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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 7-28-2016 <br />Name Manny Bueno <br />Department Environmental <br />Services <br />BPW Date 8-09-2016 Phone Extension 5798 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name <br />Controller ❑ Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. ❑ Traffic Control <br />F1 Other: <br />Company or <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />uired Information <br />Imagineering Finishing Technologies, Inc. <br />Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE I-1 WBE <br />Re-Newal - Industrial Discharge Permit <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination. Non -Debarment. E-Verifv. Iran. et( <br />uired For Chanoe Orders <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />