CN-370000-LE706-4I55755.pdf
PDF 226 KB Posted
- Contract number
- LE706
- 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. The document authorizes work to be performed by Cliff Berry, Inc. under Contract LE706 for incident 2016-4I-55755 occurring on July 5, 2016, in Polk City, Polk County, Florida. The work involves the response to an abandoned drum discovery at Brown Shinn Road, off Deen Still Road. The On-Scene Coordinator is Jeff Tobergte, with contact information provided for both office and mobile communications.
The contracted work consists of overpacking and transporting one 55-gallon drum containing partially solidified styrene resin into an 85-gallon over-pack container to a Treatment, Storage, and Disposal Facility (TSDF). The work assignment is structured as a fixed-price contract with an estimated amount of $2,075.00. The material is profiled as D001 Ignitable waste. The level of effort includes one supervisor and one recovery technician, a response truck with lift-gate capability, necessary cones, manifests, profiles, labels, and placards. Funding is allocated from Project LE706 under Organization Code 37040100000, Fund Category 099001, with Grant Module 102577. The work was authorized on July 8, 2016, and approved by Domenic LetoBarone (DEP Representative), Jon Sandora (Contractor Representative), and Amanda Hartsfield (OER Budget Representative) on the specified dates.
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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
Cliff Berry, Inc. 2016-4I-55755
LE706 Jon Sandora 7/5/2016
Abandoned resin drum Jeff Tobergte
Brown Shinn Road, off of Deen Still Road (813) 470-5954
Polk City Polk (813) 267-3521
✔ Please schedule for Monday (7/11/16) at 10:00 a.m.
✔ ✔ ✔ 1
1 x 55-gallon drum of partially solidified styrene resin. The drum will need to be placed into an 85-gallon over-pack.
1 x 85
Work Clothes, Leather gloves
Cones with liftgate
✔ manifest, profile, labels, placards over-pack 55-gallon drum into an 85, transport to disposal facility. Please bring a truck with a lift-gate.
✔ D001 Ignitable
2,075.00
LE706 37040100000 FL 139900 099001 102577 $2075. 00
Domenic LetoBarone Domenic LetoBarone Digitally signed by Domenic LetoBarone Date: 2016.07.08 14:36:41 -04'00' 7/8/16
Jon Sandora Jon Sandora Digitally signed by Jon Sandora DN: cn=Jon Sandora, o, ou, email=jsandora@cliffberryinc.com, c=US Date: 2016.07.08 14:49:33 -04'00' 7/8/16
Amanda Hartsfield Amanda Hartsfield Digitally signed by Amanda Hartsfield Date: 2016.07.11 12:53:29 -04'00' 7/11/16
Austin Hofmeister Austin Hofmeister Digitally signed by Austin Hofmeister Date: 2016.07.11 12:51:02 -04'00'
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