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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />4/21/17 <br />Jeff Hudak <br />Department Central Services <br />❑ <br />Agreement <br />❑ Contract LJ Proposal LJ 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 />F-1 <br />Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE 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 />Jordan Ford <br />Yes ® No ❑ If Yes, Approved by Purchasing <br />n MBE n WBE <br />❑ No ❑ Yes Name of Company <br />Spec G - One (1) or More 2017 or Newer One Ton Four Wheel <br />Drive Pickui) Truck <br />2017 Solid Waste Capital Lease Principal 611-0610-415-37-11 & <br />Interest 611-0610-415-37-12 subject to lease funding) <br />$ 44,132.00 <br />Bid Opening Date: 4/11/17 <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of ❑ increase <br />❑ Decrease <br />Previous Amount $ <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />® <br />❑ <br />❑ <br />❑ <br />Dispersal After Approval <br />Jeff Hudak & Sheila Enos, Central Services <br />Carol Kurzhal & Mike Bronstetter, Solid Waste <br />