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i <br /> CALIFOR, A UNDERGROUND STORAGE TANK C. iNUP FUND <br /> COST PRE-APPROVAL REQUEST <br /> (Complete form, enclose required items, sign, date 8L retum ) <br /> TO: Fax: (916) 2274530 <br /> UST Cleanup Fund, 2014 T Street, Sacramento, CA 95814 <br /> I . CLAIM INFORMATION <br /> A. CLAIM NOV B. CLAIMANT <br /> C. CLAIM STATUS (complete appropriate section) <br /> LOC ISSUED FOR $ <br /> 1 LIST YES NO IF YES PRIORITY CLASS ❑ A ❑ B ❑ C ❑ D <br /> I' ON PRIORITY , <br /> NOT YET FILED, EXPECTED FILE DATE: <br /> CONTACT PERSON : PHONE: <br /> ADDRESS : FAX : <br /> II , TYPE OF REQUEST (check appropriate boxes) <br /> ❑ PRE-APPROVAL ❑ ,_ 3-BID REVIEW <br /> THE FOLLOWING DOCUMENTS ARE REQUIRED FOR THE SPECIFIED REQUEST, ALL DOCUMENTS <br /> REQUESTED MUST BE SUBMITTED IN THEIR ENTIRETY OR THE REQUEST ( S ) WILL BE RETURNED <br /> UNPROCESSED . <br /> A . REQUEST FOR PRE-APPROVAL OF PROPOSED COSTS - The following items are required before review <br /> and determination 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 /> 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 IP/CAP. <br /> 3 . _A complete copy of the Request For Bids, including all attachments . A list of all firms requested to <br /> bid must be included. <br /> 4 . _Complete copies of all bids and other correspondence submitted in response to the Request For bids . <br /> S . _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 estimated <br /> 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 - 11 21 3 AND 4 as described <br /> in Item A above. <br /> III . CERTIFICATION <br /> I certify under penalty of perjury that all information submitted with this request is complete and accurate and in <br /> accordance with all applicable laws and regulations. <br /> Signed <br /> Dated USTCF028.CST 03/95NEW <br />