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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date: 12/6/23 <br />Name: Gemma Stanton Department of Public Works — Engineering Division <br />BPW Date: 12/19/23 Phone Extension: 9083 <br />Required Prior to Submittal to Board <br />BPW Attorney X Attorney Name Michael Schmidt <br />Dept. Attorney ❑ Attorney Name <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Re uired or All Submissions <br />❑ Professional Services Agreement <br />❑ Contract <br />❑ Proposal <br />❑ Open Market Contract <br />❑ Amendment/Addendum <br />❑ Special Purchase, QPA <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Reject Bids/Quotes <br />❑ Proposal Opening <br />❑ C/O & PCA No. <br />❑ PCA <br />❑ Chg. Order, No. <br />❑ Traffic Control <br />❑ Resolution <br />® Other: Authorization for <br />❑ Ease./Encroach <br />Entry <br />Information <br />Company or Vendor Name Stantec Consulting Services <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 />U Yes U If Yes, Approved by Purchasing <br />❑ No <br />E] MBE ❑ WBE Completed E-Verify Form Attached ❑❑ Nos <br />N/A <br />N/A <br />N/A <br />PR/PO # N/A <br />N/A <br />Authorization for Entry for Stantec for sewer vapor sampling <br />This document authorizes Stantec to conduct sewer vapor sampling at three <br />manholes near South Bend Avenue and N. Hill Street <br />For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />Increase % <br />Decrease <br />Increase % <br />Decrease <br />