Purchase complete to FS and Eu.pdf

From: Cisco, Jesse To: EPA.FiscalServ Cc: Crain, Ethan Subject: PRF 27168 PO P-100622 Date: Thursday, August 13, 2026 10:34:00 AM Attachments: 27168 BOL Cicero.pdf

PO P-100622.PDF

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Good morning , This purchase is complete.

Thank you, Jesse Cisco Executive 2 / Buyer Fiscal / Procurement 217-558-5377 Jesse.w.cisco@illinois.gov

Join our team: Illinois EPA Employment mailto:Jesse.W.Cisco@Illinois.gov mailto:EPA.FiscalServ@Illinois.gov mailto:Ethan.Crain@illinois.gov https://epa.illinois.gov/ https://epa.illinois.gov/ https://www.facebook.com/IllinoisEpa/ https://x.com/ILEPA?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor https://www.linkedin.com/company/illinois-environmental-protection-agency https://www.instagram.com/illinoisepa/?hl=en https://bsky.app/profile/did:plc:ttbxmv2i4w4x5houptso6pcq https://epa.illinois.gov/about-us/employment.html

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: Ethan Crain

Email Address: ethan.crain@illinois.gov

Phone: 2177857095

Date: 7/16/2026

Location: Headquarters

Bureau: Land

Section: Office of Site Evaluation

Request Type:Small Purchase under $10,000

Type of Procurement:Supplies, Non-IT

Delivery Address: 2520 W Iles Springfield Illinois 62704

Proposed Contract Dates

Start:

End:

↓↓ For Staff Use Only ↓ ↓ Tracking Number: 27168

Approver Approvals Bureau Chief

Accounts Payable

Cost Recovery / Grants

Finance Manager

CFO

IT/DoIT Manager

(if applicable)

Suggested Vendor #1

Name: Cicero

Address:

City: State: Zip:

Contact:

Email:

Phone:

Suggested Vendor #2

Name:

Address:

City: State: Zip:

Contact:

Email:

Phone:

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.).

Larger manhole covers needed for our 2 inch monitoring wells. These were not included with our original well contract with cicero. Please use PR50 funding code.

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

8" Cam Lock Water Tight Manhole Cover Yes 10 each

-- Choose --

-- Choose --

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.)

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

Estimated Multi-Year Funding

FY Amount FY Amount

↓↓ For Fiscal Use Only ↓ ↓

Funding Source(s)

Fund Functional Area Cost Center GL Internal Order Amount

0065900000 19000001NE000000 5323030730 5???? 301760

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

Field Operations

Permits

Waste Reduction & Comp.

Remedial Project Mgmt.

Federal Site Remediation

Office of Site Evaluation

Contract Number:

Contract Name:

Vendor Name:

Vendor Project Contact:

Vendor Email:

Vendor Phone:

Amount:

Cooperative Agreement Number:

Agreement Expiration Date:

CurrentPage:

PageCount:

Requestor: Ethan Crain

Email: ethan.crain@illinois.gov

Enter the phone number with area code, like 123-456-7890.: 2177857095

Enter the date like 12/31/2018.: 2026-07-16

Location: Headquarters

Bureau: Land

Section: Office of Site Evaluation

RequestType: SmallPurchaseUnder

TypeOfProcurement: Supplies, Non-IT

DeliveryAddress:

Enter the date like 12/31/2018.:

Enter the date like 12/31/2018.:

TrackingNumber: 27168

Approval:

ContractNumber:

ContractName:

CSFANumbers:

AgencyContact:

LegalCounsel:

VendorContact:

VendorName: Cicero

VendorProjectContact:

AuthorizedSigner:

AuthorizedSignerTitle:

Address:

City:

State:

Zip:

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: Larger manhole covers needed for our 2 inch monitoring wells. These were not included with our original well contract with cicero. Please use PR50 funding code.

GataDescriptionOfServices:

ObjectCode:

ItemDescription: 8" Cam Lock Water Tight Manhole Cover

Equipment: Yes

Equipment: -- Choose --

Equipment: -- Choose --

Quantity: 10.00000000

UnitofMeasure: each

UnitPrice:

TotalPrice: 0.00000000

TotalPrice: 0.00000000

TotalPrice: 0.00000000

TotalPrice: 0.00000000

TotalPrice: 0.00000000

TotalPrice: 0.00000000

Shipping: 0.00000000

AddRow:

DeleteRow:

Yes:

No:

FederalSource:

AgreementNumber:

Enter the date like 12/31/2018.:

TimeCode:

FY:

Fund: 0065900000

FunctionalArea: 19000001NE000000

CostCenter: 5323030730

Enter the amount like 12345.67. Do not include the dollar sign or commas.: 5????

Enter the amount like 12345.67. Do not include the dollar sign or commas.: 301760

27-532EPA-LAND5-P-100622

Vendor Number: V00003271 Cicero Mfg. & Supply Company, Inc.

1849 ELMDALE AVENUE

GLENVIEW, IL 60026

tsnower@cicerosupply.com null

Purchase Order

EPA - Environmental Protection Agency

27-532EPA-LAND5-P-

100622

Contract/Ob #:

Contract/PO #:

Purchase Order Number

Master Contract? N

S H I P

T O

Field Operations Section 2520 W Iles Avenue Springfield, IL 62704

US

Email: noreply@illinois.gov

(000) 000-0000

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

--Please see specific requirements provided by the purchasing entity.

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: United Parcel Service Shipping Terms:

Contract Begin Date: 08/11/2026 Contract End Date: 09/30/2026

V E N D

R

Freight Terms: Freight Prepaid

Payment Terms: NA

Delivery Calendar Day(s) A.R.O.: 0

Item # 1 Class-Item 100-08

8" Cam Lock Water Tight Manhole Cover - w/ 7 1/2" Cast Iron Skirt

Quantity UOMUnit Price Discount % Total Discount Amt. Tax Rate Tax Amount Freight Total Cost

10.00 EA$ 180.00 0.00 % $ 0.00 $ 0.00 $ 50.00 $ 1,850.00

TOTAL: $ 1,850.00

TAX: $ 0.00

FREIGHT: $ 50.00

27-532EPA-LAND5-P-100622

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__________________________