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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 101212018 <br />❑ Agreement <br />❑ Contract U Proposal jJ Addendum <br />® Professional Services <br />❑ Resolution <br />❑ Bid Opening <br />❑ Bid Award [] Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening <br />❑ Quote Award <br />❑ Change Order No. <br />❑ CIO & PCA No. ❑ PCA <br />❑ Ease/Encroach. <br />❑ Traffic Control <br />n Other: <br />Company or Vendor Name <br />ACM Engineering and Environmental Services <br />New Vendor <br />❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBEIWBE Contractor <br />❑ MBE ❑ WBE <br />MBE/WBE Contractor Requested <br />❑ No ❑ Yes Name of Company <br />Project Name <br />Erskine Clubhouse Renovation <br />Project Number <br />116-108 <br />Funding Source <br />Golf Operationsp <br />Account No. <br />Amount <br />$ TBD <br />Terms of Contract <br />Purpose/Description <br />Lead and Asbestos testing of Erskine Clubhouse <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, , Iran, etc. <br />Required For Change Orders Onl <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 />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />