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CALIFORNIA UNDERGROUND STORAGE TANK CLEANUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign, date r& return) <br /> TO : Linda Sandborn Fax: (916) 227-4530 <br /> L CLAIM INFORMATION <br /> A. CLAIM NO. 008449 B. CLAIMANT Canaria's Car Wash <br /> C. CLAIM STATUS (complete appropriate section) <br /> i) LOC ISSUED FOR $_ 350,000.00 <br /> ii) ON PRIORITY LIST? OYES E] NO IF YES, PRIORITY CLASS 01 A M B LI C O D <br /> iii) NOT YET APPLIED TO THE FUND, EXPECTED APPLICATION DATE: <br /> D. CONTACT PERSON: Remo Canepa PHONE: (209) 478-5515 <br /> ADDRESS : 1536 Hunter Street FAX: (209) 478-6342 <br /> Stockton, CA 95207 <br /> H. TYPE OF REQUEST (check appropriate boxes) <br /> PRE-APPROVAL $ 481005e80 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) 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 . ✓❑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.EIA signed copy of the oversight agency approval letter for the Workplan/CAP. <br /> 3 .0✓ A complete copy of the Request for Bids, including all attachments. A list of all firms requested to bid must be <br /> included. <br /> 4.0✓ Complete copies of all bids and other correspondence submitted in response to the Request for Bids. <br /> 5 .QA time schedule, if not part of bid documents, anticipated for project initiation and duration. <br /> 6.0✓ A 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 trust be submitted - 11213 AND 4 as described in Item <br /> A above. <br /> 111. CERTIFICATION <br /> I certi . , under penalty qfpcjrjury that all in o -nation sal matt d with this request is complete and accurate and in accordance withall <br /> "pplicable taws and rcTalations. I7rst b e rvr ed by c! _ r t or erven desienated an the Anthoriri ed RereseTtative Desinnetioris <br /> KJA <br /> c_mo d � � YtePa L - x3 uI <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 reference <br /> for consultants F nd .Qntractors. 171YES LLQ NO <br /> Signature Date <br />