Pollution Incident Daily Resource Report
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1
2CONTRACTOR/
U.S. DEP A RTME NT OF
SUBCONTRACTOR
HOMELAND SECURITY
POLLUTION INCIDENT DAILY RESOURCE REPORT
U.S. COAST GUARD
MATERIALS/OTHER EXPENSES
C G-5136E -3 (06-04)
Page
_____
of
_____
(RCN-16451-1)
FPN/CERCLA NUMBER
DATE
CONTRACTOR:
PO/CONTRACT NO:
If information described below is documented separately, in a form or format previously reviewed and found acceptable by the
National Pollution Funds Center and the Contracting Officer, this form need not be completed.
SUBCONTRACTORS
Were any subcontractors hired?
YES
NO
If yes, list them below and attach subcontractor Daily Reports
CLIN
SUBCONTRACTOR'S NAME
COST
ADMIN FEE
TOTAL COST
TOTAL COST OF SUBCONTRACTORS FOR THIS DATE:
MATERIALS USED/OTHER EXPENSES
CLIN
DESCRIPTION
UNITS
UNITS USED
UNIT COST
OFFICE USE
TOTAL COST OF MATERIALS USED/OTHER EXPENSES FOR THIS DATE:
CONTRACTOR'S CERTIFICATION:
ON SCENE COORDINATOR'S/LEAD TRUSTEE'S REVIEW:
I certify that this report is a true and complete record
I certify that inspection and acceptance of the listed items has been made by me
of the materials, labor, equipment and subcontractors
or under my supervision, except as noted herein or on supporting documents.
provided by the contractor on the date listed above for
the project number cited above:
Contractor's Authorized Representative
FOSC/Lead Trustee
Reset
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