SURCHARGE FOR SUPER VACUUM TRUCK WORK

ORDER FOR SUPPLIES OR SERVICES 1. CONTRACT/PURCH ORDER/AGREEMENT NO. 2. DELIVERY ORDER/CALL NO. 4. REQUISITION/PURCH REQUEST NO.3. DATE OF ORDER/CALL (YYYYMMMDD) 5. PRIORITY 6. ISSUED BY 7. ADMINISTERED BY (If other than 6) 8. DELIVERY FOB CODE CODE 9. CONTRACTOR FACILITY CODE NAME AND ADDRESS 10. DELIVER TO FOB POINT BY (Date) (YYYYMMMDD) 12. DISCOUNT TERMS 13. MAIL INVOICES TO THE ADDRESS IN BLOCK Submit Invoices IAW DFARS 252.232-7003 DESTINATION OTHER (See Schedule if other) 11. X IF BUSINESS IS SMALL SMALL DISAD- VANTAGED WOMEN-OWNED 14. SHIP TO 15. PAYMENT WILL BE MADE BY CODE 16. TYPE OF ORDER DELIVERY/ CALL This delivery order/call is issued on another Government agency or in accordance with and subject to terms and conditions of above numbered contract. PURCHASE Reference your 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 CONTRACTOR SIGNATURE TYPED NAME AND TITLE DATE SIGNED (YYYYMMMDD) If this box is marked, supplier must sign Acceptance and return the following number of copies: 17. ACCOUNTING AND APPROPRIATION DATA/LOCAL USE 18. ITEM NO. 19. SCHEDULE OF SUPPLIES/SERVICES 20. QUANTITY ORDERED/ ACCEPTED* 21.UNIT 22. UNIT PRICE 23. AMOUNT * If quantity accepted by the Government is same as quantity ordered, indicate by X. If different, enter actual quantity accepted below quantity ordered and encircle. 24. UNITED STATES OF AMERICA CONTRACTING/ORDERING OFFICER 25. TOTAL 26. DIFFERENCES 27a. QUANTITY IN COLUMN 20 HAS BEEN INSPECTED RECEIVED ACCEPTED, AND CONFORMS TO THE CONTRACT EXCEPT AS NOTED: b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVEc. DATE (YYYYMMMDD) e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 28. SHIP. NO. 29. D.O. VOUCHER NO. 30. INITIALS 32. PAID BY FINAL PARTIAL 33. AMOUNT VERIFIED CORRECT FOR f. TELEPHONE NUMBER g. E-MAIL ADDRESS 36. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT. a. DATE (YYYYMMMDD) b. SIGNATURE AND TITLE OF CERTIFYING OFFICER DD FORM 1155, DEC 2001 37. RECEIVED AT 38. RECEIVED BY (Print) 39. DATE RECEIVED (YYYYMMMDD) PREVIOUS EDITION IS OBSOLETE. 31. PAYMENT COMPLETE PARTIAL FINAL 40. TOTAL CON- TAINERS 41. S/R ACCOUNT NUMBER 42. S/R VOUCHER NO. 34. CHECK NUMBER 35. BILL OF LADING NO. SP4500-20-D-0021 SP4500-23-F-1544 2022 DEC 11 See Schedule DLA DISPOSTION SERVICE - EBS DLA DISP SVCSS HAZ CONTRACT 74 NORTH WASHINGTON BATTLE CREEK MI 49037-3092 USA Criticality: C Pre-Award Survey : None 0RFA6 W31G1Y X TRI-STATE GOVERNMENT SERVICES, INC. 4762 HWY 58 STE 120 CHATTANOOGA TN 37416-2293 USA SEE SCHEDULE Net 30 days X X SEE SCHEDULE, DO NOT SHIP TO ADDRESSES ON THIS PAGE DEF FIN AND ACCOUNTING SVC BSM P O BOX 182317 COLUMBUS OH 43218-2317 USA X AA: 97X4930 5CBX 001 2520 S33189 $9399.00 $9,399.00 See Schedule SP4500 SP4500 SL4701 DLA DISPOSTION SERVICE - EBS DLA DISP SVCSS HAZ CONTRACT 74 NORTH WASHINGTON BATTLE CREEK MI 49037-3092 USA Local Admin: Elizabeth Roberts Tel: 215-737-8126 Email: Elizabeth.Roberts@dla.mil CODE Adobe Professional 8.0 Raymond Empie Raymond.Empie@dla.mil 2022 DEC 11 3.000 PAGE 1 OF 5 MARK ALL PACKAGES AND PAPERS WITH IDENTIFICATION NUMBERS IN BLOCKS 1 AND 2. Raymond Empie CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED: CONTINUED ON NEXT PAGE PAGE 2 OF 5 PAGES SP4500-20-D-0021 - SP4500-23-F-1544 COR: Alan George DOR: 6897 LIC: 4B LOC: ANAD POP: 14 Days After TO Issuance 3 Lines CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED: CONTINUED ON NEXT PAGE PAGE 3 OF 5 PAGES SP4500-20-D-0021 - SP4500-23-F-1544 SECTION B DO Counter: 000596 SUPPLIES/SERVICES: S222-V00013120 ITEM DESCRIPTION: Service: Surcharge for Permit - Required Confined Space Work, Daily, Crew of Three (3) (See 3.20), 0 HIN:1083SV ITEM NO. BASIC SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT REF CLIN . 0001 0030 S222-V00013120 1.000 EA $ 2,560.00 $ 2,560.00 Surcharge for Confined Space Work PRICING TERMS: Firm Fixed Price PREP FOR DELIVERY: See Attached Statement of Work. W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US M/F: (TCN) W31G1Y23132147 RDD: PROJ: TP 3 SUPP ADD: W31G1Y SIG: B FOR GOVERNMENT USE ONLY: (IPD) 15 DIC: DIST: ADV: FC: VE EPA WASTE CODE ______ UD QTY PICKED UP __________ UO UNIT OF ISSUE ________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ GOVT USE External External External Customer RDD/ ITEM PR PRLI PR PRLI Material Need Ship Date . 0001 7000815363 0001 AAHR2340 N/A N/A N/A * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SUPPLIES/SERVICES: S222-V00013114 ITEM DESCRIPTION: Service: Industrial Cleaning Services, Daily, Crew of Three (3) (See 3.14), 0 CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED: CONTINUED ON NEXT PAGE PAGE 4 OF 5 PAGES SP4500-20-D-0021 - SP4500-23-F-1544 SECTION B SUPPLY/SERVICE: S222-V00013114 CONT'D HIN:1007SV ITEM NO. BASIC SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT REF CLIN . 0002 0004 S222-V00013114 1.000 EA $ 5,389.00 $ 5,389.00 Industrial Cleaning Services, Daily PRICING TERMS: Firm Fixed Price PREP FOR DELIVERY: See Attached Statement of Work. W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US M/F: (TCN) W31G1Y23132148 RDD: PROJ: TP 3 SUPP ADD: W31G1Y SIG: B FOR GOVERNMENT USE ONLY: (IPD) 15 DIC: DIST: ADV: FC: VE EPA WASTE CODE ______ UD QTY PICKED UP __________ UO UNIT OF ISSUE ________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ GOVT USE External External External Customer RDD/ ITEM PR PRLI PR PRLI Material Need Ship Date . 0002 7000815364 0001 AAHM2340 N/A N/A N/A * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * SUPPLIES/SERVICES: S222-V00013121 ITEM DESCRIPTION: Service: Surcharge for Super Vacuum Truck Work, Daily, Crew of Three (3) (See 3.21), 0 HIN:1084SV CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED: PAGE 5 OF 5 PAGES SP4500-20-D-0021 - SP4500-23-F-1544 SECTION B SUPPLY/SERVICE: S222-V00013121 CONT'D ITEM NO. BASIC SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT REF CLIN . 0003 0031 S222-V00013121 1.000 EA $ 1,450.00 $ 1,450.00 Surcharge for Super Vacuum Truck Work PRICING TERMS: Firm Fixed Price PREP FOR DELIVERY: See Attached Statement of Work. W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US W31G1Y W0LX ANNISTON DEPOT PROP DIV ANNISTON ARMY DEPOT BLDG 513 7 FRANKFORD AVE ANNISTON AL 36201-5021 US M/F: (TCN) W31G1Y23132149 RDD: PROJ: TP 3 SUPP ADD: W31G1Y SIG: B FOR GOVERNMENT USE ONLY: (IPD) 15 DIC: DIST: ADV: FC: VE EPA WASTE CODE ______ UD QTY PICKED UP __________ UO UNIT OF ISSUE ________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ MANIFEST _____________________ PG/LINE CODE _____ PICKUP DATE _____________ GOVT USE External External External Customer RDD/ ITEM PR PRLI PR PRLI Material Need Ship Date . 0003 7000815362 0001 AAHP2340 N/A N/A N/A * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * AUTH TRANSPORTER NAME ______________________ AUTH TRANSPORTER EPS # ________________ AUTH TSDF NAME _____________________________ AUTH TSDF EPA # _______________________ TRANS SIGNATURE ____________________________ TRANS PRINTED NAME ____________________ KTR SIGNATURE ______________________________ KTR PRINTED NAME ______________________ AUTH COR SIGNATURE _________________________ AUTH COR PRINTED NAME _________________