Exhibits_Part_3.pdf

1. Service Requirement: Natural Resource Protection and Enhancement.

2. Corresponding Contract Section: C-5.

3. Method of QA: 100% Inspection

4. Acceptable Quality Level: N/A

5. Lot Size for Sampling: N/A

6. Sampling Size: NIA

7. Reject Level: N/A

8. Sampling Procedures: The Government will inspect all work at the completion of each work order and the COR may elect to have the work periodically inspected during performance.

9. Inspection Procedures: The inspector will get a copy of the work order, scope of work, and measuring devices needed to verify work and record all aspects of the work on an inspection checklist form. The Contractor will be informed of deficiencies in his performance.

10. Performance Criteria: The Contractor shall perform all work as specified in the individual work orders. For all identified deficiencies the Contractor will be allowed to re-perform if the work order and the contract specifications allow. Defects in Contractor performance may be addressed by issuance of a CDR. A CDR will be issued should the Contractor fails to correct deficiencies by re-performance, or for any defects/rejects in service requirements.

1. Service Requirement: Recreation Area Maintenance

2. Corresponding Contract Section: C-5

3. Method of Q.A.: 100% Inspection.

4. Acceptable Quality Level: NIA

5. Lot Size for Sampling: NIA

6. Sampling Size: N/A

7. Reject Level: NIA

8. Sampling Procedures: The Government will inspect all work at the completion of each work order and the COR may elect to have the work periodically inspected during performance.

9. Inspection Procedures: The inspector will get a copy of the work order, scope of work, and measuring devices needed to verify work and record all aspects of the work on an inspection checklist form. The Contractor will be informed of deficiencies in his performance.

10. Performance Criteria: The Contractor shall perform all work as specified in the individual work orders. For all identified deficiencies the Contractor will be allowed to re-perform if the work order and the contract specifications allow. Defects in Contractor performance may be addressed by issuance of a CDR. A CDR will be issued should the Contractor fails to correct deficiencies by re-performance, or for any defects/rejects in service requirements.

1. Service Requirement: Boundary Marking

2. Corresponding Contract Section: C-5.

3. Method of Q.A.: 100% Inspection

4. Acceptable Quality Level: NIA

5. Lot Size for Sampling: NIA

6. Sampling Size: N/A

7. Reject Level: N/A

8. Sampling Procedures: The Government will inspect all work at the completion of each work order and the COR may elect to have the work periodically inspected during performance.

9. Inspection Procedures: The inspector will get a copy of the work order, scope of work, and measuring devices needed to verify work and record all aspects of the work on an inspection checklist form. The Contractor will be informed of deficiencies in his performance.

10. Performance Criteria: The Contractor shall perform all work as specified in the individual work orders. For all identified deficiencies the Contractor will be allowed to re-perform if the work order and the contract specifications allow. Defects in Contractor performance may be addressed by issuance of a CDR. A CDR will be issued should the Contractor fails to correct deficiencies by re-performance.

1. Service Requirement: Drift, Debris, and Trash Removal.

2. Corresponding Contract Section: C-6.

3. Method of Q.A.: 100% Inspection.

4. Acceptable Quality Level: NIA

5. Lot Size for Sampling: N/A

6. Sampling Size: N/A

7. Reject Level: N/A

8. Sampling Procedures: The Government will inspect all work at the completion of each work order and the COR may elect to have the work periodically inspected during performance.

9. Inspection Procedures: The inspector will get a copy of the work order, scope of work, and measuring devices needed to verify work and record all aspects of the work on an inspection checklist form. The Contractor will be informed of deficiencies in his performance.

10. Performance Criteria: The Contractor shall perform all work as specified in the individual work orders. For all identified deficiencies the Contractor will be allowed to reperform if the work order and contract specifications allow. Defects in Contractor performance may be addressed by issuance of a CDR. A CDR will be issued should the Contractor fail to correct deficiencies by reperformance.

' I

Table A-1 ,----~-~-~-~~-S_a_m,pleSjzesa~£_R_e~j~ec_t_L~e._v_e!~s~-~~~~~~~---.

Normal Surveillance .. .,_...,.._.,._, __ ••H"'''''' ........ ............... , .. _ .. ,,.,_ .............. ......... ___ , ........ -.................. -..... ,, ... __ ,, ______ .. , ..

AQL5% AOL 10%

Population Size . ~(ll~P.l.<: ~!:::: Reject Size Sampie Size Reject Size

U; :\ 1 3 2

!HS 5 2 5 2

16-25 ll 2 a 3

26-50 13 3 13 4

50 15 3 17 4 m 16 3 19 4

100 17 3 21 5

125 18 3 22 5

150 18 3 22 5

11ri 19 3 23 5

200 19 3 1.3 5

225 19 3 24 5

25() 19 3 24 5

275 rn 3 24 " ,, ...................................... ......................... ····-----T·--· 3()0 20 3 24 5

326 20 3 24 5 I

350 20 3 24 5

375 20 :~ 25 5

400 20 3 25 5

460 20 3 25 5

500 20 3 25 5

550 20 3 2!) s ___ '" _____

HOO 20 ;J 25 5

550 20 3 25 5

700 20 3 25 s 750 20 3 25 5

........... ·····"·································-··~····· . ····-•~¥----~~~--. ., ••••o•o•••o•o•oo•o••o .. HH

300 20 3 25 5

900 20 ;; 26

1.000 21 4 26 6

1,:100 21 25 5

1.400 21 4 26 6

1,tiOO 21 4 5

1,800 21 4 6

2.000 11 4 26 6

:?,501) 21 4 26 6

3,1JOll 21 4 26 6

3.600 21 4 26 6

4.000 21 26 6

5,000 21 4 26

6,000 21 4 26

6.000 ..... , .. ,w_, __ • 21 26 6

2·8 5 2 5

9-15 8 2 il

H3~25 13 2

26-50 20

50 33 4 6

75 42 5 8

100 49 5 58 9

125 55 6 66 10

1fi0 59 6 72 11 t'ff> 63 7 12

2(}(j 66 13

225 OB 7 13

250 lQ 89 14

275 72 8 92 14

300 74 8 95 15

~125 75 8 97 ·15

350 76 8 99 15

3'75 77 8 101 in

40() 78 ll 103 16

4'50 80 8 106 10

(lt)() 82 9 109 17

S50 83 H 111 17

600 84 9 113 17

650 85 9 ·114 18

700 ()0 9 116 18

/60 es 9 117 18

8tJO 87 9 118 18

900 88 9 120 18

1,00() 89 9 122 19

1,200 9 124 19

1.400 91 10 126 1H l 60[1 92 10 1W 20

1,llDO 92 10 129 20

93 10 1:)0 20

",500 94 10 131 20

:rnoo 94 10 132 20

3.~)00 9[} 10 133 2()

95 10 134 21

5,000 96 1() 135 21

96 10 135 2·1

Table A·3

·····----~_:;?~~~t~~~-~§ -:::::i~-: ·:·---~j

Population Size ' Sample S~ze _ Size .. __ ~air~i::'_e -~:~:' ___ _ ___ .. ~eject Size J 2 1 2 1

3 1 3 2 i---·-----.. -·-···---1----5---+ ;;--- -----r-----5 --- , ----2---.. -

2 .. 3

9-15

16-25

26-50

; : i---tj-- :

I :--8

9 3

9 3

-;-11 9 . 3

10 3

'10

1()

-~~-~-·--··--- .. --·-··············; ..... _ ............................... , ......... ~---1---··-···- .................. ______ -r-----------.. -----·+-----···-·------·--<

800 10

900 10

1,000 10

1,200 10 i,400 10

1,600

1,800

2,000 10

SECTION VI

INSPECTION CHECKLISTS

SEE EXHIBIT Q

Exhibit I

Sample Work Schedule

Contractor Name

Exhibit I

Sample Work Schedule

Beech Fork Lake

Cleaning and Policing Schedule

Monday and Fridays

Time

07:00 AM

07:30 A.M.

09:00 A.M.

Area

Upstream Rec Area

Downstream Rec Area

Office

Exhibit J

Sample Invoice Format

FROM: Contractor's Name Address Phone Number

Exhibit J

SAMPLE INVOICE

INVOICE NO:

INVOICE FOR MONTH OF: DATE OF INVOICE:

CONTRACT NUMBER:

TO: Resource Manager Beech Fork Lake 3784 Beech Fork Road Lavalette, WV 25535

DATE WORK ORDER NUMBER

7-1-93 Work Order Number 0001

AMOUNT

Item No 0005, Mowing Upstream Dam Item No 0014, Mowing Spillway

7-7-93 Work Order Number 0002 Item No 0032, Laborer Item No 0039, Truck Operator

TOTAL INVOICE

$3,000.00 $500.00

$700.00 $300.00

$4,500.00

Exhibit K

Task Order Form, DD Form 1155

Exhibit L

Job Request Form, CELRH 2770

GOVERNMENT COPY

1. AREA

JOB REQUEST FORM

The proponent agency is CELRH-CT.

2. LOCATION

1. CONTRACT NUMBER

3. SUBMITTED BY (Las~ First Ml and Title)

5. DESCRIPTION OF SERVICES REQUIRED (Attach additional plans, specifications or other information as necessary).

SECTION II - GOVERNMENT COST ESTIMATE

4. DATE (YYYYMMDD)

1. DATE (YYYYMMDD) 2. SIGNATURE (Assigned to Contractor) 3. DATE (YYYYMMDD) 4. SUBMITTED BY (Last, First Ml and Title)

5. a. b. c. d. e.

ITEM SERVICES QUANTITY UNIT UNIT PRICE ($) AMOUNT($)

f. TOTAL($)

1. LOCATION 2. REMARKS

3. a. b.

ITEM DESCRIPTION QUANTITY

4a. DATE (YYYYMMDD) b. SIGNATURE (For GFM Received By Contractor's RepresentatiVe)

1. RECOMMENDATION OF 2. ESTIMATED COMPLETION 3. SIGNATURE DATE 4. RECOMMENDED BY SIGNATURE

START DATE (YYYYMMDD) DATE (YYYYMMDD) (YYYYMMDD)

5. ASSIGNED INSPECTOR (Last, First Ml) 6. ASSIGNED WORK ORDER NUMBER 7. COST CODE

8. AMENDMENT 9. SIGNATURE DATE (YYYYMMDD) 10. SIGNATURE OF APPROVAL FOR RECOMMENDATION (COR)

D YES D NO

CELRH FORM 2770, IVIAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Exhibit M Page 1 of3

VERSION 1.1

GOVERNMENT COPY

1. ACTUAL ST ART DA TE

(YYYYMMDD)

2. ACTUAL COMPLETION DATE 3. EXCESS GOVERNMENT FURNISHED MATERIALS (GFM) RETURNED (If (YYYYMMDD) no attach explanation)

D YES D NO D NOT APPLICABLE

4. SERVICES HAVE BEEN INSPECTED AND ARE OR ARE NOT ACCEPT ABLE(Explain below) D ARE D ARE NOT ACCEPTABLE

5. INSPECTOR (Las~ Frst Ml Title and E-mail Address) 6. DATE (YYYYMMDD) 7. INSPECTOR'SSIGNATURE

ITEM

NUMBER

a.

DATE

(YYYYMMDD)

b.

TIME (0001-

2400hours)

16. FINAL REMARKS OR COMMENTS (Not noted elsewhere).

CELRH FORM 2770, MAY2010

c. d.

LOCATION NOTES

Exhibit M

1. AREA

JOB REQUEST FORM

The proponent agency is CELRH-CT.

2. LOCATION

1. CONTRACT NUMBER

3. SUBMITTED BY (Las~ First Ml and Title) 4. DATE (YYYYMMDD)

5. DESCRIPTION OF SERVICES REQUIRED (Attach additional plans, specifications or other information as necessary).

1. DA TE (YYYYMMDD) 2. SIGNATURE (Assigned to Contractor) 3. DA TE (YYYYMMDD) 4. SUBMITTED BY (Las~ First Ml and Title)

5. a. b. c. d. e.

ITEM SERVICES QUANTITY UNIT UNIT PRICE ($) AMOUNT ($)

f. TOTAL($)

1. LOCATION 2. REMARKS

3. a. b.

ITEM DESCRIPTION QUANTITY

4a. DATE (YYYYMMDD) b. SIGNATURE (For GFM Received By Contractor's Representative)

5. ADDITIONAL REMARKS OR COMMENTS (Not noted elsewhere).

CELRH FORM 2770, MAY 2010 Exhibit M Page3 of 3

Exhibit M

Contract Discrepancy Report, CELRH 1104

1. CONTRACT NUMBER

3. TO (List Contractor or Manager's Name)

CONTRACT DISCREPANCY REPORT

The proponent agency is CELRH-CT.

2. WORK ORDER NUMBER(s)

4. FROM (Contracting Officer's Representative)

5. PREPARED DATE

(YYYYMMDD)

6. ORAL NOTIFICATION DATE

(YYYYMMDD)

7. RETURNED BY CONTRACTOR 8. ACTION COMPLETE DATE

DATE (YYYYMMDD) (YYYYMMDD)

9. DISCREPANCY OR PROBLEM (Describe in detail, including refetences in contract or work order, attach continuation sheets as necessary) 0

10a. SIGNATURE DATE (YYYYMMDD) b. SIGNATURE OF CONTRACTING OFFICER OR AUTHORIZED REPRESENTATIVE

11. TO (Contracting Officer or Authorized Representative) 12. FROM (Contractor)

~8 m§ z c:

0 z

13. CONTRACTOR'S RESPONSE AS TO CAUSE, CORRECTIVE ACTION AND ACTIONS TO PREVENT REOCCURENCE 0 (Attach continuation sheet if necessary and cite applicable Quality Control program procedures or new Quality Control procedures).

14a. SIGNATURE DATE (YYYYMMDD) b. SIGNATURE OF CONTRACTOR'S REPRESENTATIVE

15. GOVERNMENT EVALUATION (Acceptable, Partial Acceptance, Rejection, attach continuation sheet if necessary).

16. GOVER NM ENT ACTIONS (Payment Reduction, Cure Notice, Show Cause or Othef).

a. NAME AND TITLE (Las~ First Ml) b. DATE (YYYYMMDD) c. SIGNATURE

17. CONTRACTOR NOTIFIED

18. CONTRACTING OFFICER'S

REPRESENTATIVE (COR)

19. CONTRACTING OFFICER

(CO)

CEl.RH FORM 1104, APR 2010 PREVIOUS EDITIONS ARE OBSOLETE.

Exhibit N

D ~8 !!I§ z c:

0 z

Exhibit N

Contractor Equipment and Supply Inspection

CONTRACTOR EQUIPMENT AND SUPPLY INSPECTION

The proponent agency is CELRH-CT.

1. DATE OF INSPECTION (YYYYMMDD)

2. CORPS PROJECT 3.CORPSINSPECTOR 4. CONTRACTOR 5. CONTRACTOR PHONE

6. FIRM OR CORPS REPRESENTATIVE 7. SOLICITATION NUMBER

CONTRACT SESSIONS: THE FOLLOWING CODES ARE TO BE USED IN SUBJECTIVELY EVALUATING THE APPARENT CONDITION AND

CONSIDERED UTILIZATION POTENTIAL OF CONTRACTOR EQUIPMENT, TOOLS ETC.

CONDITION CODES: (A) NEW, APPARENT CONDITION (B) USED, SERVICEABLE AND APPARENT GOOD CONDITION

(C) USED, SERVICEABLE (D) USED, UNSERVICEABLE (E) NIA NOT APPLICABLE

NOTE: DUE TO THE SIMILARITY IN SERVICES AND THE EQUIPMENT AND TOOLS USED TO PERFORM THESE SERVICES; SECTIONS II., V., VI., VU., VIII., X., XIII. AND XIV. HAVE BEEN COMBINED.

1. RIDING EQUIPMENT (e.g., Tractors, etc.)

a. b. c. d. ROLLOVER e. f. g.

PROTECTION SEATBELTS PHOTO(s)

CONDITION

EQUIPMENT ITEM MODEL NUMBER SERIAL NUMBER YES NO YES NO YES NO C.ODE

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D

2. POWER LAWN MOWERS (Self-Propelled)

a. b. c. d. GUARDS e. f. g.

(discharge, belts, BACK etc.) GUARD PHOTO(s)

CONDITION

EQUIPMENT ITEM MODEL NUMBER SERIAL NUMBER YES NO YES NO YES NO CODE

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D

3. POWER LAWN MOWERS (Push Type)

a. b. c. d. GUARDS e. f. g.

(discharge, belts, BACK etc.) GUARD PHOTO(s)

CONDITION

EQUIPMENT ITEM MODEL NUMBER SERIAL NUMBER YES NO YES NO YES NO CODE

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D

CELRH FORM 2800, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. ExhibitO Page 1 of4

4. TRIMMERS (String Type)

a. b. c. d. GUARDS e. f. g.

(discharge, belts, BACK etc.) GUARD PHOTO(s)

CONDITION

EQUIPMENT ITEM MODEL NUMBER SERIAL NUMBER YES NO YES NO YES NO CODE

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D 0

5. HAND TOOLS (List hand tools displayed and describe t11eir general condition)

6. PESTICIDE APPLICATION EQUIPMENT

a. b. c. d. PHOTO(s) e.

CONDITION

EQUIPMENT ITEM MODEL NUMBER SERIAL NUMBER YES NO CODE

0 D D 0 0 D

NOTE: USE THIS SECTION TO EXPAND UPON OR TO PROVIDE FURTHER ELABORATION, THAT WILL AIDE THE DETERMINATION PROCESS AND IN THE UNDERSTANDING OF ANY CONCLUSION OR DETERMINATION (e.g., rating or condition codes selected) MADE ON THE ADEQUACY OF PROPOSED EQUIPMENT TO PROVIDE SERVICES REQUESTED UNDER SECTION Ill.

7. COMMENTS

1a.

EQUIPMENT ITEM

b.

SERIAL NUMBER

(If applicable) c.

SAFETY FEATURES

(If applicable)

d. PHOTO(s)

YES NO

D D D 0 D D D D D D

NOTE: USE THIS SECTION TO ELABORATE ON ANY OF THE FOREGOING OBSERVED ITEMS AND TO PROVIDE SUPPLEMENTARY INFORMATION THAT COULD ASSIST IN THE EVALUATION PROCESS. FOR EXAMPLE, SHOULD ANY ITEMS DEEMED NECESSARY TO PROVIDE THE SERVICES REQUIRED UNDER SECTION IV. (and noted in the "SPECS') NOT BE AVAILABLE FOR INSPECTION (e.g., expendable items such as brooms, brushes, toilet bowl swabs, etc) NOTE HERE THE RESPONSE PROVIDE TO QUERIES INTO THE

PROPOSED ACQUISITION, ETC.

2. COMMENTS

CELRH FORM 2800, MAY2010

Exhibit 0

1a. b. c. d. PHOTO(s) e.

SERIAL NUMBER SAFETY FEATURES CONDITION

EQUIPMENT ITEM (If applicable) (If applicable) YES NO CODE

D D D D D D D D D D D D D D D D D D D D D D D D D D D D D D

NOTE: USE THIS SECTION TO SHOW HOW THE FIRM OR CORPORATION REPRESENTATIVES PROPOSE TO ENSURE THE GOVERNMENT THEY HAVE ADEQUATE EQUIPMENT TO PERFORM THE SERVICES THAT MAY BE REQUIRED UNDER THESE SECTIONS. FOR EXAMPLE AND FOR ANY EQUIPMENT NOT OBSERVED ON THE DATE OF INSPECTION, DESCRIBE THE METHOD (e.g., rental, acquisition, etc.) PROPOSED OR EVIDENCE USED BY THE FIRM REPRESENTATIVE TO ENSURE THE AVAILABILITY OF SUCH

EQUIPMENT.

2. COMMENTS

NOTE: PROVIDE HERE COMMENTS ON PERSONAL PROTECTIVE EQUIPMENT AND ANY ITEMS TO TOPICS OF SAFETY NOT ADDRESSED IN THE PRECEDING SECTIONS. THE FOLLOWING IS A LIST OF SOME ITEMS THAT SHOULD BE ADDRESSED; USE THE COMMENTS SECTION TO PROVIDE EXPLANATORY STATEMENTS. FOR THOSE ITEMS OF PERSONAL EQUIPMENT (e.g., safety shoes) THAT ARE NOT NORMALLY OR REASONABLY EXPECTED TO BE SEEN FOR THIS INSPECTION, IT IS SUFFICIENT TO PROVIDE REMARKS ON

THESE ITEMS IN THE COMMENT SECTION.

1a. b. PHOTO(s) c. 1a. b. PHOTO(sJ c.

CONDITION CONDITION

EQUIPMENT ITEM YES NO CODE EQUIPMENT ITEM YES NO CODE

WELDING SAFETY EQUIPMENT D D EYE PROTECTION D D

LEG CHAPS D D GLOVES D D

PERSONAL FLOTATION DEVICES D D SAFETY SHOES (Steel toe, spark proof) D D

EAR PLUGS D D PROTECTIVE CLOTHING D D

BLAZE ORANGE SAFETY VEST D D D D

PROTECTIVE MASK D D D D

BREATHING APPARATUS D D D D

HARDHATS D D D D

CELRH FORM 2800, MAY 2010 Exhibit 0

2. COMMENTS

1. PROVIDE HEREAWRITIEN SUMMARIZATION OF THE INSPECTION RESULTS TOGETHER WITH A FINAL RATING OF THE FIRM OR CORPORATION. INSPECTION RESULTS AND THIS SUMMARIZATION MUST SUPPORT A CONCLUSION MADE ON THE ADEQUACY OF

EQUIPMENT TO PROVIDE THE SERVICES UNDER THE REQUIREMENT CONTRACT.

D 2. OTHER DOCUMENTATION AND OR PHOTO(s) ARE ATTACHED

1a. E-MAIL ADDRESS b. NAME AND JOB TITLE (Last, First Ml)

c. DATE OF INSPECTION (YYYYMMDD) d. INSPECTOR'S SIGNATURE

CELRH FORM 2800, MAY 2010 Page 4 of 4

Exhibit 0

Exhibit O

Vehicle Operation Record, CELRH 2813

Pre-Operation Checklist, CELRH 2796

Property Control Receipt, ENG Form 4900-R, ENG Form 4866 m >< :r tr "tJ

ADMINISTRATIVE VEHICLE OPERATIONAL RECORD

1. REPORT PERIOD (lncluda Dates) 2. NOMENCLATURE 3.GROUP 4. TAG NUMBER I BAR CODE I ADMIN NO.

FROM TO

5. LOCATION ACTIVITY 6. START MILEAGE 7. SIGNATURE OF DISPATCHER

DATE u NAME OF DRIVER DESTINATION SPEEDOMETER TRIP PR&C FUNDED

ADDEDTOTAL TRIP

INSPECTION

(YYYYMMDD) CODE READING END OF MILEAGE NUMBER WORK ITEM STATUS

TRIP (PR&CLine NFN Number) GAS/GAL. OIL/QT. (No faults noted)

a. b. c. d. e. f. g. h. I. j. k.

I. TOTAL - .,.

::~~i~~~~,~~~~

CELRH FORM 2813, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. \IERSION1.0

EQUIPMENT PRE-OPERATIONAL CHECKLIST 1. TYPE OF EQUIPMENT OR PLANT NUMBER 2. WORK ORDER NUMBER

The proponent agency is CELRH-OR.

INSTRUCTIONS: Prior to operating any government Vehicle or Boats, the Contractor shall perform the following inspection. Should the inspection reveal the need for corrective action(s), the Contractor shall, prior to operating the equipment, contact the COR. Put remarks below on this form to document any service needs or comments. Write "None" if item does not apply.

NOTE: CHECKS ARE PERFORMED BEFORE, DURING AND AFTER EQUIPMENT OPERATIONS.

INSPECTED ITEM DESCRIPTION OK NEEDS SERVICED INSPECTED ITEM DESCRIPTION OK NEEDS SERVICED

1. ENGINE OIL LEVEL D D 1. HULL CONDITION D D

2. TRANSMISSION FLUID LEVEL D D 2. MOORING ROPES, ANCHOR, POLE, D D BUMPERS OR PADDLES

3. RADIATOR COOLANT D D

3. FUEL SUPPLY LEVEL (3/4 or more full) D D

4. HYDRAULIC OIL LEVEL D D

4. BATTERY CONDITION D D

5. POWER STEERING LEVEL D D

5. OIL LEVEL D D

6. FUEL TANK LEVEL (314 or more fu/Q D D 6. HOUR METER (If supplied) READING

7. GEAR BOX OIL LEVEL D D D D

8. SEAT BEL TS 0 D

9. ROLLOVER PROTECTION D D 7. BILGE VENTILATION AND LEAKAGE D 0

10. PARKING BRAKE D 0 8. STEERING CONTROLS D 0

11. FIRE EXTINGUISHER D D 9. NAVIGATION EQUIPMENT D D (Lights, horns, etc.,)

12. REVERSE SIGNAL ALARM D D

10. PROPELLER CONDITION D D

13. EMERGENCY FLASHERS D 0

11. ENGINE AND LOWER UNIT 0 0

14. REFLECTIVE TRIANGLE D D

12. WINDSHIELD AND OPERATOR D D 15. FIRST AID KIT D D COMPARTMENT

16. TIRE PRESSURE D D 13. FIRE EXTINGUISHER CONDITION 0 D

17. TRACK ADJUSTMENT D D 14. CLEANLINESS D D

18. LUBRICATE AND GREASE AS 15. COOLANT LEVEL 0 0

RECOMMENDED BY MANUFACTURER D D

MANUAL LUBE ORDER 16. BODY DAMAGE D 0

19. LIGHTS D D 17. FLOTATION SAFETY DEVICES D D

20. CLEANLINESS D D 18. COMMUNICATION EQUIPMENT D D

21. OTHER: D D 19. OTHER: D D

22. PREVENTATIVE MAINTENANCE CHECKS & SERVICES REMARKS 20. PREVENTATIVE MAINTENANCE CHECKS & SERVICES REMARKS

c. ISSUED BY SIGNATURE c. RETURNED BY SIGNATURE

Sa. ISSUED TO DATE (YYYYMMDD) b. TIME (0001-2400 hours) ?a.RETURNED TO DATE (YYYYMMDD) b. TIME (0001-2400 hours)

c. ISSUED TO SIGNATURE c. RETURNED TO SIGNATURE

CELRH FORM 2796, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Exhibit P

VERSION "1.1

::l" C"

PROPERTY CONTROL RECEIPT (ER 700-1-1) Sheet of -- -- LOSING HAND RECEIPT HOLDER (HRH) GAINING HAND RECEIPT HOLDER (HRH) FIPS EXCESS/TRANSFER

Name: Name: Date:

OffSym:

HRH Number: OffSym: HRH Number:

Reviewed By: (Name)

Room No: Phone: Room No: Phone:

Signature: Signature: Signature:

REQUESTED ACTION TRANSFER (To Another UIC)

TRANSFER (Internal Only) RETURN DATE Gaining Command: Gaining UIC:

Gaining PBO:

PROPERTY PASS

Ship to Address:

REPAIR (Property Ptiss)

EXCESS Recetved By: Date:

ITEM BAR TAG NOMENCLATURE COND. SERIAL ACQUI. ACQUISITION DOCUMENT

NO. NUMBER CODE NUMBER DATE PRICE NUMBER

PRINT/TYPE: NAME/OFFICE SYMBOLNENDOR REMOVING OR RECEIVING PROPERTY: SIGNATIJRE AND DATE:

LOSINGPBO: Date:

Aetlon Posted By:

ENG FORM 4900-R, DEC 1992

ENG 4900-R Received In Logistics For Processing: Date:

Received By:

FEB 92 EDITION IS OBSOLETE. (Proponent CELO-MS.S) PEv1.DO

>< ::r O" "'tJ

INTERIM HAND RECEIPT

For use of this fonn, see ER 700-1-1; the proponent agency is CELO-MS

TAG NUMBER NOMENCLATURE NSN/MCN SERIAL NUMBER LOCATION HRA

I, THE UNDERSIGNED, ACKNO\NLEDGE RECEIPT OF THE ABOVE ITEM.

1. PRINTED NAME 2. DATE (YYYYMMDD) 13. SIGNATURE

4. ADDITIONAL COMMENTS, NOTES, INSTRUCTIONS OR REMARKS

ENG FORM 4868, AUG 1989 PREVIOUS EDITIONS ARE OBSOLETE.

Exhibit P

Inspection Forms

O"

D

INSPECTION CHECKLIST, CLEANING SERVICES RECREATIONAL AREAS 11 · PROJECT (Location) The proponent agency Is CELRH-CT.

Routine Uses: Validation of Services and Maintenance Performed to the Contractual Standard.

3. CONTRACT NUMBER 4. CONTRACTOR 5. WORK ORDER NUMBER

7a. SERVICE CONTRACT REQUIREMENT

CLEANING SERVICES RECREATIONAL AREAS

1. SAFE WORKING HABITS

2. SERVICEABILITY OF EQUIPMENT

3. RESTROOMS AND PICNIC SHELTERS

4. PLUMBING AND LIGHTING FIXTURES

5. INSECTS AND THEIR NESTS

6. ,coMMODES, URINALS, LAVATORIES AND

TOILET TISSUE

7. I CREEK BANKS, RIPRAP AND SHORELINE

8. 1 WALLS (Inside and Out}, FLOORS,CEILINGS,

2. DATE SERVICE PERFORMED

(YYYYMMDD)

6. WEATHER CONDITIONS

Sa. DATE (YYYYMMDD)

b. TIME (0001 - 2400 Hours}

c. SIGNATURE (CR or QC/ Who Reviewed)

ROOFS, WINDOWS AND MIRRORS

--------+---+---+---+--+--+--+---+---+---+---+---+--49a.DATE(YYYYMMDD)

9.

10.

11.

12.

13.

14.

15.

I 16.

!CLEANING COMPOUNDS AND SANITARY

METHODS

FISHING PIERS

RECEPTACLES

UNIFORMED EMPLOYEES AND MARKED

VEHICLES

GROUNDS, ROADS, PARKING LOTS AND PAVED

AREAS

PICNIC SHELTERS, PICNIC TABLES AND PARK

BENCHES

b. TIME (0001 - 2400 Hours)

c. SIGNATURE (CR or QC/ Who Received a Copy)

GRILLS AND COOKERS

DRINKING FOUNTAINS

10. SEE PAGE 2 FOR NOTED

------------+--+--+---t----r--1----t---t--t---t--1--1!------1Q DEFICIENCY DESCRIPTION(S) (If

Applicable)

CELRH FORM 2773·2, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of2 er D

7a. SERVICE CONTRACT REQUIREMENT

CLEANING SERVICES RECREATIONAL AREAS

18.

19.

20.

21.

PLAYGROUND EQUIPMENT AND BALLPARKS

TRAILS

REPORTING OF DAMAGED OR

MALFUNCTIONING EQUIPMENT

11a. DATE (YYYYMMDD) I b. SIGNATURE (lnspectoQ 12a. DATE (YYYYMMDD) I b. SIGNATURE (COR)

14. COMMENTS AND DEFICIENCIES, WHICH SHALL BE CORRECTED BEFORE WORK WILL BE ACCEPTABLE AND SATISFACTORY ARE AS FOLLOWS

15. COMMENTS ON CORRECTION OF DEFICIENCIES.

18. INSPECTOR'S E-MAIL ADDRESS 17a. DATE (YYYYMMDD) b. SIGNATURE FINAL (lnspectoc)

CELRH FORM 2773-2, AfAV 2010 Page2 of2

>< :::r

CT

D

INSPECTION CHECKLIST JANITORIAL SERVICES

The proponent agency is CELRH-CT.

1. PROJECT (Location) 2. DATE SERVICE PERFORMED

(YYYYMMDD)

Routine Uses: Valklatlon of Services and Maintenance Performed to the Contractual Standard.

3. CONTRACT NUMBER 4. CONTRACTOR 5. WORK ORDER NUMBER 6. WEATHER CONDITIONS

7a. SERVICE CONTRACT REQUIREMENT

1.

2.

3.

4.

5.

6.

7.

6.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

JANITORIAL SERVICES

SAFE WORKING HABITS 8a. DATE (YYYYMMDD)

SERVICEABLE EQUIPMENT

I REMOVE TRASH AND REPLACE RECEPTACLE

LINERS

b. TIME (0001 - 2400 Hours)

!VACUUM CARPET

--------------+---+---t---+---11----t--+---+---+---t--r--+---1c. SIGNATURE(CRorQCI Who Revfewed)

SWEEP FLOORS

MOP FLOORS AND WAX

SIDEWALKS

CLEAN MATS

OUSTING AND ASHTRAYS 9a. DATE (YYYYMMDD)

I CLEANING GLASS, WINDOW SILLS AND

HARDWARE

-----------+--+---1---1---1---+---+---1---+---t---11--1----1 b. TIME (0001-2400 Hours)

DRINKING FOUNTAINS

DISPLAYS

--------------+---+---+-~--1--+---+---t---+--l'---i--+---1 c. SIGNATURE (CR or QC/ Who RecelWd

SPOT CLEANING a Copy)

CLEAN GROUNDS

INSECT NESTS AND COB WEBS

PARKING LOTS SWEPT

LIGHTS 10. SEE PAGE 2 FOR NOTED

-------------1---1---11--11---11--11---11---1---1---1---1---1----10 DEFICIENCY DESCRIPTION(SJ (If

RESTROOMS Appllcab/e)

CELRH FORM 2773-3, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Pege 1 of2

7a. SERVICE CONTRACT REQUIREMENT

20.

21.

22.

23.

JANITORIAL SERVICES

PARKING LOTS HOSED (Per Working Schedule)

UNIFORMED EMPLOYEES AND MARKED

VEHICLES

11a. DATE (YYYYMMDD) I b. SIGNATURE (Inspector) 12a. DATE (YYYYMMDD) I b. SIGNATURE (COR)

14. COMMENTS.AND DEFICIENCIES, WHICH SHALL BE CORRECTED BEFORE WORK WILL BE ACCEPTABLE AND SATISFACTORY ARE AS FOLLOWS m >< :::r -· C"'

15. COMMENTS ON CORRECTION OF DEFICIENCIES.

0 I 16. INSPECTOR'S E-MAIL ADDRESS

CELRH FORM 2713-3, MAY 2010

17a. DATE (YYYYMMDD) b. SIGNATIJRE FINAL (Inspector)

Page2of2

>< ::r -· C"

INSPECTION CHECKLIST GRASS MOWING AND MAINTENANCE

The proponent agency ls CELRH-CT.

Routine Uses: Valldatlon of Services and Maintenance Perfonned to the Contractual Standard.

3. CONTRACT NUMBER 4. CONTRACTOR

7a. SERVICE CONTRACT REQUIREMENT

GRASS MOWING AND MAINTENANCE

1. SAFE WORKING HABITS

2. SERVICEABLE EQUIPMENT

3. MOWING:

4. I GENERAL APPEARANCE

1. PROJECT (Locetfon)

5. WORK ORDER NUMBER

2. DATE SERVICE PERFORMED

(YYYYMMDD)

6. WEATHER CONDITIONS

Ba. DATE (YYYYMMDD)

b. TIME (0001 - 2400 Hours)

-----------1---1---+---lf---T--+---t---+---1--t----1---;---ic. SIGNATURE (CR orQCI Who Reviewed) 5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

I 18.

HEIGHT OF CUT

PREVENTION OF SCALPING

TIRE DAMAGE TO TURF

RAKING

TRASH AND LIITER REMOVAL 9a. DATE (YYYYMMDC>)

SWEEPING SIDEWALKS AND PAVED AREAS

TRIM WORK: b. TIME (0001 - 2400 Hours)

I

DITCH LINES AND ROADWAYS

RIPRAP (Foundation of Large Stones)

CREEK BANKS

SHORELINE

PIEZOMETERS (Mllasures Pl&88Ure snd or CompressibUlty)

c. SIGNATURE (CR orQCI Who Received a Copy)

PLANT BEDS

LANDSCAPED MOUNDS

10. SEE PAGE 2 FOR NOTED

----------+--+--+--+--+--+--t----+---+---+----1----1--10 DEFICIENCYDESCRIPTION(SJ (If

Appllcsble)

CELRH FORM 2773-5, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Paga 1 of2

::l"' O"'

7a. SERVICE CONTRACT REQUIREMENT

20.

21.

22.

23.

GRASS MOWING AND MAINTENANCE

PREVENTION OF DAMAGE TO DAM

INSTRUMENTATION

UNIFORMED EMPLOYEES AND MARKED

VEHICLES

11a. DATE (YYYYMMDD) I b. SIGNATURE (Inspector)

13. PROJECT (Locetlon}

128. DATE (YYYYMMDD) I b. SIGNATIJRE (COR)

14. COMMENTS AND DEFICIENCIES, WHICH SHALL BE CORRECTED BEFORE WORK WILL BE ACCEPTABLE AND SATISFACTORY ARE AS FOLLOWS

15. COMMENTS ON CORRECTION OF DEFICIENCIES.

16. INSPECTOR'S E-MAIL ADDRESS 17a. DATE (YYYYMMDD) b. SIGNATURE FINAL (Inspector}

CELRH FORll 2m-s, MAY 2010 Page2of2

::r C" D

INSPECTION CHECKLIST CONTRACTORS QUALITY CONTROL PROGRAM 11· PROJECT (Locstion) The proponent agency is CELRH-CT.

Routine Uses: Validation of Services and Maintenance Performed to the Contractual Standard.

3. CONTRACT NUMBER 4. CONTRACTOR 5. WORK ORDER NUMBER

7a. SERVICE CONTRACT REQUIREMENT

CONTRACTORS QUALITY CONTROL PROGRAM

1. SAFE WORKING HABITS

2. !SERVICEABLE EQUIPMENT

3. CONTRACTORS INSPECTION SYSTEM

4. CONTRACTORS METHOD OF IDENTIFYING

2. DATE SERVICE PERFORMED

(YYYYMMDD}

6. WEATHER CONDITIONS

8a. DATE (YYYYMMDD)

b. TIME (0001 - 2400 Hours)

I I DEFICIENCIES

FILE OF CONTRACTOR CONDUCTED I I I I I I I I I I I I I c. SIGNATURE (CR or QC/ Who Reviewed)

5. INSPECTIONS

6.

7.

I s. I I I I I I I I I I I I I !Sa.DATE(YYYYMMOO) 9.

I 10. I I I I I I I I I I I I I I b. TIME (0001 - 2400 Houis) 11.

I ::: I I I I I I I I I I I I I 1~:,~:RE{CRorQC>-- 14.

15.

16.

I 17

· I I I I I I I I I I I I I I 10.SEEPAGE2FORNOTED

.0 ~:;~:fy DESCRIPTION(S)(lf

CELRH FORM 2n3·10, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 af2 VERSlON 1.1 tr ;:j:

7a. SERVICE CONTRACT REQUIREMENT

CONTRACTORS QUALITY CONTROL PROGRAM

20.

21.

22.

23. 13. PROJECT (Location)

24.

11a. DAlE (YYYYMMDD) I b. SIGNATURE (lnspectorj 12a. DAlE (YYYYMMDD) I b. SIGNATURE (COR)

14. COMMENTS AND DEFICIENCIES, WHICH SHALL BE CORRECTED BEFORE WORK WILL BE ACCEPTABLE AND SATISFACTORY ARE AS FOLLOWS

15. COMMENTS ON CORRECTION OF DEFICIENCIES.

16. INSPECTOR'S E-MAIL ADORESS 17a. DAlE (YYYYMMDD) b. SIGNATURE FINAL (Inspector)

CELRH FORll 2773-10, MAY2010 Page 2of2

>< :::r C" D

1.PROJECT 2. CONTRACT NUMBER 3. CONTRACTOR 4. WORK ORDER NUMBER 5a. START DATE (YYYYMMDD)

PLAYGROUND INSPECTION

CHECKLIST

The proponent agency Is CELRH-OR· TR. b. ENO DATE (YYYYMMDD)

6.AREAS RATING CODES 0 7. FOR ANY RATING OF 2 OR 3, SEE PAGES 2 OF 3 AND 3 OF 3 FOR (1) NO PROBLEMS, SAFE FOR PUBLIC USE.

(2} INADEQUATE, NEEDS CORRECTION, BUT NOT AN IMMEDIATE DANGER. DESCRIPTION OF PROBLEM, DANGER OR CORRECTION NEEDED.

(3) UNACCEPTABLE, CONTRACTOR SHALL IMMEDIATELY TAKE ACTION TO

REMOVE lHE PARTICULAR ITEM FROM PUBLIC USE AND NOTIFY COR. SAT. SUN. MON. TUE. WED. THU. FRI.

a. VISIBLE CRACKS, BENDING, WARPING, RUSTING OR BREAKAGE OF ANY COMPONENT

b. DEFORMATION OF OPEN HOOKS, SHACKLES, RINGS, LINKS ETC.,

c. WORN SWING HANGERS AND CHAINS

d. MISSING, DAMAGED OR LOOSE SWING SEATS, HEAVY SEATS WITH SHARP EDGES OR CORNERS

e. BROKEN SUPPORTS AND ANCHORS

f. FOOTINGS EXPOSED, CRACKED OR LOOSE IN GROUND

g. ACCESSIBLE SHARP EDGES OR POINTS

h. EXPOSED ENDS OF TUBING THAT SHOULD BE COVERED BY PLUGS OR CAPS

I. PROTRUDING BOLT ENDS THAT DO NOT HAVE SMOOTH FINISH CAPS OR COVERS, LOOSE BOLTS, NUTS ETC.

j. SPLINTERED, CRACKED OR OTHERWISE DETERIORATED WOOD

k. BROKEN OR MISSING RAILS, STEPS, RUNGS OR SEATS

I. SURFACING MATERIAL WORN OR SCATTERED (In landing pits, etc.,)

m. CHIPPED OR PEELING PAINT

n. VANDALISM (Broken glssB, trash. etc.,)

o. PINCH CRUSH POINTS (Exposed Mechankmls, junctwe of moving components, e.g., axis of seesaw)

p. TRIPPING HAZARDS SUCH AS ROOTS, ROCKS OR OTHER ENVIRONMENTAL OBSTACLES

q. POOR DRAINAGE AREAS

r. UNSAFE ACCESS s.OTHER

t. ACTUAL TIME INSPECTION COMPLETED (using m0it81y time 0001 • 24-00 hours)

u. INITIALS OF CONTRACTOR INSPECTOR

ALL PLAYGROUND EQUIPMENT

Ba. DATE (YYYYMMDD) b. CONTRACTOR'S SIGNATURE 9a. DATE (YYYYMMDD) b. COR'S SIGNATURE

DESCRIBED IN THE CONTRACT HAS

BEEN INSPECTED AS INDICATED.

CELRH FORM 2788, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE. Page 1 of3

VERSION1.1

:T C"

THIS NOTICE IS TO ADVISE YOU OF DEFICIENCIES FOUND DURING INSPECTION. THE DEFICIENCIES FOUND ARE IN THE PERFORMANCE AND I OR QUANTITY OF WORK. THE

DEFICIENCIES ARE TO BE CORRECTED AS SPECIFIED.

10a. LOCATION

b. COMMENTS AND DEFICIENCIES, WHICH SHALL BE CORRECTED BEFORE WORK WILL BE ACCEPTABLE AND SATISFACTORY ARE AS FOLLOWS;

c. COMMENTS ON CORRECTIONS OF DEFICIENCIES:

11a. INSPECTOR'S NAME (Last, F/rstMI) b. DATE (YYYYMMDD) c. INSPECTOR'S SIGNATURE

CELRH FORM 2788, MAY 2010 Page2 of3

THIS NOTICE IS TO ADVISE YOU OF DEFICIENCIES FOUND DURING INSPECTION.

12a. LOCATION

b. COMMENTS AND DEFICIENCIES:

c. COMMENTS ON~ ACTION TAKEN

[ I 13a. CONTRACTOR INSPECTOR'S NAME (Last, First Ml} I I I c. CONTRACTOR INSPECTOR'S SIGNATURE b. DATE (YYYYMMDD) D

CELRH FORll 2788, MAY2010 Page 3of3

1. PROJECT 2. CONTRACTOR 3. CONTRACT NUMBER

SWIMMING BEACH

INSPECTION CHECKLIST

The proponent agency is CELRH-OR-TR. 4. WORK ORDER NUMBER

DIRECTIONS: CHECK "YES'' OR "NO" AS APPROPRIATE. LIST ANY REMARKS, FOR ANY DEFICIENCY, SAFETY HAZARD OR PROBLEM, PUT A NUMBER IN THE REMARKS COLUMN. THEN LIST THAT NUMBER WITH A CORRESPONDING DETAILED DESCRIPTION OF THE PROBLEM.

TASK YES NO

1. BEACH AREA ABOVE THE WATER LINE 0 0

a. SIGNS 0 0

(1) ARE ALL SIGNS SHOWN OR EXHIBITED IN PLACE? 0 0

(2) IN GOOD CONDITION - LEGIBLE? 0 0

b. BEACH RULES 0 0

(1) CLARITY IDENTIFIED? 0 0

(2) LEGIBLE? 0 0

c. SAFETY EQUIPMENT (List furnished by CQR) 0 0

(1) IS THE EQUIPMENT READILY AVAILABLE? 0 0

(2) IS IT COMPLETE AND OPERABLE? 0 0

(3) CLEARLY MARKED? 0 0

d. BEACH SURFACE 0 0

(1) DOES SAND (or soft materiaO COVER ALL OF THE DESIGNATED 0 0 AREAS?

(2) SMOOTH AND FREE FROM EROSION? 0 0

(3) CLEAR OF WEEDS AND GROWTH? D D

(4) CLEAR OF LITIER (Glass, can lids, etc.,)? D D

e. TELEPHONE D D

(1) OPERATIONAL? D D

(2) ANY REPAIRS REQUIRED? D D

(3) EMERGENCY NUMBERS POSTED? 0 0

2. SWIMMING AREAS 0 D

a. BUOY LINES AND MARKER BUOYS (Locations and depths specific 0 0 to the site)?

(1) ARE THE BUOY LINES PROPERLY INSTALLED? 0 0

(2) HAVE THEY MOVED FROM THEIR ORIGINAL POSITION? D D

(3) ARE THEY IN GOOD CONDITION? D 0

(4) ARE THEIR ROUGH PARTS THAT COULD INJURE? D D

(5) ARE BOAT WARNING BUOYS PROPERLY PLACED? 0 D

b. WATER DEPTH INDICATORS? D D

(1) ARE THEY PRESENT AT THE DESIGNATED LOCATION? D D

(2) ARE THEY LEGIBLE? D D

c. WATER CONDITIONS FAVORABLE D D

CELRH FORM 2790, MAY 2010 PREVIOUS EDITIONS ARE OBSOLETE.

REMARKS

ExhibitQ Page 1 of2

TASK YES NO REMARKS

(1) DESCRIBE WATER CLARITY (Abnormal Colorations)? D D

(2) IS THE SURFACE FREE OF FLOATING DEBRIS? D D

(3) ARE THEIR ANY IN WATER HAZARDS VISIBLE OR REPORTED D D BY SWIMMERS?

3. OTHER NOT PREVIOUSLY IDENTIFIED?

D D

1. DESCRIPTION OF DEFICIENCY, SAFETY HAZARD OR PROBLEM. GIVE EXACT LOCATION AND ANY RECOMMENDED CORRECTIONS.

{COR comments on deficiencies are located below).

2a. DATE OF INSPECTION (YYYYMMDD) b. TIME INSPECTION COMPLETED (0001-2400 hours) c. CONTRACTOR REPRESENTATIVE'S

SIGNATURE

3a. DATE RECEIVED (YYYYMMDD) b. COR'S SIGNATURE

4. COR'S COMMENTS ON THE CORRECTION OF DEFICIENCIES

CELRH FORM 2790, MAY2010 Page 2 of 2

Exhibit Q

EQUIPMENT INSPECTION f MAINTENANCE WORKSHEET F<:>" use ofUlls form,~ ER 750-1·1, lhu pr~c11tagencyi$ CELO·MS.

1. ACTIVITY 2. NOMENCLATURE f MOOEl

3. BAR CODE NUMBER 14. AOM!N. NUMBER 5 ACCOUNT CODE 6. MILES 7. HOURS It. DATE (YYYYMMOD!

9a. INSPECTOR (last, First MQ b. DATE (YYYYMMOD) c. INSPECTOR'S SIGNATURE

10a. SUPERVISOR (Las(. First MJ) b. DATE (YYYYMMOD) c. SUPERVISOR'S SIGNATURE

11. MAJNTENTANCE FAULT ANO ACTION

a. b. c. d. '" EQUIPMENT FAULT CORRECTIVE ACTION STATUS INITIALS HOURS

ENG FORM 5007, AUG 1989 PREVIOUS EDITIONS ARE OBSOLETE.

Exhibit Q