CN-370000-LE807-3I66233.pdf
PDF 242 KB Posted
- Contract number
- LE807
- Issued by
- Florida
About this file
Work Authorization Form Summary
This document is a Work Authorization Form (OER_13, Effective 7-01-2017) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER). The work authorization is executed between FDEP and ACT (contractor), with representation by Jason Huffman for ACT and Lina Ramirez for FDEP. The incident is located at Buckingham Road and Palm Beach Boulevard in Fort Myers, Lee County, Florida, under DEP Incident #2020-3I-66233, dated August 28, 2020.
The work authorization authorizes response activities for diesel contamination consisting of approximately four drums of contaminated soil requiring spill response, soil removal, and sampling services. The level of effort includes one recovery technician, one general scientist, a pickup or van, one stakebed truck, four 55-gallon drums, and PPE Level D equipment. The work scope encompasses backfill, sod, closure samples, and disposal activities, with analytical and disposal arrangements handled via contractor. The authorization is issued as a fixed-price work assignment with a not-to-exceed amount of $562.52, funded through Project No. LE807, Organization Code 37040100000, Object Code 139900, Fund Category 099001, and Account 101492. All required signatures were executed between December 15, 2020, and January 21, 2021.
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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: $___________________________
Funding Information: (information provided by OER budget rep., budget rep to sign after WAF executed, but prior to transmittal to F&A)
Project No. Organization Code EO Object Code Fund Category/Yr Amount
Approved:
DEP Representative: __________________________ Signature: _______________________________ Date: __________________
Contractor Rep: __________________________ Signature: ___________________________________ Date: __________________
OER Budget Rep: __________________________ Signature: __________________________________ Date: __________________
Deliverable will be reviewed and evaluated by the DEP Contract Manager to ensure appropriate documentation reviewed and/or provided and that the documentation submitted is complete, accurate, and submitted timely
ACT 2020-3I-66233
LE807 Jason Huffman 8/28/2020
Buckingham Rd. & Palm Beach Blvd. Lina Ramirez
Buckingham Rd. & Palm Beach Blvd. 239-344-5623
Fort Myers Lee 239-770-7418
Diesel, ~4 drums worth
D
General Scientist
1 stakebed truck
4,500
Lina Ramirez 12/15/2020
Jason Huffman 12/15/20
Melissa Woehle
Diesel Contaminated Soil
Backfill, Sod, Closure Samples, Disposal
Jason Huffman Digitally signed by Jason Huffman DN: cn=Jason Huffman gn=Jason Huffman c=United States l=US e=jhuffman@act.com Reason: I have reviewed this document Location:
Date: 2020-12-15 13:52-05:00
Lina Ramirez Digitally signed by Lina Ramirez Date: 2020.12.15 08:24:00 -05'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.12.21 15:07:55 -05'00'
01-21-2021______$ 562.52
LE807 37040100000 FC 139900 099001 101492 562 52
Kristin Gousse 1/21/21
File details come from the government source that posted it. Updated .