CN-370000-LE706-1C-66539.pdf
PDF 231 KB Posted
- Contract number
- LE706
- Issued by
- Florida
About this file
Work Authorization Form Summary
This is a Work Authorization Form (OER_13, effective July 1, 2017) issued by the Florida Department of Environmental Protection's Office of Emergency Response to Cliff Berry Inc for emergency response services. The authorization documents work performed at Fort Clinch State Park in Fernandina Beach, Nassau County, Florida, in response to DEP Incident #2020-1C-66539 dated November 3, 2020. Key personnel include Kajani Cole as the On-Scene Coordinator, Yvonne Cerna as the contractor representative, and Kristin Gousse as the OER Budget Representative.
The work involved overpack and transport of one 55-gallon drum containing an unknown organic material (possibly mineral oil based on HazMat identification) classified as an abandoned drum, with transport to a Treatment Storage and Disposal Facility (TSDF). The work assignment was structured as a fixed-price contract with a not-to-exceed amount of $1,000. Personnel deployed included one supervisor and one equipment operator, utilizing a pickup/van and overpack drum equipment. Analytical and disposal arrangements were coordinated through the contractor. Funding was authorized under Project No. LE706, Organization Code 37040100000, Object Code 139900, Fund Category 099001, and assigned $1,000 from fund category 102577. All required signatures were executed digitally between November 5-6, 2020.
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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
Cliff Berry Inc 2020-1C-66539
LE706 Yvonne Cerna 11/03/2020
Fort Clinch State Park Kajani Cole
2601 Atlantic Ave (904)256-1692
Fernandina Beach Nassau (904)510-2643
11/06/2020 14:00
1 55 gallon drum. Unknown organic, based on HazMat ID Elite possibly mineral oil
LE706 37040100000 FL 139900 099001 102577 1000
Kajani Cole 11/5/2020
Yvonne Cerna 11/05/2020
Kristin Gousse 11/06/2020
Cory Dilmore
✔ 1
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.11.06 13:45:27 -05'00'
Yvonne Cerna Digitally signed by Yvonne Cerna Date: 2020.11.05 16:07:33 -05'00'
Kajani Cole Digitally signed by Kajani Cole Date: 2020.11.05 15:05:10 -05'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2020.11.06 13:29:35 -05'00'
File details come from the government source that posted it. Updated .