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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/30/18 <br />Name Jeff Hudak Department <br />❑ Agreement <br />❑ Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />❑ Change Order No. <br />❑ Ease/Encroach. <br />IJ1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />MBENVBE Contractor <br />Requested <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of ❑ <br />El <br />Central Services <br />❑ No ❑ Yes Name of Company <br />Spec O — One (1) or more 2018 or Newer Combination Jet <br />Rodder/Vacuum Machine with Cab & Chassis <br />2018 Sewer Department Capital Budget <br />Bid Opening Date: <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verifv, Iran, etc. <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 />® <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />Dispersal After Approval <br />Jeff Hudak <br />Derick Roberts, Dale Helpingstine, Terri Swift <br />