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-- �G yam.-,i vv i ,.`ten: �i I JI'IL' `.V r' JVJ VVJ�• -. ___ . __ <br /> i t _ <br /> NOW <br /> CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign, date U return) COPY <br /> TO: I'le, Ha r Fax: (916) 227-4530 <br /> UST Cleanup Fund, 20,r4 T Street, Sacramento, CA 95814 <br /> I. CLAIM INFORMATION <br /> A. CLAiM NO. �g7� B. CLAIMANT <br /> C. CLAIM STATUS (complete appropriate section) <br /> 1) LOC ISSUED FORS I.dB©_ <br /> 11) ON PRIORITY LIST? OYES El NO IF YES, PRIORITY CLASS ❑ A ❑ B L 1 C ❑ D <br /> 111) NOT YET APPLIED TO THE FUND, EXPECTED APPLICATION DATE: <br /> D. CONTACT PERSON: ah Ur v T PHONE: ,Q�IYj 9yL—Z 37? <br /> ADDRESS: D a FAX: <br /> -C 4 G h <br /> 11. TYPE OF REOUEST (check anproorlate_boxes) <br /> PRE-APPROVALI/q AMOUNT REQUESTED <br /> ❑ 3-BID REVIEW PREFERRED BID (if applicable) <br /> THE FOLLOWING DOCUMENTS ARE REQUIRED FOR THE SPECIFIED REQUEST. ALL <br /> DOCUMENTS REQUESTED MUST BE SUBMITTED OR THE REQUEST(S) WiLL BE RETURNED <br /> UNPROCESSED. <br /> A. REO EST FOR PRE-APPROVAL- OF PROPOSED COSTS - The following items are required before review <br /> and determination will be made by Fund staff. <br /> I.,ZA 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 alternatiive. <br /> 2. signed copy of the oversight agency approval letter for the..Workplan/CAP. <br /> 3.jt A complete copy of Elie Request For Bids, Including all attachments. A list of all firms requested to bid <br /> must be included. <br /> 4.4AComplete copies of all bids and ocher correspondence submitted In response to the Request For bids. <br /> S.t/A time schedule, If not part of bid documents, anticipated for project initiation and duration. <br /> 6. detailed project budget, which includes breakdowns of staff/task/hour with associated estimated totals. <br /> B. THREE-BI b R V1W/ .VA IATiON/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 <br /> Item A above. <br /> ill. CERTIFICATJON <br /> I certify undeipenalty of perjury that all information submitted with this request is complete and accurate and in accordance with 0 <br /> applicable laws and regulations. <br /> Signature Date V51 cza._st o;v <br />