FIELD MATERIAL REQUISITION / RETURN - SOLICITUD / RETORNO DE MATERIALES

Tipo de requerimiento
Material: Devolución (Return):
Compra (Ingenieria): RFQ / FMR No.
Equipo
(Tag) Bulk Pagina (Page) 1 de 1 Otros (others):

area CWP Fecha (Date) Entregar a / Deliver to : RAS (Required at site)

2000 26100040004 19/07/2022

Numero de contrato/ Numero de BoM Ing. / Engineering BoM No. Disciplina / Discipline
Contract No.

6. Cantidad 7. ESTIMATED VALUES

1. Código 3. UDM 5. Cant. Req. / Qty
2. Tamaño 4. Descripción (Description) Entregada / Qty.
(item / Size (Unit) Required UNIT RATE SUBTOTAL
Issued
code) /
Tag #
1 Pza TUBE-HYDRAULIC #20 ORS p/n 230-0699 1 622.00 622.00
2 Pza TUBE-HYDRAULIC #16 ORS p/n 230-0701 1 641.00 641.00
3 Pza TUBE-HYDRAULIC #20 ORS p/n 230-0702 1 887.00 887.00
4 Pza TUBE-HYDRAULIC 1 1/2IN p/n 230-0753 1 521.00 521.00
5 Pza O RING FF9446-29 (FOR #24 ORS FITTING) p/n 1801970 4 2.00 8.00
6 Pza O RING FF9446-21 (FOR #16 ORS FITTING) p/n 1801393 4 2.00 8.00
7 Pza HOSE ASSEMBLY p/n H237-LLL-061 1 334.00 334.00
8 Pza HOSE ASSEMBLY p/n H239-MMM-049 1 749.00 749.00
9 Pza SUPPORT HALVES/HOSE CLAMP p/n 1002791 4 11.00 44.00
10 Pza INSERT-RUBBER 1.25 ID 5320SRI p/n 1010129 4 13.00 52.00
11 Pza STUD-0.375 NC X 3.75IN LG-ZINC FINISH p/n 1009769 4 10.00 40.00
12 Pza LOCKNUT-0.375NC ESNA p/n 1932006 4 2.00 8.00
13 Pza SUPPORT HALVES 2 1/2IN p/n 1002798 4 26.00 104.00
14 Pza INSERT-RUBBER 1.50 ID 6381SRI p/n 1002800 4 32.00 128.00
15 Pza STUD-0.4375 NC X 5 LG.-ZINC PLATED p/n 1009768 4 7.00 28.00
16 Pza O RING FF9446-25 (FOR #20 ORS FITTING) p/n 1801394 4 2.00 8.00

(USD) TOTAL 4,182.00

THE FOLLOW INFORMATION IS REQUIRED TO PROCEED WITH THE ISSUANCE OF THE PURCHASE ORDER
Company PO to be issued by: PO to be signed by:
Code
SMI acting as agent for AAQSA AAQSA
SMI Purchase SMI
Fluor Purchase Fluor
OTHER COST ELEMENTS REIMBURABLE

COST CODE NOT REIMBURABLE

Servicios Minería, Inc. – Sucursal del Perú
DATE / DATE / Fecha :
ORIGINATOR / Preparado por: APPROVED BY CONTRUCTION:
Fecha :

Name and Signature / Nombre y Firma

Name and Signature / Nombre y Firma
DATE / DATE / Fecha :
MAT. CONTROL: SITE MANAGER:
Fecha :

Name and Signature / Nombre y Firma

Name and Signature / Nombre y Firma
DATE / DATE / Fecha :
PROJECT CONTROLS: PROJECT DIRECTOR:
Fecha :

Name and Signature / Nombre y Firma

Name and Signature / Nombre y Firma
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