CN-370000-LE807-3C65476C.pdf
PDF 273 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 Office of Emergency Response. The form authorizes emergency response services for incident 2020-3C-65476C at 3355 N. Key Lane in North Fort Myers, Lee County. The contractor is ACT under Contract LE 807, with John Chroniak serving as the primary contact. The incident, dated March 28, 2020, was managed by Heidi Hoffman as the On-Scene Coordinator, with all required signatures obtained from departmental representatives, the contractor, and the budget representative by March 30, 2020.
The work authorization authorizes immediate spill response services for an estimated 10-25 gallons of gasoline contamination. The contractor is authorized to deploy one supervisor and one equipment operator using a response trailer and vacuum truck (with a note indicating a jet truck would be used instead to prevent lateral impacts). Services include analytical and disposal arrangements to be handled via the contractor. The work is assigned as fixed price with a not-to-exceed amount of $3,200.00. Funding is sourced from Project No. 37040000222, Organization Code ZC, EO 139900, Object Code 780001, Fund Category/Year 10027, with the $3,200.00 authorization date of March 30, 2020, and approved by OER Budget Representative Kristin Gousse on May 27, 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 708 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.
3,200.00
Heidi Hoffman March 29, 2020
John Chroniak
Heidi Hoffman Digitally signed by Heidi Hoffman Date: 2020.03.29 10:14:48 -04'00' re: _____________________________
Heidi Hoffman g y g y Da
03/29/2020
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.03.30 08:51:51 -04'00'
37040000222 ZC 139900 780001 10027 3200
Kristin Gousse 5/27/2020
File details come from the government source that posted it. Updated .