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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2/15/2016 <br />Name George King <br />Department Administration and <br />Finance <br />BPW Date Phone Extension 9977 <br />Required Prior to Submittal to Board <br />Legal x Attorney Name MSchmidt <br />Controller x 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 x <br />Check the Appropriate Item Type — Required for All Submissions <br />Agreement ❑ Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award x 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 />Fl Other: <br />Company or Vendor Name <br />Required Information <br />Various Water Treatment Chemical <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 -21Q46=204=7-Water Treatment Chemical Bid <br />Project Number 1-7-2_0t9 <br />Funding Source Various Operational Budgets <br />Account No. <br />Amount $ <br />Terms of Contract One Year <br />Purpose/Description Water Treatment Chemicals <br />X Required Contractor's Certification Form Attached (Non -Collusion, <br />Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />Required For Change Orders Only <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 Original <br />x ❑ George King <br />❑ ❑ <br />❑ ❑ <br />