CN-370000-LE807-3C65476.pdf
PDF 261 KB Posted
- Contract number
- LE807
- 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's Office of Emergency Response. The document authorizes work performed by contractor ACT (LE 807) under contract LE 807, with John Chroniak serving as the contractor representative. The incident (DEP Incident #2020-3C-65476C) occurred on March 28, 2020, at 3355 N. Key Lane in North Fort Myers, Lee County, Florida, with Heidi Hoffman designated as the On-Scene Coordinator.
The work authorization covers immediate spill response services for a gasoline spill involving 10-25 gallons. The contractor mobilized one supervisor and one equipment operator, utilizing a response trailer and jet truck (rather than a standard vacuum truck to prevent lateral impacts). The work is authorized as a fixed-price contract with a not-to-exceed estimate of $1,300.00. Analytical and disposal arrangements were handled via the contractor. Funding for this work was allocated from Project LE807, Organization Code 37040100000, Object Code 139900, Fund Category 099001. The work authorization was executed and signed by the DEP Representative (Heidi Hoffman) and Contractor Representative (John Chroniak) on May 19, 2020, with final budget approval from OER Budget Representative Kristin Gousse on June 22, 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
ACT 2020-3C-65476C
LE 807 John Chroniak March 28, 2020
N. Key Ln, Storm Drain Heidi Hoffman
3355 N. Key Ln. (239) 344-5684
North Fort Myers Lee (239) 872-2323
Gasoline, 10-25 gallons
1 D
Response trailer
Using jet truck instead of vacuum truck in case of lateral impacts.
1300.00
Heidi Hoffman May 19, 2020
John Chroniak May 19, 2020
Heidi Hoffman Digitally signed by Heidi Hoffman Date: 2020.05.19 11:33:37 -04'00'
Melissa Woehle Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.06.19 16:48:47 -04'00'
LE807 37040100000 FC 139900 099001 1300
Kristin Gousse June 22, 2020
File details come from the government source that posted it. Updated .