OMB APPROVAL
OMB Number 0704-0187
Expires:Dec. 31, 1993 ORDER FOR SUPPLIES OR SERVICES
Public reporting burden for this collection of information is
estimated to average 1 hour per response, including the time for
reviewing instructions, searching existing data sources,
gathering and maintaining the data needed and completing and
reviewing the collection of information. Send comments regarding
this burden estimate of any other aspect of this collection of
information, including suggestions for reducing this burden to
Washington Headquarter Services, Directorate for information
Operations and Reports, 1215 Jefferson Davis Highway, Suite 1204,
Arlington, VA 22202-4802 and to the Office of Management and
Budget, Paperwork Reduction Project (0704-0187), Washington, DC
20503.
PLEASE DO NOT RETURN YOUR FORM TO EITHER OF THESE ADDRESSES.
SEND YOUR COMPLETED FORM TO THE PROCUREMENT OFFICIAL IDENTIFIED
IN ITEM 6.
1. Contract/Purchase Order No.:
SP0450-96-D-4103
2. Delivery Order No.:
Z001
3. Date of Order:
June 10, 1996
4. Requisition/P.R. No.:
YPG95352000630
5. Certified for National Defense Under DMS Reg. 1:
6. Issued By: Code:
DEFENSE GENERAL SUPPLY CENTER SP0400
ATTN: DGSC PROCUREMENT
8000 JEFFERSON DAVIS HIGHWAY
RICHMOND, VA 23297-5803
A/C (804) 279-9220
FAX (804) 279-6008
7. Administered By:(if other than 6) Code:
DEFENSE GEN SUPPLY CENTER SP0400
DGSC-JDPD (P36) PH: 804-279-3220
8000 JEFFERSON DAVIS HIGHWAY
RICHMOND, VIRGINIA 23297-5804
SURV CRIT DES: CD: C
8. Delivery FOB:
X Dest
Other (See Schedule if Other)
9. Contractor/Quotes Code: Facility Code:
OL7A9 SEE SCHEDULE
Name and Address:
DELTA-OMEGA TECHNOLOGIES LTD.
7608 HIGHWAY 90 WEST
NEW IBERIA, LA 70560
10. Deliver to for Point By:
See Schedule
11. Check if Business is:
X Small
Small/Disadv.
Women Owned
12. Discount Terms:
Net 30
13. Mail Invoices to:
See Block #15
14. Ship to: Code:
See Schedule
15. Payment will be made by: Code: MARK ALL
PACKAGES &
DFAS - Columbus Center S44073 PAPERS WITH
Attn: DFAS-CO-SEG CONTRACT OR
P.O. Box 182317 ORDER NUMBER
Columbus, Ohio 43218-6231
16. Type of Order:
X Delivery
Purchase
This delivery order is issued on another Government agency or in
accordance with and subject to terms and conditions of above-
numbered contract.
Reference your written quote of and furnish the following on
terms specified herein
ACCEPTANCE: The contractor hereby accepts the offer represented
by the numbered purchase order as it may previously have been or
is now modified, subject to all of the terms and conditions set
forth, and agrees to perform the same.
Name of Typed Name
Contractor Signature and Title Date Signed
[ ] If this box is marked, supplier must sign Acceptance and
return
the following number of copies.
17. Accounting and Appropriation Data/Local Use
X GG: 97x4930 5CG0 01 0C26 S33-150
AA: 97x4930 5CG1 01 0C25 S33-150
19. Remarks:
If Block 16 is marked "Delivery", the terms and conditions of the
Basic Agreement are applicable.
If DGSC Administered (See Block 7 above), the Transportation
Office
Phone No. is 804-279-4589/4693.
* If quantity accepted by the Government is same as quantity
ordered, indicate by an X. If different, enter actual
quantity accepted below quantity ordered and encircle.
24. United States of America:
By: Signature illegible
Contracting/Ordering Officer
25. Total:
$27,500.00
26. Quantity on Attached Has Been:
[ ] Inspected
[ ] Received
[ ] Accepted and Conforms to the Contract Except as Noted
Date: Signature of Authorized Govt. Representative
27. Ship No.:
[ ] Partial
[ ] Final
28. D.O. Voucher No.
29. Differences:
30. Initials:
31. Payment
[ ] Complete
[ ] Partial
[ ] Final
32. Paid By:
33. Amount Verified Correct for:
34. Check Number:
35. Bill of Lading Number:
36. I certify this account is correct and proper for payment:
Date: Signature and Title of Cert. Officer
37. Received At:
38. Received By:
39. Date Received:
40. Total Containers:
41. S/R Account Number:
42. S/R Voucher Number:
CONTINUATION SHEET
Reference Number of Document Being Continued:
SP0450-96-D-4103-Z001
Page of 02
04 Pages
SHIPPING POINT/PLACE INSPECTION (SUPPLIES & PACKAGING):
SAME AS BLOCK 9, PAGE 1
INSPECTION OFFICE (SUPPLIES & PACKAGING):
DCMAO SAN ANTONIO
615 EAST HOUSTON STREET
P.O. BOX 1040
SAN ANTONIO, TX 78294-1040
CONTINUATION SHEET
Reference Number of Document Being Continued:
SP0450-96-D-4103-Z001
Page of 03
04 Pages
Name of Offeror or Contractor:
SECTION B
Item Supplies/ Unit
Number Services Quantity Unit Price Amount
PR YPC95352000630
NSN 6850-01-339-5228
ITEM DESCRIPTION:
CLEANING COMPOUND, AEROSPACE EQUIPMENT
QPL APPLIES
UNIT DRUM CONTAINS 55 GALLONS NET.
I/A/W SPEC NR MIL SPEC MIL-C-87937B
BASIC DTD 94 JAN 27
AMEND NR DTD
TYPE NUMBER: TYPE II
0001 PR YPG95352000630 100 DR $275.00 $27500.00
PRLI 0002
QTY VARIANCE: PLUS 5% MINUS 5%
INSPECTION POINT: ORIGIN
ACCEPTANCE POINT: ORIGIN
PREP FOR DELIVERY
PKGING DATA - MIL-STD-2073-1B&MIL-STD-2073-2C,
21 JUN 1991
QUP+001: PRES MTHD=10: CLNG/DRY=1: PRESV MAT=XX:
WRAP MAT=XX: CUSH/DUN MAT=XX: CUSH/DUNN THKNESS=X:
UNIT CONT=ZZ: LEVEL PRESV=A:
INTRMDTE CONT-YY: INTRMDTE CONT QTY=YYY:
PACK CODE=U: PACKING LEVEL=C:
MARKING SHALL BE IN ACCORDANCE WITH MIL-STD-129M
SPECIAL
MARKING CODE: ZZ-SPECIAL REQUIREMENTS.
SUPPLEMENTAL INSTRUCTIONS
DRUM SHALL CONFORM TO D.O.T. SPECIFI-
CATION FOR 1A1, 18/18 GAUGE. COLOR#
34084 OF FED-STD 595 OR BLACK. INTERIOR
COMPATIBLE W/CONTENTS. STENCIL MARKINGS.
BLOCK/BRACE ON TRANSPORT VEHICLE.
(Note: IAW Basic Contract)
DOD LOGMARS BAR CODE MARKING REQUIRED IAW MIL-STD
129M,
DATED 15 JUNE 93 AND MIL-STD-1189B, DATED 10 AUG 89
DELIVERY FOB: DESTINATION BY: 96 JUNE 01
PARCEL POST ADDRESS:
CONTINUED ON NEXT PAGE
CONTINUATION SHEET
Reference Number of Document Being Continued:
SP0450-96-D-4103-Z001
Page of 04
04 Pages
PR YPG95352000630 PRL1 0002 CONT'D
SW0400
DEFENSE DISTRIBUTION DEPOT RICHMOND
8000 JEFFERSON DAVIS HIGHWAY
RICHMOND, VA 23297-5900
FREIGHT SHIPPING ADDRESS:
SW0400
DEFENSE DISTRIBUTION DEPOT RICHMOND
CHIPPENHAM PARKWAY RTE 150 ENTRANCE
GATE 13
RICHMOND, VA 23297-5900
NON-MILSTRIP RDD 06/01/96 PROJ W1X
REMIT PAYMENT TO:
DELTA-OMEGA TECHNOLOGIES LTD.
7608 WEST HIGHWAY 90
NEW IBERIA, LA 70560