CN-370000-LE807-3I-65807.pdf
PDF 161 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 (DEP), Office of Emergency Response (OER). The document authorizes work under Contract #LE807 with contractor ACT in response to DEP Incident #2020-3l-65807. The incident occurred on June 3, 2030, at Interstate 75 Mile Marker 136 North in Fort Myers, Lee County, Florida. Key parties include OSC Lina Ramirez, DEP Representative Lina Ramirez, Contractor Representative Jason Huffman, and OER Budget Representative Kristin Gousse.
The work authorization covers spill response and soil removal activities involving the cleanup of approximately 50 gallons of diesel-contaminated soil. The scope includes mobilizing 1 General Scientist, 2 Truck Drivers, 1 Project Manager, 2 Roll-Off Trucks, 1 Stakebed Truck (2 Ton capacity), and 1 Utility Trailer. Equipment specified includes 2 roll-off containers, vapor detector, PPE Level D, and MOT. Analytical and disposal arrangements are handled via the contractor, with wastes profiled as diesel-contaminated soil and backfill. The work assignment is established on a fixed-price basis with a not-to-exceed estimate of $18,500. Funding is allocated from Project LE807, Organization Code 37040100000, Object Code 139900, Fund Category 099001, with the full amount of $18,500 authorized. The form was executed and approved on July 1-8, 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 2020-3I-65807
LE807 Ashley Shives 6/3/3030
I-75 MM 136 N Lina Ramirez
I-75 MM 136 median ; 26.3651 -81.4813 239-344-5623
Fort Myers Lee 239-770-7418
Diesel, 50 gallons
1 D
General Scientist
2 Truck Drivers, 1 Project Manager , 2 Roll Off Trucks, 1 Stakebed Truck (2 Ton), 1 Utility Trailer
18,500
LE807 37040100000 FC 139900 099001 101492 18500
Lina Ramirez 7/1/2020
Jason Huffman 7-6-20
Kristin Gousse 7-8-2020
Melissa Woehle
Diesel Contaminated Soil
Backfill
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.07.08 15:28:49 -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: 2020-07-06 11:27-04:00
Lina Ramirez Digitally signed by Lina Ramirez Date: 2020.07.01 13:33:30 -04'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.07.08 14:38:05 -04'00'
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