TE H-Latrine Request.pdf

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APD LC v1.00ES

FH FORM 350-25, MAR 2017

For use of this form, see FH REG 420-36; the proponent agency is DPW.

PORTABLE LATRINES AND HAND WASH STATION SERVICES

PREVIOUS EDITIONS ARE OBSOLETE.

SECTION I - INFORMATION

1. DELIVERY DATE:

2. DELIVERY TIME:

3. PICK UP DATE:

4. PICK UP TIME:

SECTION II - REQUEST

8. MONTHLY NUMBER OF PORTABLE LATRINES REQUIRED WITH STANDARD SERVICES

EVERY 2ND DAY:

ADDITIONAL SERVICES

YES

NO

9. MONTHLY NUMBER OF HAND WASH STATIONS REQUIRED WITH STANDARD SERVICES

EVERY 2ND DAY:

YES

10. DAILY NUMBER OF PORTABLE LATRINES REQUIRED:

NO

YES

ADDITIONAL SERVICES

11. DAILY NUMBER OF HAND WASH STATIONS REQUIRED:

NO

YES

ADDITIONAL SERVICES

12. DAILY NUMBER OF HANDICAP LATRINES REQUIRED:

NO

YES

ADDITIONAL SERVICES

PART III - LOCATION

13. LATRINES REQUIRED AT:

15. OTHER:

14. BLDG:

16. GRID COORDINATES:

SECTION IV - CONTRACT DATA

17. CONTRACT NUMBER:

18. TASK ORDER NUMBER:

19. CONTROL NUMBER:

20. THIS REQUIREMENT IS FOR CLIN:

SECTION V - REQUESTOR

21. TYPED NAME OF AUTHORIZING OFFICIAL:

22. SIGNATURE:

23. DATE:

24. REMARKS:

7. NUMBER OF PERSONNEL:

ADDITIONAL SERVICES

NO

5. SERVICE PERIOD START DATE:

6. SERVICE PERIOD END DATE:

10.0.2.20120224.1.869952.867557

DHR/ASD

Fort Hood Form 350-25 Portable Latrines and Hand Was Station Services