80712 - Contract Data Requirements List A001 - Test Inspection Report

CONTRACT DATA REQUIREMENTS LIST

Form Approved

OMB No. 0704-0188

(1 Data Item)

The public reporting burden for this collection of information is estimated to average 110 hours 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 or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate (0704-0188). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Please do not return your form to the above organization. Send completed form to the Government Issuing Contracting Officer for the Contract/PR No. listed in Block E.

A. CONTRACT LINE ITEM NO.

B. EXHIBIT

0004

C. CATEGORY:

A

D. SYSTEM/ITEM

E. CONTRACT/PR NO.

F. CONTRACTOR

HALON ANALYZER

1. DATA ITEM NO.

A001

2. TITLE OF DATA ITEM

3. SUBTITLE

TEST/INSPECTION REPORT

N/A

4. AUTHORITY (Data Acquisition Document No.)

5. CONTRACT REFERENCE

DI-NDTI-80809/NOT 3

7. DD 250 REQ

NO

8. APP CODE

N/A

9. DIST STATEMENT

REQUIRED

A

17. PRICE GROUP

10. FREQUENCY

12. DATE OF FIRST SUBMISSION

1TIME

802 MXSS/MXDTA

14.

DISTRIBUTION

SEE BLK 16

11. AS OF DATE

SEE BLK 16

18. ESTIMATED

TOTAL PRICE

6. REQUIRING OFFICE

PD Para 2.4.1.1

13. DATE OF SUBSEQUENT

SUBMISSION

b. COPIES

a. ADDRESSEE

16. REMARKS

Final

Draft

SEE BLK 16

Reg

Repro

SEE BLOCK 16

BLK 10, 11, 12, 13: Within 10 days of successful testing, the Contractor shall provide an Installation Acceptance Report to verify that the installation and configuration were performed in strict accordance with technical specifications. Primary Govt POC: Michael Tew, [email protected]
Alternate Govt POC: Della Smith, [email protected]
CSMO/WAWF Primary: Dustin Knowles, [email protected] CSMO/WAWF Alternate: Kelsey Jackson, [email protected] Contracting Officer: Andrew Harth, [email protected]

15. TOTAL

G. PREPARED BY

H. DATE

Digitally signed by

CHANCE.TRACI.S.1242831710 CHANCE.TRACI.S.1242831710

Date: 2026.08.18 10:15:37 -04'00'

DD FORM 1423-1, FEB 2001

8/18/2026

I. APPROVED BY

8/18/2026

CHANCE.TRACI.S.12428317 Digitally signed by

CHANCE.TRACI.S.1242831710

Date: 2026.08.18 10:15:53 -04'00'

PREVIOUS EDITION MAY BE USED.

J. DATE

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