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MAILING ADDRESS: PHYSICAL ADDRESS: <br /> - STATE WATER RESOURCES CONTROL STATE WATER RESOURCES CONTROL <br /> DIVISION OF FINANCIAL ASSISTANCE DIVISION OF FINANCIAL ASSISTANCE <br /> UST CLEANUP FUND UST CLEANUP FUND <br /> P.O.BOX 944212 1001 1 STREET <br /> SACRAMENTO,CA 94244-2120 SACRAMENTO,CA 95814 <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign,date and return) <br /> Mail to: USTCF, PO Box 944212, Sacramento, CA 94244 or Fax to: (916) 341-5806 <br /> I- CLAIM INFORMATION <br /> Claim No. CP 0034 County or Regional Board: RWQCB-CVR Central Valley <br /> Claimant: Chevron Environmental Management Company <br /> Contact Person: Stacie Hartung-Frerichs Phone: (925) 842-9655 <br /> Address: 6001 Bollinger Canyon Road Fax: (925) 842-8370 <br /> San Ramon, CA 94583 E-mail: stadehf@chevron.com <br /> Consultant: SECOR International Phone: (916) 861-0400 <br /> Address: 3017 Kilgore Road, Suite 100 _ Fax: (916) 861-0430 <br /> Rancho Cordova, CA 95670 E-mail. bcarey@secor.com <br /> I1. TYPE OF REQUEST(check appropriate boxes) <br /> Pre-Approval $ l u l-11 7—S7 - Amount Requested <br /> ❑ 3-Bid Review $ Preferred Bid(if applicable) <br /> ❑ The Cleanup Fund is authorized to transmit pre-approval information to my consultant. <br /> THE FOLLOWING DOCUMENTS ARE REQUIRED FOR THE SPECIFIED REQUEST. ALL DOCUMENTS <br /> REQUESTED MUST BE SUBMITTED OR THE REQUEST(S) WILL BE RETURNED.UNPROCESSED. <br /> A. Request for Pre-Approval of Proposed Costs—The following items are required before review and <br /> determination will be made by Fund Staff <br /> 1. X A complete signed copy of the proposed Investigation Workplan or Corrective Action Plan (CAP) (as <br /> defined and required by Article 11, Chapter 16, California Underground Storage Tank Regulations). <br /> Corrective Action Plans must include the required feasibility study and chosen cost-effective alternative. <br /> 2. X A signed copy of the oversight agency approval letter for the Workplan/CAP. <br /> 3. _ A complete copy of the Request for Bids, including all attachments. <br /> 4. _ Complete copies of all bids (including subcontractor bids)and other correspondence submitted in <br /> response to the Request for Bids. <br /> 5. X A time schedule, if not part of bid documents,anticipated for project initiation and duration. <br /> 6. X A detailed project budget, which includes breakdowns of staff/task/hour with associated estimated totals. <br /> B. Three-Bid Review/Evaluation/Determination—Fund staff will assist any claimant requesting an evaluation of <br /> bids upon request. The following information must be submitted— 1, 2, 3, and 4 as described in Item A <br /> above. <br /> III. CERTIFICATION <br /> I certify under penalty of perjury that all information submitted with this request is complete and accurate and in <br /> accordance with all applicable laws and regulations. [further certify that the work requested under this pre- <br /> approval has not been implemented. Must be signed by claimant or person desi ted on the Power o{Attorney <br /> form. <br /> i,. J n c* ar u n - ire-+r'I c,�.S 2 8/Os; <br /> Signature Printed Name Date <br /> Revised 02-05-03 <br />