CN-370000-LE706-7I55716C.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, authorizing work under an indefinite delivery vehicle contract. The contractor is Cliff Berry Inc, operating under Contract No. LE-706. The work authorization pertains to DEP Incident No. 2016-7I-55716C, dated July 7, 2016, located near Owl Street SW in Palm Bay, Brevard County, Florida. The On-Scene Coordinator (OSC) is Holly Fortune, with primary contact Paul Meding.
The work involves the consolidation and repackaging of gasoline materials, specifically consolidating 4-1 gallon jugs of gasoline and repackaging gasoline from a 55-gallon metal drum into smaller containers, with disposal of empty containers. The gasoline will be packed into a 30-gallon poly container with empty containers placed into 1-5 gallon buckets, and the 55-gallon drum will be shipped as a RCRA empty. The work assignment is valued at $2,000.00 as a cost estimate. The reimbursement potential includes both OPA-'90 reimbursement and Responsible Party Reimbursement. Funding is allocated under Project No. LE706, Organization Code 37040100000, Fund Category 099001, and Module/OCA 102577, with the approved grant amount of $2,000.00. The WAF was executed and approved on July 7-8, 2016, by representatives from DEP, Cliff Berry Inc, and the OER Budget office.
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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 2016-7I-55716C
LE-706 Paul Meding 7.7.16
Owl Holly FortuneP P near Owl Street SW (407) 897-4340
Palm Bay Brevard (407) 448-4585
✔ 7.7.16 - after SOSC samples and inspects drums consolidate 4-1 gallon jugs of gasoline, repackage gasoline from 55-gallon metal drum to smaller containers.
Dispose of empty containers
Gasoline packed into a 30-gallon poly. empty little containers into 1-5g bucket. 55-g drum shipped as RCRA empty
✔ gasoline
2,000.00
LE706 37040100000 FL 139900 099001 102577 2000. 00
Holly Fortune Fortune_H Digitally signed by Fortune_H Date: 2016.07.07 16:44:37 -04'00' 7/7/16
Paul Meding Paul Meding Digitally signed by Paul Meding Date: 2016.07.08 08:07:51 -04'00' 7/8/16
Amanda Hartsfield Amanda Hartsfield Digitally signed by Amanda Hartsfield Date: 2016.07.08 09:31:27 -04'00' 7/8/16
Austin Hofmeister Austin Hofmeister Digitally signed by Austin Hofmeister Date: 2016.07.08 09:53:28 -04'00'
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