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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 6/28/2023 <br />Department Public <br />Name Kieran Fahey Works <br />BPW Date 7/11/2023 Phone Extension 5993 <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 />M Schmidt <br />Dept. Attorney ® Attorney Name M Schmidt <br />Purchasing ❑ <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 Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <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: Opening of ❑ Ease./Encroach <br />Qualifications for WWTP CSO <br />tank via GSC contract <br />Required 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 />Yes ❑ If Yes, Approved by Purchasing <br />No <br />El MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />WWTP CSO tank RFQ Guaranteed savings contract <br />121-071 <br />Funding applied for to IFA <br />NA <br />NA <br />Terms of Contract Agenda Request for the Opening of Qualifications for the WWTP CSO <br />Tank RFQ Guaranteed Savings Contract — Project No. 121-071-a <br />Guaranteed Savings Contract for construction of CSO storage tank at South <br />Bend's WWTP. <br />Purpose/Description As above <br />For Chance Orders Onl <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount $ <br />Increase % <br />Current Percent of Change: Decrease % <br />New Amount $ <br />