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-CIM CA -M 40=1 t.W1 �-G i-tTJ Qom•v 1 p.8:s <br /> 1 <br /> CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRI:-APPROVAL uQum- <br /> (Complete form,enclose required items,sign,date Bt re(u,n) <br /> TO: Fax: (916) 227-4530 <br /> UST Cleanup rand, 2014 T Street,Sacramento, CA 95814 <br /> t - <br /> I. CLAIM INFORMATION <br /> . l <br /> A. CLAIM NO. B. CLAIMANT <br /> C. CLAIM STATUS (complete appropriate section) <br /> LOC ISSUED FOR $ <br /> ON PRIORITY LIST YES NO IF YES, Pltl pry CLASS ❑A ❑n ❑C El D <br /> - r <br /> NOT YET FILED, EXPECTED FILE DATE: <br /> CONTACT PERSON; PHONF: _ <br /> ADDRESS: FAX: <br /> IL TYPE OF REQUEST (check appropriate boxes) <br /> PRE-APPROVAL 3-0ID REVIEW <br /> THE. FOLLOWING DOCUMENTS ARE REQUIRED FOR THE SPECIFIED REQUEST. ALL DOCUMEN"IS <br /> REQUESTED MLISi BE S1JEiMITTED IN THEIR ENTIRETY OR THE REQUEST(S) WILL BE RETURNED <br /> UNPROCESSED. <br /> A. R.DUFS1 FORTRF.,-APPROVAL OF PROP(15Ep J,$ The following items are required before review <br /> and detenulnation will be made by Fund staff. <br /> 1. __A complete signed copy of the proposed Investigation Workplan (IP) or Corrective Action Plan <br /> (CAP) (as defined and required by Article 11, Chapter 16, California Underground Storage Tank <br /> PCF111a1lons). Corrective Actlon Plans must Include the required feasibility study and chosen <br /> cost-effective alternative. <br /> 2. .. As]1"I let,cony of the oveesighI igenty approval letter for die IP/CAP. <br /> 3. . ­A complete copy of the Request For Rids, Including all attachment-i.- A list of all funis requested to <br /> Jaid must be Included. <br /> 4. • -._Complete copies of all hills and other correspondence submitted In response to the'Request for bids. <br /> 5. <br /> -...A lime schedule, if not part of bid documents, anticlpated for project Initiatlon and duratlon. <br /> G, _A delailed project budget, which includes breakdowns of staff/task/hour with associated estimated <br /> totals. <br /> B. 31IRI;F-0ID REVIEW/EVAf.iIATION/f.)ETERMINAT,jQ[� - Fund staff will assist any ttainwnt requesting an <br /> evaluation a(bids upon request. The following information must be submitted- 1, 2, 3 AND 4 as described <br /> to Item A above. <br /> Ili_ (FR7'IEjCo_kUQN ' <br /> . I <br /> I certify under penalty of perjury that all information submitted with this request Is complete and accurate and in <br /> accoldance%i 111 all alapllcable laws and regulations. <br /> Signed <br /> Dated 01110 on.M 03 MNtw <br /> r <br /> f <br />