CN-370000-LE706-4I66215Z.pdf
PDF 232 KB Posted
- Contract number
- LE706
- Issued by
- Florida
About this file
This is a Work Authorization Form (OER_13, effective 7-01-2017) issued by the Florida Department of Environmental Protection, Office of Emergency Response. The form authorizes work under Contract LE706 between the State of Florida and Cliff Berry Inc. for emergency response services. The work authorization was executed on August 25, 2020, for incident 2020-4I-66215Z located at the Hillsborough Ditch on S 31st Avenue in Tampa, Hillsborough County, with Jordan Luscier designated as the On-Scene Coordinator.
The authorized work involves the transport of two 55-gallon drums full of used oil and 19 empty pails to a Treatment, Storage, and Disposal Facility (TSDF), classified as an abandoned drum response with materials profiled as used oil and empty pails. The work assignment was structured as a fixed price with a not-to-exceed estimate amount of $908. Resource allocation included one supervisor and one recovery technician, one response truck, six 55-gallon drums, and PPE Level D equipment, with labels and placards required. Analytical and disposal arrangements were handled via the contractor. Funding was allocated from Project No. LE706, Organization Code 37040100000, Object Code 139900, Fund Category 099001, for a total authorized amount of $908. All required signatures were obtained, including approval from the DEP Representative (Jordan Luscier, 8/25/20), Contractor Representative (Nicole Collins, 08/26/20), and OER Budget Representative (Kristin Gousse, 09/10/2020).
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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. 2020-4I-66215Z
LE706 Jon Sandora 8/25/20
Hillsborough Ditch Jordan Luscier
S 31 st Ave 813-267-3521
Tampa Hillsborough 813-267-3521
Two 55-gallon drums full of used oil and 19 empty pail
Level D
Labels
LE706 37040100000 FC 139900 099001 101492 908
Jordan Luscier 8/25/20
Nicole Collins0826-20 08/26/20
Kristin Gousse 09/10/2020
Melissa Woehle
Used Oil and Empty Pails
Bring all necessary labels, placards, and paperwork.
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.09.10 09:32:34 -04'00'
Nicole Collins Digitally signed by Nicole Collins Date: 2020.08.26 12:21:13 -04'00'
Jordan Luscier Digitally signed by Jordan Luscier Date: 2020.08.25 20:34:11 -04'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.09.09 13:07:58 -04'00'
File details come from the government source that posted it. Updated .