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AW <br /> CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign, date & return) <br /> TO : MS • L. t w on CA MJ3o2w] Fax: (916) 341 -5806 <br /> I. CLAIM INFORMATION /� / + <br /> A. CLAIM NO, 8 ,q <{ 9 B. CLAIMANT (?AAiEPAS t A2 iJASH <br /> C. CLAIM STATUS (complete appropriate section) <br /> i) LOC ISSUED FOR $ 3rd O <br /> ii) ON PRIORITY LIST? YE50 NOE] IF YES, PRIORITY CLASS 0ADB QCFID <br /> iii) NOT YET APPLIED TO THE FUND, EXPECTED APPLICATION DATE: <br /> D. CONTACT PERSON: REP10 CA[ 60eW PHONE: 209 - 01?9 - Mr <br /> ADDRESS : l S3 6 At mt Ajrjr� 12, S r FAX: Z09 - 428 - ( 312, <br /> H. TYPE OF REOUEST (check appropriate boxes) <br /> PIPRE-APPROVAL $ 48 i 31 'F ° AMOUNT REQUESTED <br /> F1 3-BID REVIEW $ PREFERRED BID (if applicable) <br /> THE FOLLOWING DOCUMENTS ARE REQUIRED FOR THE SPECIFIED REQUEST, ALL DOCUMENTS REQUESTED MUST <br /> 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 <br /> review and determination will be made by Fund Staff. <br /> 1 , Q A complete signed copy of the proposed Investigation Workplan or Corrective Action Plan <br /> (CAP) (as defined and required by Article 11 , Chapter 16, and California Underground Storage <br /> Tank Regulations). Corrective Action Plans must include the required feasibility study and chosen <br /> cost-effective alternative. <br /> 2. ❑ 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. A list of all firms <br /> requested to bid must be included. <br /> 4. ❑ Complete copies of all bids and other correspondence submitted in response to the Request for <br /> Bids. <br /> 5 . Q A time schedule, if not part of bid documents, anticipated for project initiation and duration. <br /> 6. ❑ A detailed project budget, which includes breakdowns of staff/task/hour with associated <br /> estimated totals. <br /> B . THREE-BID REVIEW/EVALUATION/DETERMINATION - Fund staff will assist any claimant <br /> requesting an evaluation of bids upon request. The following information must be submitted - 1 ,2,3 AND 4 <br /> as described in Item A above. <br /> III. CERTIFICATION <br /> I certify under penalty ofperjury that all information submitted with this request is complete and accurate and in <br /> accordance with all applicable laws and regulations. Must be signed by claimant or person designated on the <br /> Authorized Repres + tail Designation form. �f <br /> fLe�v grrfio J (4-�1j�3 O <br /> Signature Printed Name f Date <br />