CN-370000-LE619-4I55070.pdf
PDF 230 KB Posted
- Contract number
- LE619
- Issued by
- Florida
About this file
This is a Work Authorization Form (WAF) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER), dated May 17-18, 2016. The form authorizes work under an existing indefinite delivery contract with EQ Florida (US Ecology), Contract Number LE619. The incident, identified as 2016-4I-65070, occurred on April 8, 2016, at the ACT Facility located at 1875 W Main Street in Bartow, Polk County, Florida. The On-Scene Coordinator (OSC) is Jamie Arleo.
The work authorization covers the disposal of wastewater drums delivered to the US Ecology facility. Specifically, two 55-gallon polycarbonate drums containing industrial wastewater with trace amounts of oxamyl (below the Universal Treatment Standard of 0.082 µg/L) were transported to the facility for disposal on May 18, 2016, by 3:00 PM. The work is classified as a fixed-price assignment with an estimated amount of $400.00, with no reimbursement potential indicated. The materials are profiled as miscellaneous liquid, non-hazardous material. Funding was provided from Project Number LE619 using Organization Code 37040100000, Object Code 139900, Fund 099001, and Grant Amount 102577. The authorization was signed by Jamie Arleo (FDEP Representative), Daniel McAllister (Contractor Representative), and Amanda Hartsfield (OER Budget Representative) on June 16, 2016, with prior approval from John Johnson.
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Text version
Florida Department of Environmental Protection
Office of Emergency Response
WORK AUTHORIZATION FORM
Required Signatures: Adobe Signature or Original Ink Supplemental WAF
Contractor: ____________________________________ DEP Incident # ______________________ Contract #: ___________ Rep: ____________________ Incident Date _______________________ Site Name: ____________________________________ OSC: ______________________________ Location: ______________________________________ Phone: Office______________________ City: __________________County: _________________ Cell ________________________
Description of Work: Respond Immediately Call OSC to set date/time__________________________________
Spill Response Overpack Drums Transport drums to TSA Abandoned Drum:
Remove Soil Sampling Transport Drums to TSDF Analysis of samples collected by OER
Other:
Suspected Materials, and amounts: _____________________________________________________________________________________
Level of Effort: (Check all that apply) Use Subcontractor per OSC
Personnel Vehicles Equipment
Supervisor: ____ Response Truck Overpack Drums: Visqueen
Recovery Tech: ____ Straight Truck 55-gal. Drums: Roll-off Containers: ___________
Field Chemist: ____ Vacuum Truck Sampling Gear EPA Level 1 Vapor Detector
Equip. Oper.: ____ Pickup or Van Sampling Gear EPA Level 2 PPE Level: __________________
Other: ____________ Backhoe or Similar Other: ________________ MOT
Other: ____________ Other: ____________ Other:______________________
Comments: ___________________________________________________________________________________________________________
Analytical & Disposal Arrangements: (analytical will usually be listed on Chain-of-Custody or other form)
Via Contractor Via Subcontractor Other: ________________________________________________
Profile Wastes as:
Work Assignment Type: fixed price cost estimate est’d amount: $____________________________
Reimbursement Potential: no yes OPA-’90 reimbursement Resp. Party Reimbursement
Funding Information: (information provided by OER budget rep., budget rep to sign after WAF executed, but prior to transmittal to F&A)
Project No. Organization Code EO Object Code Fund Category/Yr
Module/ OCA Grant Amount
Approved:
DEP Representative: __________________________ Signature: _______________________________ Date: __________________
Contractor Rep: __________________________ Signature: ___________________________________ Date: __________________
OER Budget Rep: __________________________ Signature: __________________________________ Date: __________________ OER_13 (Effective 9-14-2015)
Prior Approval received by printed name: Signature
EQ Florida (US Ecology) 2016-4I-55070
LE619 Daniel Mcallister 04/08/16
ACT Facility Jamie Arleo
1875 W Main Street (813) 470-5954
Bartow Polk (813) 267-3561
✔ 05/18/16 - Drums will be delivered before 3:00 PM
✔ 2
✔ Disposal of wastewater drums delivered to facility.
(2) 55-gal poly drums of industrial wastewater with trace amounts of oxamyl
(below UTS at .082 ug/L).
✔ 2 work clothes✔
OER will transport the poly 55-gal containers to the US Ecology facility for disposal on 05/18/16.
✔ miscellaneous liquid, non-hazardous material
400.00
LE619 37040100000 FL 139900 099001 102577 400. 00
Jamie Arleo Arleo_J Digitally signed by Arleo_J Date: 2016.05.17 11:01:22 -04'00' 5/17/16
Daniel McAllister Daniel Mcallister Digitally signed by Daniel Mcallister Date: 2016.05.18 12:51:44 -04'00' 5/18/16
Amanda Hartsfiedl Amanda Hartsfield Digitally signed by Amanda Hartsfield Date: 2016.06.16 14:15:13 -04'00' 6/16/16
John Johnson John Johnson Digitally signed by John Johnson Date: 2016.06.16 14:29:24 -04'00'
File details come from the government source that posted it. Updated .