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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 5/16/19 <br />Name Michelle Smith Department Utilities Water Works <br />BPW Date 5/28/19 Phone Extension 5994 <br />u;niuiii- BIDIr;'Yh'Wvti2'f P'MJbA�kI.Y+YII�'INMVMViJ@fay... �W�'P��li�dtlli�:'/�YnfiMY.✓�'�YG�v3,' IPoNiYpP.WdvY&C!/ .ev NYk'd�WY/ <br />�...._ ......_. Required <br />................... ............... .._ w. <br />Prior to Submittal to Board <br />- �....... ... _.........._ <br />BPW Attorney ® Attorney Name Clara McDaniels <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate Item Type - <br />Professional Services Agreement E] Contract <br />❑ Open Market Contract <br />D <br />Amendment/Addendum <br />❑ Bid Opening <br />El <br />Bid Award <br />❑ Quote Opening <br />[l <br />Quote Award <br />Proposal Opening <br />[:] <br />C/O & PCA No. <br />[- <br />Chg. Order, No. <br />El <br />Traffic Control <br />El Other: <br />All Submissions <br />L Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise <br />E] Reject Bids/Quotes <br />PCA <br />El Resolution <br />Ease./Encroach <br />❑ Title Sheel <br />BZequiaed Information <br />Company or Vendor Name American St�.ru for j ointt <br />........ ...... _....r .. .. ......... <br />New Vendor ❑ Yeso If Yes, Approved by Purchasing <br />No <br />MBE/WBE Contractor � WBE Completed E-Verify Form Attached MBE❑❑ Nos <br />Project Name Wellhead Protection Plan 5-Year Update ......... <br />Project Number <br />�......... ....... ..... <br />Funding Source Water Works Operations & Maintenance <br />Account No. 620.0640.603.3135 <br />Amount $.................. �...�... .� ... <br />24,850 <br />Terms of Contract <br />Purpose/Description <br />Preparation of the Wellhead Protection Plan 5-Year Update that is required <br />by the Indiana Department of Environmental Management on or before <br />l/l/20 <br />_........... <br />For Change Orders1 <br />Amount of <br />Increase $ ...�... ..._���.w.....—...�.....m_a <br />❑ <br />Decrease ($ ) <br />Previous Amount <br />m . ............................... mm <br />$ <br />Increase /o <br />Current Percent of Change: <br />............... ..�.... „m�� .......... <br />Decrease ( %) <br />New Amount <br />............................................................a......................�.�................ <br />$ <br />�........... .............. <br />o _�......�....... <br />Increase /o <br />Total Percent of Change: <br />o ) <br />Decrease ( /o <br />Time Extension Amount: <br />New Comp ate: <br />Completion D..... <br />