�AC:C:

F. CONTRACTOR

3. SUBTITLE

Operation, Maintenance, and Repair Manuals

6. REQUIRING OFFICE

PURCHASING ACTIVITY

14. DISTRIBUTION

DD o· ONE/R SEE BLOCK 16* b. COPIES

B. APP CODE 11. ASOFOATE 13. DATE OF SUBSEQUENT

N/A NIA SUBMISSION

N/A

16. REMARKS

Block 9: Distribution Statement D. Distribution authori:z:ed to DoD and Dao contractors only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow r,NAWF) e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFQACertifications.FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

G. PREPARED BY H. DATE

/s/ Joseph Houck 3/6/2019

DD Form 1423-1, FEB 2001

DOCUMENT NO.: 9050-2055

I. APPROVED BY

Is/ P MEYERS

Previous edition may be used.

A. ADDRESSEE Final Draft Reg Repr

N4523A 0 1 0

TOTAL 0 1 0

J. DATE

3/6/2019

Page _1 _ of _1 _ Pages

17. PRICE

I GROUP

18.

I ESTIMAT

ED

0002AB B

A002

Public reporting burden for this collection of Information Is estimated to average 11 O hours per response, lncludlng the time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collectlon of Information. Send comments regarding this burden estimate or any other aspect of this collection or lnrormatlon, Including suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate ror lnrormatlon Operations and Reports (0704-0188), 1215 Jefferson Davis H ghway, Suite 1204, Arlington VA 22202-4302.

Please 00 NOT RETURN your form to either of these address. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. Listed lnBlockE.

A. CONTRACT LINE ITEM NO.

I

B.EXHIBIT

I c.

GORY

TM t'ITl-11::� • .,.,,..

0. SYSTEM/ITEM I E. CONTRACT/PR NO. F. CONTRACTOR

Paint Mix and Dispense Machine

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

CERTIFICATION/DATA REPORT POL YCHLORINATEO BIPHENYL (PCB)

r.�� ,,. .. �IA.TION

4. AUTHORITY {Data Acquisition Document No} I 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-MISC-80678 PER CONTRACT PURCHASING ACTIVITY

7. DD250REQ 9. DIST STATEMENT 10. FREQUENCY 12. DATE OF FIRST 14. DISTRIBUTION

REQUIRED SUBMISSION

7 PRICE IDD D* ONE/R SEE BLOCK 16* b. COPIES GROUP

8. APP CODE 11 AS OF DATE 13. DATE OF SUBSEQUENT A. ADDRESSEE

Final

NIA NIA SUBMISSION

11e. I NIA Dralt Reg Repr :� T

�::. 16. REMARKS

Block 4: Tailored lo allow the vendor lo only provide: 10.1, 10.2, 10.2.4, 10.3, N4523A 0 1 0

10.3.1-Provide actual values IAW procurement specification. Ensure certs provided are traceable to material via unique markings, 10.5.

Block 9: Distribution Statement 0. Distribution authorized to DoD and DoD contractors only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow �AWF) e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFQACertifications.FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

TOTAL 0 1 0

G. PREPARED BY J HOUCK I H. DATE I 1. APPROVED BY P MEYERS I J. DATE

90502055

0002AC C

A003

Public reporting burden for this codectlon of lnf01111atton Is estimated to average 110 hours per response, Including the lime for reviewing Instructions, searching existing dala sourcn, gathering and ma ntalnlng the data needed, and completing and reviewing the collecllon of Information. Send comments regarding this burden estimate or any other aspect or lh"s collectlon or Information, lneludlng suggestions for reducing the burden, to Department of Defense, Washington Headquarters Services, Directorate for Information Operatrons and Reports (0704-0188), 1215 Jefferson Davis H'ghway, Sulla 1204, Arllnglon VA 22202-4302.

Please DO NOT RElURN your f01111 lo either of these address. Send completed form to the Government lasu'ng Contracting Officer for the Contract/PR No. Listed In Block E.

A. CONTRACT LINE ITEM NO. B.EXHIBIT

I c,;:;EGORY

D. SYSTEM/ITEM I E. CONTRACT/PR NO.

Paint Mlx and Dispense Machine

1, DATA ITEM NO. 2. TITLE OF DATA ITEM

CERTIFICATION/DATA REPORT

4. AUTHORITY (Data Aequisition Document No) I 5. CONTRACT REFERENCE DI-MISC-80678 DDl PER CONTRACT

7 DD2SOREQ 9 DIST STATEMENT 10. FREQUENCY 12. DATE OF FIRST

REQUIRED SUBMISSION

DD D* ONE/R SEE BLOCK 16*

TM nTl•fl:I::! Ml�r.

F. CONTRACTOR

3. SUBTITLE

NATIONAL RECOGNIZED TESTING

I !l;:;.,--•-,;;.·T INRTLl .r�11r-11�ATION

6. REQUIRING OFFICE

PURCHASING ACTIVITY

14. DISTRIBUTION

b. COPIES

8 APPCODE 11. AS OFDATE 13. DATE OF SUBSEQUENT A. ADDRESSEE

Flnel

N/A NIA SUBMISSION

N/A Draft Reg Repr

16, REMARKS

Block 4: Tailored to allow the vendor to only provide: 10.1, 10,2, 10.2.4, 10.3, N4523A 0 1 0 10.3.1-Provide actual values IAW procurement specification. Ensure certs provided are traceable to material via unique markings, 10,5.

Block 9: Distribution Statement D. Distribution authorized to DoO and DoD contractors only. Administration and operations only, effective 3/6/2019. Other U.S. requests shan be referred to COMNAVSEASYSCOM.

Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow {WAWF) e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFQACertifications FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with lhe corresponding material and will not be accomplished prior to shipment of material.

TOTAL 0 1 0

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

/s/ Joseph Houck 3/6/2019 /s/P MEYERS 3/6/2019

DOCUMENT NO.: 9050-2055

17 PRICE I GROUP

18. I

ESTIMAT

ED

0002AD D

A004

Public reporting bunlen for this colledlon of lnfonnallon Is estimated to average 110 hours per response. Including 1he lime for reviewing lnstrudlons, searching existing data souri:es, gathering and maintaining the data needed. and completing and reviewing the collection of Information. Send comments reganllng 1hls burden estimate or any other aspect of this colledlon of lnformat on, Including suggestions for reducing the burden, 10 Department of Defense, Washington Headquarters Services, Dlrec1orate for lnlormatlon Operations and Reports (0704-0188), 1215 Jefferson Davis H ghway, Sulle 1204, Arlln!llon VA 22202-4302.

Please DO NOT RETURN your fonn to either of these address. Send completed lorm to the Government Issuing Contrading Officer ror the Contract/PR No. Listed In Block E.

A, CONTRACT LINE ITEM NO. B. EXHIBIT

I c.

EGORY

TLII nTl-lr::� u,c,,-.

D. SYSTEM/ITEM

I

E. CONTRACT/PR NO. F. CONTRACTOR

Paint Mix and Dispense Machine

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

CERTIFICATION/DATA REPORT MILESTONE/SCHEDULE

4. AUTHORITY (Data Acquisition Document No) I 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-MISC-80678 PER CONTRACT PURCHASING ACTIVITY

7 DD250REO 9 DIST STATEMENT 10 FREQUENCY 12. DATE OF FIRST 14, DISTRIBUTION

REQUIRED SUBMISSION

DD o· ONE/R SEE BLOCK 16* b. COPIES

B. APP CODE 11 AS OF DATE 13 DATE OF SUBSEQUENT A. ADDRESSEE Fln•I

N/A N/A SUBMSSION

N/A

16. REMARKS

Block 9: Distribution Statement D. Distribution authorized to OoD and DoD contractors only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 12 - Certification/Data Report documentation shall be attached in the Wide Area Workflow �AWF) e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFQACertifications.FCM@navy mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

G. PREPARED BY

/s/ Joseph Houck

H. DATE

3/6/2019

DOCUMENT NO.: 9050-2055

I. APPROVED BY

/s/PMEYERS

Draft Reg Repr

N4523A 0 1 0

TOTAL 0 1 0

J. DATE

3/6/2019

17 PRICE

I GROUP

18.

I ESTIMAT

ED

T,...T•t

0002AE E

A005

CONTRACT DAT A REQUIREMENTS LIST Form Approved (2 Data Items) 0MB No. 0704-0188

The public nportlng burden far this c.ollectlon of lntormaUon j1 estimated ta average 220 hours per 1e1pon1e, Including the t me tor reviewing fn,1ructlon1, aeerchtng eJ:llllng data sources. gathering and malnllining the data needed, and completing and reviewing tho colloctlon of Information Senct comments tegardlng this burden e1tlmate or any olher aspect of tMs coUectlon of Information, lncludlng 1ugges1lon1 for reducing the burden. to the Department ot Defen1e, Executive Services Olrec1orale (0704-0188). Respondenll lhould be aware that notwlth1landlng ■ny other provl1lon of law, no poraon 1h1ll be 1ubjocl to any penally for lolling to comply wllh a collect on of Information If II does not display a currently valid 0MB control number Plouo do not ratum your lorm to tho above orvanlutlon. Send completed form to tho Government tnulng Contracting Officer lor tho Contract/PR No. llstod In Block E.

A. CONTRACT LINE ITEM NO. B. EXHIBIT lr% 'p

CATEGORY:

TM __ OTHER SESSIMISC __

D.SYSTEM/ITEM

I

E. CONTRACT/PR NO. F. CONTRACTOR

Paint Mix and Dispense Machine

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

PRODUCT DRAWINGS/MODELS AND ASSOCIATED LISTS ENGINEERING DRAWINGS

•· AUTHORITY /0111 Acquisition Document No./

I

5, CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-SESS-81000E PER CONTRACT PURCHASING ACTIVITY

7. DD 25D REQ 9. DIST STATEMENT 10. FREQUENCY 12, DATE OF FIRST SUBM ISSJON

DD REQUIRED ASREQ

D

SEE BLOCK 16" 14. DISTRIBUTION

b. COPIES

8, APP CODE 11. AS OF DATE 13. DATE OF SUBSEQUENT

a. ADDRESSEE Final A" NIA SUBMISSION Draft

N/A Rog Ropro

16, REMARKS

N4523A IO 1 IO

Block 9: Distribution Statement D. Distribution authorized to DoD and DoD contractors only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 10 • Submit Engineering Drawings unless proof of prior acceptance by NAVSEA Activity.

Block 12 • Allow 45 Days from date of entry in WAWF for certification acceptance prior to material shipment

Block 14 • Certification/Data Report documentation shall be attached in the Wide Area Workflow rt-JAWF) e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFOACertifications.FCM@navy.mil. Acceptance/Rejection of Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

15. TOTAL � 1 0

G. PREPARED BY

I

H.DATE

I. APPROVED BY J. DATE

/S/ Joseph Houck 3/6/2019 S/ P MEYERS 3/6/2019

For Document# 9050-2055

DD FORM 1423-2, AUG 96 PREVIOUS EDITION MAY BE USED. Page _1_ of _1_ Pages

17. l'RICE GAOtJI

19. ESTIMA1al lOOII..Fff:E

0002AF F

A006

Public: repor1Ing burden for lhls collec1Ion ol lnlormatlon Is estimated to average 110 hours per response, lnc:ludlng the time for reviewing lnstruc:11ons, searching existing data sources, gathering and maintaining the data needed, and c:ompletlng and reviewing the c:olledlon of lnfO!Tllallon. Send comments regarding this burden es11male or any other aspect of this c:ollec:tlon of Information, lnc:ludlng suggestions for reducing the burden, lo Department of Defense, Washington Headquarters Services, Dlrec1ora1e for Information Operations and Reports (0704-0166), 1215 Jefferson Davis Highway, Suite 1204, Arlington VA 22202-4302.

Please DO NOT RETURN your form to either of these address. Send c:ompleled form to the Government Issuing Contracting Officer for the Contract/PR No. Listed In Block E.

A. CONTRACT LINE ITEM NO. B.EXHIBIT

I C-

GORY

TUI nTI-IC:D cc:c,c, D. SYSTEM/ITEM

I

E. CONTRACT/PR NO. F. CONTRACTOR

Paint Mix and Dispense Machine

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

WARRANTY PERFORMANCE REPORT WARRANTY DOCUMENTATION

4. AUTHORITY (Data Acquisition Document No) I 5. CONTRACT REFERENCE 6. REQUIRING OFFICE

DI-SESS-81639A PER CONTRACT PURCHASING ACTIVITY

7. DD250RE Q 9. DIST STATE MENT 10. FREQUENCY 12. DATE OF FIRST 14. D ISTRIBUTION

REQUIRED SUBMISSION 17 PRICE

I DD o• ONE/R SEE BLOCK 1s• b. COPIES GROUP

8. APP CODE 11. ASOFDATE 13. DATE OF SUBSEQUENT A. ADDRESSEE

Flnal

N/A N/A SUBMISSION 18.

I N/A Draft Reg Repr ESTIMAT

ED 16. REMARKS .......... ,.,

Block 9: Distribution Statement D. Distribution authorized to DoD and DoD contractors N4523A 0 1 0 only. Administration and operations only, effective 3/6/2019. Other U.S. requests shall be referred to COMNAVSEASYSCOM.

Block 4 - Tailored to allow vendor to provide only 3.1.1 (a, c, d, e}, 3.1.2 (a, b, c, d, e, f, g, h, j, k, I, m}. I

Block 12 - Certification/Data Report documentation sh all be attached in the Wide Area Workflow r,NAWF} e-Business Suite.

Upon submission in WAWF send email notifications to:

PSNS.WAWFOACertifications.FCM@navy.mil. Acceptance/Rejection of

Certification/Data Report documentation will be accomplished with the corresponding material and will not be accomplished prior to shipment of material.

TOTAL 0 1 0

G. PREPARED BY H. DATE I. APPROVED BY J. DATE

/s/ Joseph Houck 3/6/2019 /s/P MEYERS 3/6/2019

DOCUMENT NO.: 9050-2055

0002AG G

A007