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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Mav 2. 2018 <br />Matt Chlebowski <br />Department Central Services <br />❑ Agreement <br />❑ <br />Contract ❑ Proposal Addendum <br />❑ Professional Services <br />❑ <br />Resolution <br />❑ Bid Opening <br />® <br />Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ <br />Quote Award <br />❑ <br />Change Order No. <br />ElC/O <br />& PCA No. ❑PCA <br />❑ <br />Ease/Encroach. <br />❑ <br />Traffic Control <br />f-1 Other: <br />Company or Vendor Name <br />New Vendor <br />MBEAVBE Contractor <br />MBE/WBE 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 />uired Informati <br />Hydro -Chem Systems, Inc <br />❑ Yes ❑ No ❑ If Yes, Approved by Purchasing <br />F MBE I] WBE <br />❑ No ❑ Yes Name of Company. <br />Spec M — One (1) or more 2018 or Newer Trash Tote Cleaning <br />Trailer System <br />Solid Waste Capital Lease <br />611-0610 <br />:It% :•1 11 <br />Award Bid <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination, Non -Debarment, E-Verify, Iran, etc. <br />Amount of ❑ 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 />Jeff Hudak <br />% <br />Dispersal After Approval <br />Mike Bronstetter <br />