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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date March 19, 2018 <br />Name Jacob M. Klosinski Department Utilities - Wastewater <br />BPW Date March 27, 2018 Phone Extension 574 235-9496 <br />I Agreement <br />U Contract <br />LI Proposal H Addendum <br />❑ Professional Services <br />❑ <br />Amendment <br />❑ Bid Opening <br />❑ <br />Bid Award <br />® Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Chg Order No. <br />❑ <br />CIO & PCA No. <br />❑ PCA <br />❑ <br />Ease./Encroach. <br />❑ <br />Traffic Control <br />❑ <br />Resolution <br />n <br />Other: <br />F I <br />Claim <br />Company or Vendor Name <br />New Vendor <br />MBEMIBE Contractor <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 />U Yes U If Yes, Approved by Purchasing <br />® No <br />❑ MBE Completed E-Verify Form Attached ❑ Yes <br />❑ WBE - ❑ No <br />Wastewater/Water Laboratory Equipment ICP-OES <br />nla <br />Previous Amount $ <br />Current Percent of Change: % <br />New Amount $ <br />Total Percent of Change: % <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />® <br />❑ <br />® <br />❑ <br />® <br />❑ <br />Al Greek, Director of Utilities <br />Jacob M. Klosinski, Assistant City Engineer <br />Emily Leyes, Director of Financial Services, Environmental Services <br />