CN-370000-LE807-3I-66233.pdf
PDF 162 KB Posted
- Contract number
- LE807
- Issued by
- Florida
About this file
This is a Work Authorization Form (OER_13) issued by the Florida Department of Environmental Protection, Office of Emergency Response, authorizing emergency response services from contractor ACT under Contract LE807. The form documents authorization for incident response activities at the Buckingham Road and Palm Beach Boulevard location in Fort Myers, Lee County, related to DEP Incident 2020-3I-66233, dated August 28, 2020, with Lina Ramirez serving as the On-Scene Coordinator.
The work authorization covers diesel-contaminated soil remediation services including spill response, soil removal, sampling, backfill, sod installation, lane closure management, closure sampling, and disposal activities. The contractor will provide three truck drivers, one general scientist, and one project manager, along with equipment including two stakebed trucks, two roll-off containers, and one disposal roll-off truck. The work is assigned as a fixed price authorization with a not-to-exceed amount of $18,500, charged to Project LE807, Organization Code 37040100000, Object Code 139900, Fund Category 099001, and funded through Account 101492. The form was executed with signatures from the DEP Representative (Lina Ramirez), Contractor Representative (Jason Huffman), and OER Budget Representative (Kristin Gousse) between October 13-22, 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 2020-3I-66233
LE807 Jason Huffman 8/28/2020
Buckingham Rd. & Palm Beach Blvd. Lina Ramirez
Buckingham Rd. & Palm Beach Blvd.
Fort Myers Lee
Diesel, ~50 gallons
1 2
1 D
3 truck drivers
1 General Scientist, 1 Project Manager; 1 Stakebed for pick up day, 1 stakebed for excavation day, 2 roll off trucks, 1 roll off truck for disposal day
18,500
LE807 37040100000 FC 139900 099001 101492 18500
Lina Ramirez
Jason Huffman 10-14-20
Kristin Gousse 10/22/2020
Melissa Woehle
Diesel Contaminated Soil
Backfill, Sod, Lane Closure, Closure Samples, Disposal
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.10.22 15:38:10 -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: 2020-10-14 10:09-04:00
Lina Ramirez Digitally signed by Lina Ramirez Date: 2020.10.13 11:38:12 -04'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.10.14 16:58:29 -04'00'
File details come from the government source that posted it. Updated .