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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/17/17 <br />Name Michelle Smith <br />Department Utility/Wastewater <br />BPW Date 3/28/17 <br />Phone Extension 5994 <br />Required Prior to Submittal to Board <br />Legal ® <br />Attorney Name Michael Schmidt <br />Controller ❑ <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing ❑ <br />Check the Appropriate <br />Item Type — Required for All Submissions <br />❑ <br />Agreement <br />❑ <br />Contract ® Proposal ❑ Addendum <br />❑ <br />Professional Services <br />❑ <br />Resolution <br />❑ <br />Bid Opening <br />❑ <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ <br />Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />❑ <br />C/O & PCA No. ❑ PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />❑ <br />Other: <br />Required Information <br />Company or Vendor Name <br />KERAMIDA <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor <br />❑ MBE ® WBE <br />MBE/WBE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name <br />Statistical Analyses of Groundwater Sampling Events <br />Project Number <br />Funding Source <br />Organic Resources Other Contractual <br />Account No. <br />641-0631-793-63-35 <br />Amount <br />$ 4650.00 <br />Terms of Contract <br />Purpose/Description <br />Required statistical evaluation of groundwater data <br />® Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Required For Change Orders Only <br />Amount of ❑ Increase $ <br />❑ Decrease $ <br />Previous Amount <br />$ <br />Current Percent of Change: <br />% <br />New Amount <br />$ <br />Total Percent of Change: <br />% <br />Dispersal After Approval <br />Copy Original <br />® ❑ Carol Kurzhal <br />® ❑ Michelle Smith <br />❑ ❑ <br />