Covington - TE 12 Non-Conformance Notification for Rework.pdf

Technical Exhibit 12

NON-CONFORMANCE NOTIFICATION FOR REWORK

IRS SITE: Cincinnati Service Center

CMMS WORK ORDER #

1. Date Government Received Completed Work Order:

2. Date of Initial Inspection:

3. NOTICE OF REWORK (circle) 1st 2nd 3rd 4th 5th

GOVERNMENT ACTION

4. TO (Site Manager Name):

5 FROM (Name of Government Representatives):

6. DESCRIPTION OF NON-CONFORMANCE (Describe in detail all discrepancies found during the inspection. Attach a copy of the S/C, P/M, or IDIQ ticket if necessary).

7. DATE TIME STAMP GIVEN TO CONTRACTOR

CONTRACTOR ACTION

8. MECHANIC (printed name) :

9. DATE RECEIVED FOR REWORK:

10. ACTIONS TAKEN TO CORRECT NON-CONFORMANCE (address each discrepancy described in section 6 above with action taken to correct the deficiency).

11. MECHANIC SIGNATURE:

12. DATE OF COMPLETION:

GOVERNMENT CLOSE OUT

13. DATE TIME STAMP RETURNED TO GOVERNMENT

14. INSPECTOR (printed name):

15. DATE OF REWORK INSPECTION:

16. REWORK INSPECTION OUTCOME (circle one)

PASS FAIL

IF FAIL, INITIATE A NEW REWORK

FORM AND ATTACH A COPY OF

THIS FORM.

17. SIGNATURE OF MECHANICAL WORK INSPECTOR:

18. DATE:

19. SIGNATURE OF SUB-COTR:

20. DATE: