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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3-14-2019 <br />Department Utilities- Water <br />Name Bradley J. VanOosterum Treatment <br />BPW Date 3-19-2019 Phone Extension 5670 <br />Rewired Prior to Submittal to Board <br />Legal ® Attorney Name Sandra Kenned <br />Controller ® Controller review is required for all Contracts $5,000.00 or more anc <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />ecktpropriata Item_y _ or AlSubmissions <br />�����he A�Sub signs <br />Agreement <br />� <br />El Contract Proposal Addendum <br />Professional Services <br />❑ Resolution <br />Bid Opening <br />[_1 Bid Award ® Req. to Advertise ❑ Title Sheet <br />E] Quote Opening <br />Quote Award <br />❑ Change Order No. <br />FJ C/O & PCA No. ❑ PCA <br />Ease/Encroach. <br />❑ Traffic Control <br />Other: <br />�.... <br />Required Inforon <br />q Information <br />.......___ <br />Company or Vendor Name <br />_ .._ .. _. .....ww_ <br />Multii IeVendors <br />New Vendor <br />Yes E No F1 If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />[:1 MBE ❑ WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Water Treatment Chemicals 2019-2020 <br />Project Number <br />Funding Source <br />... _Y <br />Account No. <br />u gets. .... .._ .. <br />Vaario6s Openorational Bud .,�..........�.,,,�.. ... .. . �.�. <br />Amount <br />$ <br />Terms of Contract <br />1 — , __._. _.__..w _— ....... .........m.... ..�....... ....—........ .. .�. <br />YEAR <br />Purpose/Description <br />Cheurmical Bid needed to secu <br />re competitive pricing <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment E-Verify, Iran, etc. <br />m... Required For Chart e Orders.Ql <br />