TE_3_Latrine_Request_Form.pdf

NOTE: Do not dispose any material in the latrine other than TE#3 Subject: Portable Latrine Request Form items provided (tissue paper) by the contractor.

(Under $2,500 submit to Contractor - Over $2,500 submit to Resource Manager) Date: .

Contract # Service Order No.

Task Order No.

Contractor: Office Phone:

1. Request and provide portable latrines to support training/event indicatedbelow:

UIC #

2. Number of personnel tobe supported: Guidelines: Vendor recommends 1 latrine per 20 persons, based on past experience. Provide proper Grid Coordinates for the

3. Number of latrines requested: Latrine Location, stay close to the road.

4. Inclusive dates required: Required Start Time:

LATE CANCELLATION WILL APPLY IF CANCELLED ON THE DAY OF DELIVERY.

Location

5. (Name & Grid):

6. POC: Office #

Cell # EmailAddress:

7. GPC Card Holder Name: Phone #:

GPC Card #: Expiration Date:

Email receiptto:

Approving Official Name: Phone #:

Billing Address:

Actual charge date may differ. Date provided will

Date to Charge GPC: be used as a guideline.

SIGNATURE:

Unit/Activity:

8. CLIN # Units: DAY= D/W/EA x $ =

CLIN # Units: WEEK= D/W/EA x $ =

9. CLIN # Units: D/W/EA x $ = CLIN # Units: D/W/EA x $ =

10. CLIN # Units: D/W/EA x $ = CLIN # Units: D/W/EA x $ =

Verified By: Date: TOTAL:

Daily Usage Delivery Weekly Usage Emergency Delivery Daily Usage Handicap Emergency /Additional Cleaning Daily Usage/Remote Relocation Charge Latrine Request Form