Procurement complete to FS and requester~11.pdf

From: Cisco, Jesse To: Matzat, Megan Cc: EPA.FiscalServ Subject: PRF 26201 PO# P-59654.1591 Date: Friday, August 8, 2025 1:48:00 PM Attachments: 26201 BOW Logsdon.pdf

Logsdon P-59654.1591.pdf

Good afternoon, This purchase is complete.

Thank you, Jesse Cisco Executive 2 / Purchaser Environmental Protection Agency 217-558-5377 mailto:Jesse.W.Cisco@Illinois.gov mailto:Megan.K.Matzat@Illinois.gov mailto:EPA.FiscalServ@Illinois.gov

IL 532 3050

ADM 237 Rev. 2/2023 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: Megan Matzat

Email Address: Megan.K.Matzat@Illinois.gov

Phone: 217-782-1654

Date: 7/18/2025

Location: Headquarters

Bureau: Water

Section: PWS - Groundwater

Request Type:Small Purchase under $10,000

Type of Procurement:Supplies, Non-IT

Delivery Address: Illinois EPA, 2520 W Iles Ave, Springfield

IL, 62704

Proposed Contract Dates

Start:

End:

↓↓ For Staff Use Only ↓ ↓ Tracking Number: 26201

Approver Approvals Bureau Chief

Accounts Payable

Cost Recovery / Grants

Finance Manager

CFO

IT/DoIT Manager

(if applicable)

Suggested Vendor #1

Name: Logsdon Office Supply

Address: 111 S Fairbank St

City: Addison State: IL Zip: 60101

Contact:

Email: customerservice@logsdonofficesupply.com

Phone: (847) 593-8282

Suggested Vendor #2

Name:

Address:

City: State: Zip:

Contact:

Email:

Phone:

ADM 237 Rev. 2/2023 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.).

Purchase of monitor arms for an approved accommodation for Lauren Hunt.

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

CIFK1D220B Chief Kontour K1D220B Mounting Arm - Black 1 each 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

Add a row Delete last row

Small Purchase with Sole Source Conditions Justification

Yes No✔ Is this a small purchase with sole source conditions?

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. 2/2023 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 5326060100 COST?? 900000

IL 532 3050 ADM 237 Rev. 2/2023

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)

(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

Monique Wantland, Max Paller

8/3/2020

Purchase Request Form

2/21/2023

Infrastructure Financial Assist.

Watershed Management

WPC - Field Operations

WPC - Permits

WPC - Surface Water

WPC - Water Quality Standards

WPC - Compliance

PWS - Groundwater

PWS - Field Operations

PWS - Permits

PWS - Drinking Water Comp.

Contract Number:

Contract Name:

Vendor Name:

Vendor Project Contact:

Vendor Email:

Vendor Phone:

Amount:

No

Cooperative Agreement Number:

Agreement Expiration Date:

No

CurrentPage:

PageCount:

Requestor: Megan Matzat

Email: Megan.K.Matzat@Illinois.gov

Email: customerservice@logsdonofficesupply.com

Enter the phone number with area code, like 123-456-7890.: 217-782-1654

Enter the phone number with area code, like 123-456-7890.: 8475938282

Enter the date like 12/31/2018.: 2025-07-18

Location: Headquarters

Bureau: Water

Section: PWS - Groundwater

RequestType: SmallPurchaseUnder

TypeOfProcurement: Supplies, Non-IT

DeliveryAddress:

Enter the date like 12/31/2018.:

Enter the date like 12/31/2018.:

TrackingNumber: 26201

Approval:

ContractNumber:

ContractName:

CSFANumbers:

AgencyContact:

LegalCounsel:

VendorContact:

VendorName: Logsdon Office Supply

VendorProjectContact:

AuthorizedSigner:

AuthorizedSignerTitle:

Address: 111 S Fairbank St

City: Addison

State: IL

Zip: 60101

JobOrderNumber:

WorkOrderNumber:

Explanation:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

FederalAmount:

StateAmount:

MatchAmount:

GranteeDuns:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

RemainingContract:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Total: 0.00000000

Description:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

NewTotal: 0.00000000

Enter the date like 12/31/2018.:

Enter the date like 12/31/2018.:

Enter the date like 12/31/2018.:

Enter the amount like 12345.67. Do not include the dollar sign or commas.:

Enter the date like 12/31/2018.:

ProjectContact:

DescriptionOfServices: Purchase of monitor arms for an approved accommodation for Lauren Hunt.

GataDescriptionOfServices:

ObjectCode: CIFK1D220B

ItemDescription: Chief Kontour K1D220B Mounting Arm - Black

Equipment:

Quantity: 1.00000000

UnitofMeasure: each

UnitPrice:

TotalPrice: 0.00000000

Shipping: 0.00000000

AddRow:

DeleteRow:

Yes:

No:

FederalSource:

AgreementNumber:

Enter the date like 12/31/2018.:

TimeCode:

FY:

Fund: 0731000000

FunctionalArea: 19000000NE000000

CostCenter: 5326060100

Enter the amount like 12345.67. Do not include the dollar sign or commas.: COST??

Enter the amount like 12345.67. Do not include the dollar sign or commas.: 900000

24-416CMS-BOSS4-P-59654:1591

Vendor Number: V00007184 Logsdon Stationers, Inc.

111 S. Fairbank St.

Addison, IL 60101

IBROWN@LOGSDONOFFICESUPPLY.COM

null

EPA - Environmental

24-416CMS-BOSS4-P-

59654:1591

Contract/PO #:

Release Order Number

Master Contract? Y

S H I P

T O

Public Water Supplies - Groundwater 2520 West Iles Avenue Springfield, IL 62704

US

Email: noreply@illinois.gov

(123) 456-7890

VENDOR INSTRUCTIONS:

PURCHASE ORDER REQUIREMENTS - STATE OF ILLINOIS AGENCIES

Prior to commencement of billable work, delivery of supplies or rendering of any service on a Purchase Order:

--Initial Purchase Order/Contract - All parties, including the State and vendor, must fully execute the contract in its entirety.

--Release from an existing Purchase Order/Contract - The vendor must receive a Purchase Order signed by the State Agency and attached in BidBuy. Note, for any additional requirements see specific State Agency instruction.

PURCHASE ORDERS REQUIREMENTS - OTHER PURCHASING ENTITIES

B I L L

T

Fiscal/Procurement 2520 West Iles Avenue Springfield, IL 62704

US

Email: epa.fiscalserv@illinois.gov

(000) 000-0000

Solicitation (Bid) No.: N/A

Shipping Method:

Shipping Terms:

Release Begin Date: 08/08/2025 Release End Date: 09/15/2025

V E N D

R

Freight Terms:

Payment Terms: NA

Delivery Calendar Day(s) A.R.O.: 1

Master Con/Ref #: 9100001720

Logsdon Shopping Cart $965.63

Quantity UOMUnit Price Discount % Total Discount

Amt.

Tax Rate Tax Amount Freight Total Cost

1.00 EA$ 1,379.47 30.00 % -$ 413.841 $ 0.00 $ 0.00 $ 965.63

$ 965.63

$ 0.00

$ 0.00

APPROVED

By:

Phone#:

Jesse Cisco

(217) 782-1249

BUYER

The undersigned agree to the Terms and Conditions as acknowledged by the Vendor and maintained in the State of Illinois' e-procurement system. This agreement consists of all terms as maintained in the state's e-procurement system inclusive of attached documents. The Vendor affirms that the Certifications and Financial Disclosures and Conflicts of Interest are true and accurate as of the date of the Vendor's execution of this Agreement. State documents will prevail in the event of a conflict between State and Vendor documents and information. The undersigned agree to the Terms and Conditions of this agreement:

OFFICIAL SIGNATURES:

Vendor Name: _______________________________

Vendor Signature: _________________________________

Printed Name: ______________________________

Title: _____________________________________

Phone #: ___________________________________

Email:______________________________________

Date: ______________________________________

State of Illinois Agency or Other Purchasing Entity Procuring State Agency or Entity: __________

Official

Designee Signature: ________________________

Legal

Fiscal

FOR STATE OF ILLINOIS USE ONLY:

Acq. Type: ________________Source Sel. Method: _______________ Using Agency Funding Source:__________________________________ Detailed Expenditure Object Code:_____________________________ Approp. Acct Code: ___________________________________________ Award Code: __________________________________________________ Original Proc. Method:________________________________________ Subcontractors Disclosed:_____________________________________ Subcontractors Utilized:______________________________________ Publication Date:____________________ Financing Needed:_______ IPG Cert/Disclosure Yes_________ No__________________________