CN-370000-LE680-4I53903.pdf
PDF 225 KB Posted
- Contract number
- LE680
- Issued by
- Florida
About this file
This is a Work Authorization Form issued by the Florida Department of Environmental Protection's Office of Emergency Response. The document authorizes SWS Environmental Services to conduct emergency response work related to a gasoline release incident. The incident, designated as 2015-4I-53903C, occurred on October 8, 2015, at the I-4 exit 21 off-ramp (eastbound) in Plant City, Hillsborough County. Jamie Arleo serves as the On-Scene Coordinator for the Florida Department of Environmental Protection, with Eric Cooper representing SWS Environmental Services as the contractor representative.
The work scope includes spill response activities and soil removal with sampling conducted by SWS Environmental. The incident involves less than 25 gallons of gasoline onto soil. SWS will be responsible for obtaining DOT permits, conducting pre-burn operations, locating utilities, providing traffic control, handling cleanfill disposal, and collecting confirmatory samples. The work assignment is structured as a fixed-price cost estimate with a total authorized amount of $10,000.00. The work carries reimbursement potential with the option of responsible party reimbursement. Funding is allocated from Project No. LE680 with organization code 37040100000, object code 139900, and fund category 212001. All required signatures from the DEP representative, contractor representative, and OER budget representative were executed on October 13, 2015.
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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
SWS 2015-4I-53903C
LE680 Eric Cooper 10/08/15
Gasoline Release Jamie Arleo
I-4 exit 21 off-ramp (east bound) (813) 470-5954
Plant City Hilllsborugh (813) 267-3561
✔ Pending less than 25-gals of gasoline onto soil
1 Pending
1 ✔
Work Clothes
✔ Dump truck pending
SWS will handle the following: DOT permit, preburn, utility locates, MOT, cleanfill, confirmatory samples, and disposal.
✔ 10,000.00
LE680 37040100000 JC 139900 104132 212001 10,000 00
Jamie Arleo Arleo_J Digitally signed by Arleo_J Date: 2015.10.13 09:49:33 -04'00' 10/13/15
Eric Cooper Eric Cooper Digitally signed by Eric Cooper DN: cn=Eric Cooper, o, ou=SWS Environmental, email=eric.cooper@swsenvironmental.com, c=US Date: 2015.10.13 09:56:41 -04'00' 10/13/15
Amanda Hartsfield Amanda Hartsfield Digitally signed by Amanda Hartsfield Date: 2015.10.13 11:36:17 -04'00' 10/13/15
John Johnson John Johnson Digitally signed by John Johnson Date: 2015.10.13 11:08:52 -04'00'
File details come from the government source that posted it. Updated .