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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 2-13-2018 <br />Department Utilities- Water <br />Name Bradley J. VanOosterum Treatment <br />BPW Date 2-20-2018 Phone Extension 5670 <br />Required Prior to Submittal to Board <br />Legal ❑ Attorney Name Clara McDaniels <br />Controller Controller review is requiired for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />0 a, 11 1111 <br />0 Agreement <br />H Contract LJ Proposal H Addendum <br />F-1 Professional Services <br />R Resolution <br />R Bid Opening <br />El Bid Award Req. to Advertise El Title Sheet <br />❑ Quote Opening <br />[I Quote Award <br />❑ Change Order No. <br />El C/O & PCA No. ❑ PCA <br />Ease/Encroach. <br />❑ Traffic Control <br />Other: <br />Company or Vendor Name <br />MultioleVendors <br />New Vendor <br />El Yes M No El If Yes, Approved by Purchasing <br />MBEANBE Contractor <br />[-] MBE n WBE <br />MBE,/WBE Contractor <br />Requested n No F] Yes Name of Company <br />Project Name <br />Water Treatment Chemicals 2018-2019 <br />Project Number <br />- <br />Funding Source <br />. . .... <br />Account No. <br />Various Operational Budgets <br />Amount <br />$ <br />Terms of Contract <br />1 YEAR <br />Purpose/Description <br />Chemical Bid needed to secure competitive pricing <br />El 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 El <br />increase $ <br />[:] <br />Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: % . .... ... <br />New Amount <br />$ <br />Total Percent of Change: % <br />Dispersal After Approval <br />Copy Original <br />E] <br />Michael Schmidt <br />❑ <br />Bradley J. Van Oosterum <br />El F] <br />