HI-15081-1_TE__4_-_Emergency_Repair_Work_Request.pdf

Technical Exhibit #4

Emergency Repair Work Request

1. From: Contracting Officer Representative/ To: Contractor Request For Diagnosis Authorizing Individual (COR/AI) Name: Mavis Takai Phone: 656-0389/864-1039 Email/Fax: mavis.f.takai.civ@mail.mil,

(808) 656-7771 Location: DPW, BOD, SCB Project Title: PM & Repair of the SPV SB Deep Well Water Plant

Contract Number: W912CN-XX-X-XXXX

Problem:

Notes/Comments:

COR Signature: Date and Time Notified:

Work Request Number:

2. From: Contractor To: COR Diagnostic Report Contractor Name:

POC: Phone: Fax:

Detail Diagnosis:_______________________________________________________________

Contractor Signature: Date and Time Diagnosis Completed:

3. From Contractor To: COR Repair And Cost Estimate Estimated Man hours: Estimated Cost of Materials:

Estimated Time to Complete Job:

Estimated Total Cost of Job:

Notes/Comments:_______________________________________________________________

Contractor Signature: Date and Time Fee Estimate Submitted:

4. From COR/AI To: Contractor Repair Approval

Signature:

Date and Time:

5. From Contractor To: COR/AI Repair Completion

Contractor Signature:

6. From: COR/AI To: Contractor Repair Inspected Notes/Comments:_______________________________________________________________

COR Signature: