CN-370000-LE807-3I-65432.pdf
PDF 232 KB Posted
- Contract number
- LE807
- 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 (DEP), Office of Emergency Response. The form authorizes work to be performed by contractor A-C-T under Contract LE807. The incident, designated as 2020-3I-65432, occurred on 3/19/2020 at SR-70 & Denco Road in Lake Placid, Highlands County, Florida. The On-Scene Coordinator is Patricia Goense. The form was executed by DEP Representative Patricia Goense on 3/31/2020, Contractor Representative Jason Huffman on 3/31/2020, and OER Budget Representative Kristin Gousse on 5/27/2020.
The work authorization covers spill response and soil removal services related to approximately 20 gallons of diesel-contaminated soil. The scope includes field screening via OVA/PID analysis to be conducted by DEP. The Level of Effort includes one Supervisor, one Recovery Technician, two Equipment Operators, a Response Truck, Backhoe or Similar equipment, a 20-yard Roll-off Container, and PPE (work clothes). Analytical and disposal arrangements are to be handled via the contractor, with wastes profiled as Diesel Contaminated Soil. The work is assigned as fixed price with a not-to-exceed estimate amount of $10,000. Funding is allocated from Project LE807, Organization Code 37040000222, EO Code ZC, Object Code 139900, Fund 780001, Category/Year 10027, with an approved amount of $10,000.
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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
A-C-T 2020-3I-65432
LE807 Jason Huffman 3/19/2020
SR-70 & Denco Rd. Patricia Goense
27.20854, -81.24274 239-344-5608
Lake Placid Highlands 239-633-5437
Diesel contaminated soil ~20 gallons
1 20-yard
2 Work Clothes
10,000
LE807 37040000222 ZC 139900 780001 10027 10000
Patricia Goense 3/31/2020
Jason Huffman 3-31-20
Kristin Gousse 5/27/2020
Melissa Woehle
Diesel Contaminated Soil
DEP to conduct OVA/PID Field Screening
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.05.27 12:05:03 -04'00'
Jason Huffman Digitally signed by Jason Huffman DN: cn=Jason Huffman gn=Jason Huffman c=United States l=US e=jhuffman@act.com Reason: I have reviewed this document Location:
Date: 2020-03-31 09:04-04:00
Patricia Goense Digitally signed by Patricia Goense Date: 2020.03.30 09:33:17 -04'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.03.31 11:14:09 -04'00'
File details come from the government source that posted it. Updated .