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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date October 18, 2016 <br />Name Jacob M. Klosinski Department Div. of Env. Services <br />BPW Date October 25, 2016 Phone Extension (574) 235-9496 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <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 />® Carol Kurzhal <br />II 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 />R Other: <br />I Required Information <br />Company or Vendor Name Greeley and Hansen, LLC <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 />Amount of <br />Previous Amount <br />Yes ZI No LJ If Yes, Approved by Purchasing <br />MBE ❑ WBE <br />Gas <br />116-050 R <br />Utilities, Wastewater Capital <br />642-0630-415-43-66 <br />Utilities requests the Board of Public Works approval of the Title Sheet <br />and Request to Advertise for the subject Project. This project will extend <br />mechanical piping from the WWTP Gas Cleaning System to the <br />Compressor Building and CNG Fuel Station. Note: Rebid <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Increase $ <br />Decrease $ <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Al Greek <br />Jacob M. Klosinski <br />Carol Kurzhal <br />Atter Approval <br />