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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />1/30/17 <br />Matt Chlebowski <br />Department Central Services <br />BPW Date 2/14/17 Phone Extension 574-235-9316 <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 ® George King <br />Agreement <br />Professional Services <br />Bid Opening <br />Quote Opening <br />Change Order No. _ <br />Ease/Encroach. <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBENVBE Contractor <br />MBEMBE Contractor <br />Requested <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 />❑ Contract ❑ Proposal ❑ Addendum <br />❑ Resolution <br />® Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Award <br />❑ C/O & PCA No. ❑ PCA <br />❑ Traffic Control <br />RequiredInformation <br />Superior Equipment LLC <br />® Yes ❑ No ❑ If Yes Approved by Purchasing <br />MBE ❑ WBE <br />❑ No ❑ Yes Name of Company <br />Spec — (C)Various Roll Off Containers <br />2017 Solid Waste Capital Lease Principal 611-0610-415-3711/ <br />Interest 611-0610-415-3712(subject to lease funding) <br />Bid Opening Date:12/13/16 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment, E-Verify, Iran, et( <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy Original <br />® ❑ Matt C <br />® Mike E <br />Dispersal After Approval <br />Sheila E <br />& Carol N <br />Wisniewski, Central Services <br />Solid Waste <br />