CN-370000-LE706-2I-67602.pdf
PDF 133 KB Posted
- Contract number
- LE706
- Issued by
- Florida
About this file
This is a Work Authorization Form (OER_13, effective July 1, 2017) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER). The form authorizes work to be performed by Cliff Berry Inc. under Contract No. LE706 in response to DEP Incident No. 2021-2I-67602. The incident occurred on May 18, 2021, at Avalon State Park in Fort Pierce, St. Lucie County, Florida. Jordan Luscier serves as the On-Scene Coordinator, with John Katzor as the contractor representative.
The work involves the recovery and disposal of an abandoned 55-gallon drum containing gasoline located in soft sand along the beach at Avalon State Park. The response requires two recovery technicians, a pickup or van, and a backhoe or similar equipment, with the drum to be transported to the nearest parking lot for recovery, transport, and disposal. The work is assigned as a fixed price of $901.00, which includes a $900 mobilization fee covering administrative costs, response activities, equipment, personal protective equipment, personnel, transport, vehicles, and supplies, plus additional disposal costs. Funding is provided through Project No. LE706, Organization Code 37040100000, Object Code 139900, Fund Category 212001, and Budget Category 104132. The work was approved by Cory Dewayne Dilmore on behalf of OER, with authorizing signatures from DEP Representative Jordan Luscier and Contractor Representative John Katzor, dated May 19-21, 2021.
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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 2021-2I-67602
LE 706 John Katzor 5/18/2021
Avalon State Park - Abandoned Drum Jordan Luscier
Avalon State Park 813-470-5791
Fort Pierce St. Lucie 813-267-3521
Gasoline, 55 gallons
C
Drum is located in soft sand along beach. Response organization should respond equipped with an All Terrain Vehicle (ATV) capable to transporting the drum to the nearest parking lot for recovery, transport, and disposal.
901.00
$900 mobilization fee (includes admin, response, eqiupment, PPE, personnel, transport, vehicles, and supplies), plus disposal costs.
LE706 37040100000 JC 139900 212001 104132 901 00
Jordan Luscier
John Katzor W/ Cliff Berry Inc 5-19-21
Precious Boatwright
Cory Dewayne Dilmore
Gasoline
✔ 1
Precious Boatwright Digitally signed by Precious Boatwright Date: 2021.06.16 15:01:05 -04'00'
John Katzor Digitally signed by John Katzor Date: 2021.05.21 11:39:52 -04'00'
Jordan Luscier Digitally signed by Jordan Luscier Date: 2021.05.21 13:04:20 -04'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2021.05.21 13:11:28 -04'00'
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