26400 LAB Fisher Scientific 1 of 3~1.pdf

IL 532 3050

ADM 237 Rev. 4/2025 Purchase Request Form Page 1 of 3

Illinois Environmental Protection Agency 2520 West Iles Avenue P.O. Box 19276 Springfield Illinois 62794-9276 (217) 782-3397

Purchase Request Form Important: This form must be completed within Acrobat. It cannot be printed and completed by hand.

Requestor Name: Carrie Dirksen

Email Address: carrie.dirksen@illinois.gov

Phone: 217-557-0271

Date: 9/2/2025

Location: Springfield Laboratory

Bureau: Laboratory

Section: Laboratory

Request Type:Order against Master Contract

Type of Procurement:Supplies, Non-IT

Delivery Address: 825 N. Rutledge 4th Floor Springfield, IL 62702

Proposed Contract Dates

Start: 9/2/2025

End: 12/2/2025

↓↓ For Staff Use Only ↓ ↓ Tracking Number: 26400

Approver Approvals Bureau Chief

Accounts Payable

Cost Recovery / Grants

Finance Manager

CFO

IT/DoIT Manager

(if applicable)

Contract Number: 12458

Vendor Name: Fisher Scientific Company, LLC

Address: 4500 Tumberry Drive

City: Hanover Park State: IL Zip: 60133

Vendor Email: state,il@thermofisher.com

Vendor Phone: (224) 532-7917

Amount: $12,339.00

ADM 237 Rev. 4/2025 Purchase Request Form Page 2 of 3

Description of Services Describe what it is that you intend to procure (software, hardware, services, maintenance, etc.) including quantity if relevant. Describe business need for the procurement, and how the procurement will meet objectives of your agency and the State. Please make sure to spell out acronyms. Explain the potential consequences if this procurement is not approved. If other than a one-time purchase, explain solicitation method and pricing structure (hourly, per item, not-to-exceed, etc.).

See attached Quotation 5245433406 for details.

Supplies for all lab methods BOL and BOW.

Object Code Item Description (Include catalog # or MFG) 1 Equipment? 2 Quantity Unit of Measure Unit Price Total Price

1350 05-719-149D WM HDPE packer 1000 mL No 450 CS 27.42 $12,339.00 1 Any IT purchases must be approved by EPA DoIT COI.

2 Mark "No" if unit price is under $100.

Shipping

Note: Attach detailed specification, if required, on separate sheet of paper. Request Total $12,339.00

Add a row Delete last row

Quality Management Plans (EPA QA/R-2)

Yes No✔ Is data generation being performed under a Quality Management Plan (QMP), Quality Assurance Project Plan (QAPP), and/or Standard Operating Procedure (SOP) for this agreement? (View QMP details here.)

Estimated Multi-Year Funding

FY Amount FY Amount

ADM 237 Rev. 4/2025 Purchase Request Form Page 3 of 3

↓↓ For Fiscal Use Only ↓ ↓

Funding Source(s)

Fund Functional Area Cost Center GL Internal Order Amount

0731000000 19000000NE000000 5322020100 5135000000

IL 532 3050 ADM 237 Rev. 4/2025 Purchase Request Form Page of .\EPA logo B&W (no words).gif Illinois Environmental Protection Agency 2520 West Iles Avenue P.O. Box 19276 Springfield Illinois 62794-9276

(217) 782-3397 Purchase Request Form Important: This form must be completed within Acrobat. It cannot be printed and completed by hand.

Proposed Contract Dates ↓↓ For Staff Use Only ↓ ↓ Approver Approvals Bureau Chief Accounts Payable Cost Recovery / Grants Finance Manager

CFO

IT/DoIT Manager(if applicable) (Person authorized to sign agreement for grantee) New Contract Job Order Costs Work Order Costs Amendment Costs or Term Changes Funding Update Suggested Vendor #1 Suggested Vendor #2 Object Code Item Description (Include catalog # or MFG) 1 Equipment? 2 Quantity Unit of Measure Unit Price Total Price 1 Any IT purchases must be approved by EPA DoIT COI.

2 Mark "No" if unit price is under $100.

Shipping Note: Attach detailed specification, if required, on separate sheet of paper.

Request Total Procurement Justification Is the combined total of this purchase over $10,000?

If Yes, download the Procurement Justification form from the Chief Procurement Office's BidBuy forms web page, then complete and attach it when you submit this form.

Sole Source Justification Did you include and email to the assigned buyer the Sole Source Justification Form?

If No, download the Sole Source Justification form from the Illinois Procurement Policy Board web page, then complete and attach it when you submit this form.

Small Purchase with Sole Source Conditions Justification Is this a small purchase with sole source conditions?

If Yes, download the Small Purchase Sole Source Justification form from the Illinois Chief Procurement Office for General Services web page, then complete and attach it when you submit this form.

Federal Source Is funding from a federal source?

Cost Recovery or Potential Cost Recovery Quality Management Plans (EPA QA/R-2) Is data generation being performed under a Quality Management Plan (QMP), Quality Assurance Project Plan (QAPP), and/or Standard Operating Procedure (SOP) for this agreement? (View QMP details here.)

If Yes, the Bureau should work with the assigned QA staff and must provide specifications outlining requirements to procurement.

Estimated Multi-Year Funding

FY

Amount

FY

Amount ↓↓ For Fiscal Use Only ↓ ↓ Funding Source(s) Fund Functional Area Cost Center

GL

Internal Order Amount Illinois EPA Procurement Officer Wally Hartshorn Andrew Shackleford, Monique Wantland, Max Paller 8/3/2020 Purchase Request Form 4/16/2025 Laboratory Contract Number:

Contract Name:

Vendor Name:

Vendor Project Contact:

Vendor Email:

Vendor Phone:

Amount:

Cooperative Agreement Number:

Agreement Expiration Date:

No

Supplies for all lab methods BOL and BOW.