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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date <br />Name <br />1/14/2019 <br />Lauren Tra <br />Department Utilities <br />............. <br />BPW Date 1/22/2019 Phone Extension 5852 <br />MEMIMMimmuuuumm <br />gym.. m: <br />Attorney Name mittal to Board .......� ���._..Lega.l.__�........ .....��.� .......... <br />Y <br />Controller review is required for all Contracts $5,000.00 or more <br />Controller El and greater than one year in length per the City Purchasing <br />Policy <br />Purchasing ❑ <br />Check the Appropriate Item Tvq _. <br />LJ Agreement <br />❑ Professional Services <br />Bid Opening <br />El Quote Opening <br />E] Chg Order No. <br />❑ Ease./Encroach. <br />® Other: Modification of <br />Industrial Wastewater <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 />H Contract <br />El Amendment <br />Bid Award <br />❑ Quote Award <br />[] C/O & PCA No <br />Traffic Control <br />U Yes <br />❑ No <br />MBE <br />WBE <br />for All Submissions <br />Propo <br />sal � _ � Addendum <br />El Req. to Advertise ❑ Title Sheet <br />F] PCA <br />El Resolution <br />Claim <br />ired Information <br />If Yes, Approved by Purchasing <br />Completed E-Verify Form Attached ❑ Yes <br />❑ No <br />For C .,_ . l.. _ ..... <br />ITmmm harw a Orders On <br />Amount of El Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change, - <br />Time Extension: <br />Copy <br />Original <br />El <br />❑ <br />El <br />❑ <br />Dispersal After Approval <br />