Tab 09 Att 11 - F76 Trace Sig Page.pdf

DEFENSE LOGISTICS AGENCY ENERGY

8725 JOHN J. KINGMAN ROAD

FORT BELVOIR, VIRGINIA 22060-6222

DISTRIBUTION STATEMENT – A: APPROVED FOR PUBLIC RELEASE. DISTRIBUTION IS UNLIMITED

F-76 Traceability Signature Page

Contract or Solicitation Number:

CLIN:

Order Number:

Shipment Number:

Traceability OPTION selected per paragraph e.5 (circle or otherwise indicate which one of the three options is chosen):

OPTION 1 OPTION 2 OPTION 3

F-76 fuel supplied under the above contract, CLIN, order number and shipment number maintains traceability with respect the materials composition, additives and their concentration levels. This signed statement certifies that at no point have any unauthorized un- hydrotreated light cycle oils, other unauthorized materials, or additives been blended into the final product or any of its associated blend components per the most recent revision of MIL-DTL-16884 at date of contract award. All materials and additives are listed below. The percentage of each material as defined in sections 3.2, 3.2.2, and 3.2.3 (i.e. refined hydrocarbon distillate fuel, Fischer-Tropsch, Hydroprocessed Renewable Diesel, etc.) and the concentration level for each additive are also shown. For the purposes of the offeror submission this signed statement attests that no unapproved additives or materials will be added to batches or components of batches of F- 76 for delivery under government contracts.

Signature:

Printed Name:

Title:

Company Name:

Date:

Material Percent

Additive Concentration Responsible Party for Injection

DEFENSE LOGISTICS AGENCY ENERGY

8725 JOHN J. KINGMAN ROAD

FORT BELVOIR, VIRGINIA 22060-6222

DISTRIBUTION STATEMENT – A: APPROVED FOR PUBLIC RELEASE. DISTRIBUTION IS UNLIMITED

F-76 Synthetic Component Certification

Contract or Solicitation Number:

CLIN:

Order Number:

Shipment Number:

Synthetic paraffinic materials supplied as indicated with the above contract, CLIN, order number, and shipment number is derived from either Fischer-Tropsch (FT) or Hydroprocessed Renewable Diesel (HRD) methods. This signed statement certifies that since the last certificate of analysis (COA), including table A-II or B-II results of MIL-DTL-16884P, Appendix A or B, no changes, including feedstock material, production location, or production processes have been made. In addition, no turnaround events have been executed on any units utilized to produce the synthetic paraffinic materials since the last COA, including table A-II or B-II, properties were tested. Please supply the date of the most recent COA and an identifying number for that report in the space provided below.

DATE OF COA: _

LAB REPORT ID NUMBER

Signature:

Printed Name:

Title:

Company Name:

Date: