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f <br /> CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign, date&return) <br /> TO: W) 1-�ALin Fax: (916) 2274530 <br /> I. CLAIM INFORMATION n <br /> A. CLAIMNO. o127S0 B. CLAIMANT �KJCLV f�\,A�- <br /> C. CLAIM STATUS (complete appropriate section) <br /> i) LOC ISSUED FOR S <br /> ii) ON PRIORITY LIST? IXYES ❑ NO IF YES,PRIORITY CLASS ❑ A IX B ❑ C❑ D <br /> iii) NOT YET APPLIED TO THE FUND,EXPECTED APPLICATION DATE: <br /> D. CONTACT PERSON: PHONE: <br /> ADDRESS: FAX: <br /> H. TYPE OF REQUEST(check anorooriate boxes) <br /> PRE-APPROVAL S AMOUNT REQUESTED <br /> 3-BID REVIEW S PREFERRED BID (if applicable) <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.gA complete signed copy of the proposed Investigation Workplan or Corrective Action Plan(CAP) (as defined <br /> and required by Article 11, Chapter 16, California Underground Storage Tank Regulations), Corrective Action <br /> Plans must include the required feasibility study and chosen cost effective alternative. <br /> 2.XA signed copy of the oversight agency approval letter for the WorkplardCAP. <br /> 3.—A complete copy of the Request for Bids, including all attachments. A list of all firms requested to bid must be <br /> included. <br /> 4_ Complete copies of all bids and other correspondence submitted in response to the Request for Bids. <br /> 5.7CA time schedule, if not part of bid documents,anticipated for project initiation and duration. <br /> 6.7A detailed project budget,which includes breakdowns of stafr/task/hour with associated estimated totals. <br /> B. THREE-BID REVIEWIEVALUATIONMETERMINATION-Fund staff will assist any claimant requesting an <br /> evaluation of bids upon request. The following information must be submitted- 1,2,3 AND 4 as described in <br /> Item A above. <br /> III. CERTIFICATION <br /> I certify under penalty of perjury that all information submitted with this request is complete and accurate and in accordance with <br /> all applicable laws and regulations. hfrrst he sinned by claimant or nen.on derirnated ori the Arithnrized Representative <br /> Dcsipnation form <br /> Signature Printed Name Date <br /> IV. Authorization for the Fund to give out your name and phone number to other claimants in your region as a <br /> reference for consultants and contractors. ❑ YES ❑ NO <br /> Signature Date <br />