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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date January 12, 2017 <br />Name Jacob M. Klosinski Department _Div. of Utilities (ORF) <br />BPW Date January 24, 2017 Phone Extension (574) 235-9496 <br />Legal ® Attorney Name Michael Schmidt, Assistant City Attornev <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 ® Carol Kurzhal <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement ❑ <br />Contract ❑ Proposal ❑ Addendum <br />❑ <br />Professional Services ❑ <br />Resolution <br />❑ <br />Bid Opening ❑ <br />Bid Award ® Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening ❑ <br />Quote Award <br />❑ <br />Change Order No. ❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. ❑ <br />Traffic Control <br />I-1 <br />Other: <br />Company or Vendor Name <br />New Vendor ❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name 2017 Trucking of Belt Pressed Biosolids for Land Application <br />Project Number <br />Funding Source Organic Resources, Contractual Services Other <br />Account No. 641-0631-793-63-35 <br />Amount $ <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />Request to advertise for the subject project for bid pricing at a "per <br />truck / per hour" price for the transportation of belt pressed biosolids <br />for land application (refer to memorandum for details). Advertise <br />01/27/2017 and 02/03/2017. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran. etc.) <br />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 />❑ Al Greek, Director of Utilities <br />® <br />❑ Jacob M. Klosinski, Assistan <br />® <br />❑ Carol Kurzhal, Director of Fir <br />Environmental Services <br />