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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 3/13/2020 <br />�e Lauren Tara Nam .................__........... _... Department Utilities . � �...�.�._.....������...._ _........ ..._......��.....�........ _. <br />BPW Date 3/24/2020 Phone Extension 5852 <br />® AMEN <br />Review and A )roval I q�t r �l Prior to Submittal to B. ������ ....__.__..... <br />El Officer Name <br />and Inclusion Officer <br />BPW Attorney ❑ Attorney Name <br />Dept. Attorney Attorney Name <br />...... <br />Purchasing...............................� ___mm����. <br />_._...._._ .._u_._. <br />Check the Appropriate Item Type — Required uired <br />F] Professional Services Agreement ❑ Contract <br />Open Market Contract <br />El <br />Amendment/Addendum <br />E] <br />Bid Opening <br />F] <br />Bid Award <br />Quote Opening <br />El <br />Quote Award <br />Proposal Opening <br />C/O & PCA No. <br />Chg. Order, No. <br />❑ <br />Traffic Control <br />® Other: Permit Renewal <br />Honeywell Groundwater <br />Company or Vendor Name <br />New Vendor <br />MBE/WBE Contractor <br />Project Name <br />Project Number <br />Funding Source <br />Account No. <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Information <br />All Submissions <br />Proposal <br />L0 Special Purchase, QPA <br />El Req. to Advertise <br />E Reject Bids/Quotes <br />[J PCA <br />❑] Resolution <br />❑ Ease./Encroach <br />U Yes U If Yes, Approved by Purchasing <br />n No <br />❑ Title Shee <br />MBE Completed E-Verify Form Attached ❑❑ No <br />WBE <br />...._..... _ _...._.. <br />�.. <br />For Change, Orders On ............... .. <br />Amount of Decrease _ .. _.............. <br />_w <br />Increase <br />($ <br />Previous Amount $ <br />Increase % <br />Current Percent of Change: Decrease ( % <br />New Amount $ _...................... <br />Increase % <br />Total Percent of Change: Decrease ( % <br />Time Extension Amount: <br />