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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 4/7/2021 <br />Department Utilities - <br />Name Nancy Clay Wastewater <br />BPW Date 4/13/2021 Phone Extension 5793 <br />Review and Approval Required Prior to Submittal to Board <br />Diversity Compliance ❑ <br />Officer Name <br />and Inclusion Officer <br />BPW Attorney <br />® Attorney Name <br />Dept. Attorney ❑ Attorney Name <br />Clara McDaniels <br />Purchasing ® Michael Schmidt <br />Check the Appropriate Item Type — Required. for All Submissions <br />❑ Professional Services Agreement ❑ Contract ❑ Proposal <br />❑ Open Market Contract ❑ Amendment/Addendum ❑ Special Purchase, QPA <br />® ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />Bid Opening <br />❑ Quote Opening ❑ Quote Award ❑ Reject Bids/Quotes <br />❑ Proposal Opening ❑ C/O & PCA No. ❑ PCA <br />❑ Chg. Order, No. ❑ Traffic Control ❑ Resolution <br />❑ Other: ❑Ease./Encroach <br />� Reauired Information <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Multinle Vendors <br />❑ Yes ❑ If Yes, Approved by Purchasing <br />® No <br />❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />Water Treatment Chemicals 2021 - 2022 <br />Various Operational Budgets <br />$ Unit Bid Pricing <br />1 Year <br />Chemical bid needed to secure competitive pricing <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Increase % <br />Decrease ( %) <br />Increase % <br />Total Percent of Change: Decrease ( %) <br />Time Extension Amount: <br />