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CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form,enclose required items,sign,date&return) <br /> TO: '0 " X e ! Fax:(916)227-4530 <br /> I. CLAIM INFORMATION <br /> ACLAIM NO. 12. �2.� B.CLAIMANT ctt,ctt �. <br /> C. CLAIM STATUS (complete appropriate section) <br /> i) LOC ISSUED FOR$ <br /> ii) ON PRIORITY LIST?BJ ES ❑ NO IF YES,PRIORITY CLASS❑ A❑ B ❑ C ChD <br /> iii) NOT YET APPLIED TO THE FUND,EXPECTED APPLICATION DATE: <br /> D. CONTACT PERSON: �r e tt t-1, er PHONE:��I z S 8 6/2 69 <br /> ADDRESS: (,0 )\ a1( far FAX: <br /> P. .� . $max 5140 <br /> 5.6-.. 2a,, . , C/A 914S13-ht1b4 <br /> 11.y1TYPE OF REQUEST(check appropriate boxes) <br /> [1.� PRE-APPROVAL s 221 9q 1. AMOUNT REQUESTED <br /> ❑ 3-BID REVIEW $ 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)RILL 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. -A complete signed copy of the proposed Investigation Workplan or Corrective Action Plan(CAP)(as defined and <br /> required by Article 11,Chapter 16,California Underground Storage Tank Regulations). Corrective Action Plans <br /> must include the required feasibility study and chosen cost effective alternative. <br /> 2. -�A signed copy of the oversight agency approval letter for the Workplan/CAP. <br /> c 3. A complete copy,of the Request for Bids,including all attachments. A list of all firms requested to bid must be <br /> tJ6 + included. <br /> (,4. Complete copies of all bids and other correspondence submitted in response to the Request for Bids. <br /> 5.iA time schedule,if not part of bid documents,anticipated for project initiation and duration. <br /> 6._,eA 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 <br /> evaluation of bids upon request. The following information must be submitted-1,2,3 AND 4 as described in Item A <br /> above. <br /> M. CERTIFICATION <br /> I cert under penalty of perjury that all information submitted with this request is complete and accurate and in accordance <br /> with all applicable laws and regulations. Must be siened by claimant or person desienated on the Authorised Representative <br /> Destenadon form <br /> ee // <br /> Signature Printed Name Date <br /> IV.Authorization for the Fund to give out youurl name and phone number to other claimants in your region as a reference for <br /> consultants and contractors. ❑ YES pl NO <br /> Signature Date _ <br />