788 AFC International .pdf

IL 532 3050

ADM 237 Rev. 5/2021 Purchase Request Form Page 1 of 3

Illinois Environmental Protection Agency 1021 North Grand Avenue East 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: Tony Falconio

Email Address: Tony.falconio@illinois.gov

Phone: 217-558-1673

Date: 5/23/2022

Location: Headquarters

Bureau: Associate Director

Section: Emergency Response

Request Type:Small Purchase over $10,000

Type of Procurement:Supplies, Non-IT

Delivery Address: 1021 North Grand Avenue East Springfield, IL 62794

Proposed Contract Dates

Start:

End:

↓↓ For Staff Use Only ↓ ↓ Tracking Number: # 788 BC 05/24/2022

Approver Approvals Bureau Chief

Accounts Payable

Cost Recovery / Grants

Finance Manager

CFO

IT/DoIT Manager

(if applicable)

New Contract Estimated Procurement Cost: $18,124.77

Suggested Vendor #1

Name: AFC International, Inc

Address: PO Box 894

City: DeMotte State: IN Zip: 46310

Contact: Pam Seneczko

Email: pjseneczko@afcint.com

Phone: (800) 952-3293

Suggested Vendor #2

Name:

Address:

City: State: Zip:

Contact:

Email:

Phone:

ADM 237 Rev. 5/2021 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.).

The Illinois EPA, Office of Emergency Response (OER) intends to purchase an UltraRAE 3000 Benzene Specific Air Monitor plus accessories and Personal 4 Gas Monitors plus accessories for use in the field at environmental emergencies. This life/safety device ensures that OER responders and other personnel are not breathing in dangerous levels of Benzene gas, a known carcinogen. The UltraRAE 3000 is an air monitor used to measure levels of Benzene in the air at sites where flammable petroleum products have been spilled. The Personal 4 Gas Monitors are to be worn by OER responders in the field while responding to environmental emergencies.

These life/safety air monitors provide OER responders with real-time data about the surrounding environment and warn against dangerous levels of toxic gases. If this procurement is not approved OER responders will not have the ability to monitor for and quantify levels of benzene gas in the atmosphere at environmental emergencies.

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

059-D31D-300 UltraRAE 3000+(Specs Attached) Yes 1 Each 5,563.89 $5,563.89

90099764 34 GAL Benzene 5ppm/Air Calgas No 1 Each 125.8 $125.80

012-3022-010 Benzene SEP Tubes pk/10 No 1 Pack/10 100.3 $100.30

M031-1111-200 MicroRAE Diffusion Monitor Yes 12 Each 704.7 $8,456.40

See Attached Specs

90098413 58 GAL Mixed Gas Cylinder No 4 Each 156.4 $625.60

50ppm CO, 10ppm H2S, 18%O2, 50% LEL(NH3)

90005510 Regulator .5LPM Stainless Steel Yes 5 Each 185.3 $926.50

M03-0300-000 Gang Charger W/Power Adapter Yes 3 Each 738.76 $2,216.28

Product Quote is Attached 1 Any IT purchases must be approved by EPA DoIT COI.

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

Shipping $110.00

Note: Attach detailed specification, if required, on separate sheet of paper. Request Total $18,124.77

Add a row Delete last row

Procurement Justification

Yes✔ No 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.

ADM 237 Rev. 5/2021 Purchase Request Form Page 3 of 3

Small Purchase with Sole Source Conditions Justification

Yes No NA Did you include and email to the assigned buyer the Small Purchase with Sole Source Conditions Justification Form?

Cost Recovery

Yes No Are costs to be recovered via Consent Order, Court Order, Invoicing, or other means?

Estimated Multi-Year Funding

FY Amount FY Amount

↓↓ For Fiscal Use Only ↓ ↓

Funding Source(s)

Fund Functional Area Cost Center GL Internal Order Amount

0074000000 19000001NA000000 5320101210 5155000000

IL 532 3050 ADM 237 Rev. 5/2021 Purchase Request Form Page of Illinois Environmental Protection Agency 1021 North Grand Avenue East 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) New Contract Job Order Costs Work Order Costs Amendment Costs or Term Changes 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 Did you include and email to the assigned buyer the Small Purchase with Sole Source Conditions Justification Form?

If No, 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 Are costs to be recovered via Consent Order, Court Order, Invoicing, or other means?

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 Monique Wantland 8/3/2020 Purchase Request Form 5/3/2021 Yes