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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4/25/17 <br />Department Environmental <br />Name Nancv Clav Services <br />BPW Date 5/9/17 Phone Extension 5793 <br />Re' uired Prior to Submittal fio Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Qg Agreement <br />Lj Contract U Proposal ] Addendum <br />❑ Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />�I Other: <br />Company or Vendor Name <br />Hach <br />New Vendor <br />❑ Yes ® No ❑ if Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ® No ❑ Yes Name of Company <br />Project Name <br />Annual Equipment Service Agreement <br />Project Number <br />V6WTP <br />Funding Source <br />O&M <br />Account No. <br />641 0630 793 6335 <br />Amount <br />$ 13,614 <br />Terms of Contract <br />One Year 6/18/17 to 6/17/18 <br />Purpose/Description <br />On -site service, calibration and replace parts for Hach Progress <br />Control Analyzers. <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease <br />$ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />❑ ❑ <br />❑ ❑ <br />