CN-370000-LE681-4i-59422.pdf
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- Contract number
- LE681
- Issued by
- Florida
About this file
This Work Authorization Form (OER_13) is issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER). The document authorizes work under Contract #LE681 for an incident involving a diesel fuel spill at 5838 Parnell Road in Zolfo Springs, Hardee County, Florida. The contractor ACT is represented by Eric Jonsson, with Jeff Tobergte serving as the FDEP On-Scene Coordinator. The form was executed on January 4-8, 2018, with funding approval provided by OER budget representative Alexa Escobar.
The work authorization covers spill response and soil removal activities for a 20-50 gallon diesel fuel spill, with petroleum-contaminated soil to be profiled and disposed of accordingly. The scope includes utility checks, right-of-way permits, preburn activities, soil confirmation sampling, and OVA (Organic Vapor Analyzer) readings. Required personnel include one supervisor and truck driver, with two recovery technicians for soil work. Equipment specified includes response trucks, pickup vehicles, backhoes, roll-off containers (2-3 units), sampling gear at EPA Levels 1 and 2, and MOT (Maintenance of Traffic). The work is assigned as a fixed-price contract with a not-to-exceed estimate amount of $25,000.00. Funding is allocated from Project LE681, Organization Code 37040100000, with Object Code 139900 from Fund 099001, Category/Year 101492. The contractor is required to submit an Environmental Site Restoration Report (ESRR) to OER/Tampa upon completion.
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Text version
OER_13 (Effective 7-01-2017)
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
Contract Rate: ____________
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 Not to Exceed estimate amount: $___________________________
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
Amount
Approved:
DEP Representative: __________________________ Signature: _______________________________ Date: __________________
Contractor Rep: __________________________ Signature: ___________________________________ Date: __________________
OER Budget Rep: __________________________ Signature: __________________________________ Date: __________________
Deliverable will be reviewed and evaluated by the DEP Contract Manager to ensure appropriate documentation reviewed and/or provided and that the documentation submitted is complete, accurate, and submitted timely
ACT 2017-4i-59422
LE681 Eric Jonsson 11/28/17
DR Transport diesel spill Jeff Tobergte
5838 Parnell Rd 8134705954
Zolfo Springs Hardee 8132673521
20-50 gallons diesel fuel
2 2-3
1 work clothes truck driver, 1-2 sod, backfill dirt; OVA; ROW permit
Submit ESRR report to OER/Tampa when done.
25000.00
LE681 37040100000 FC 139900 099001 101492 25000 .00
Jeff Tobergte 1/4/2017
Eric Jonsson 1/5/18
Alexa Escobar 1/08/17 petroleum-contaminated soil
Utility check and ROW permit. Preburn + Soil confirmation samples and OVA readings; submit ESRR to OER/Tampa.
Alexa Escobar Paez Digitally signed by Alexa Escobar Paez Date: 2018.01.08 15:27:23 -05'00'
Eric Jonsson Digitally signed by Eric Jonsson Date: 2018.01.05 14:51:47 -05'00'
Jeff Tobergte Digitally signed by Jeff Tobergte Date: 2018.01.04 14:01:25 -05'00'
John Johnson Digitally signed by John Johnson Date: 2018.01.05 15:09:48 -05'00'
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