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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />03/15/20 18 <br />Jeri Hockenhull <br />Department Admin & Fitzice <br />-BPW.Date 03/15/2018 Phone Extension 9822 <br />Required Prior �to Submittal <br />�e �d to �Board������ <br />Legal Attorney Name Clara McDaniels <br />Controller 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 />ZMEMENV®R <br />H Agreement <br />N Contract E] Proposal El Addendurn— <br />M Professional Services <br />❑ Resolution <br />F] Bid Opening <br />0 Bid Award ❑ Req. to Advertise ❑ T'itle Sheet <br />E] Quote Opening <br />F] Quote Award <br />Change, Order No. <br />E:1 C/O & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />Other: <br />Company or Vendor Name Umbaugh & Associates <br />New Vendor <br />Yes ®No 0 If Yes, Approved by Purchasing <br />MBEANBE Contractor <br />F-1 MBE F-1 WBE <br />M'BEMBE Contractor Requested M No El Yes Name of Company <br />Project Name <br />Financial Assurance Test-IDEM Requirement <br />Project Number <br />Funding Source <br />General Fund-Admin Fin Budget <br />Account No. <br />101-0401-415-31-06 <br />Amount <br />$5,250.00 <br />Terms of Contract <br />Due upon completion of contract <br />Purpose/Description <br />IDEM requires a financial assurance test on an annual basis for the <br />closed landfill. Umbaugh is able to perform the required assurances <br />which meet the needs of [DEM. <br />Z Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verjfv, Iran, etc.) <br />Amount of F-1 <br />El <br />increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />M <br />F] <br />E] <br />El <br />Ral <br />Dispersal After Approval <br />Jennifer Hockenhull <br />