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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />4/13/17 <br />Matt Chlebowski <br />U Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. _ <br />❑ Ease/Encroach. <br />n Other: -- <br />Company or Vendor Name <br />New Vendor <br />MBEIWBE Contractor <br />MBE/WBE 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 />Previous Amount <br />Department Central Services <br />U Contract <br />❑ Resolution <br />® Bid Award <br />❑ Quote Award <br />❑ C/O & PCA No. <br />❑ Traffic Control <br />Required Informati <br />Best Equipment Company, <br />❑ Yes Z No L1 If Y <br />F 1 MBE n WBE <br />Addendum <br />❑ Title Sheet <br />_❑ No ❑ Yes Name of Company <br />Spec D — One (1) or more 2016 or Newer 28 Cubic Yard Single Arm <br />Side Loadina Refuse Truck <br />2017 Solid Waste Capital Lease Principal 611-0610-415-37-11 and <br />Interest 611-0610-415-37-12 subject to lease funding) <br />Bid Opening Date: 3/14/17 <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 />0 <br />Dispersal After Approval <br />Matt Chlebowski & Sheila Enos <br />Mike Bronstetter, Al Greek, & Carol Kurzhal <br />