CN-370000-LE807-4167635C.pdf
PDF 133 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 (FDEP), Office of Emergency Response (OER). The document authorizes emergency response services under Contract LE807 between FDEP and ACT, Inc. The incident involved a diesel fuel spill/discharge in Winter Haven, Polk County, Florida, reported on May 27, 2021, with On-Scene Coordinator Domenic LetoBarone overseeing the response.
The work authorization covers spill response and soil removal services valued at a fixed price of $4,900.00. Authorized activities include sweeping up contaminated absorbent materials into 55-gallon drums for disposal, using a vacuum unit to remove impacted soil from a storm drain, and replacing soil with clean backfill. The response involved four recovery technicians, response trucks, a vacuum truck, pickup/van, 55-gallon drums, an ER trailer, and work clothes. Diesel-impacted soils and absorbent material were profiled as waste via contractor. Funding was allocated under Project No. LE807, Organization Code 37040100000, Object Code 139900, Fund Category 212001, Category/Year 104132, with the full $4,900.00 amount authorized. The document was executed with signatures from FDEP Representative Domenic LetoBarone (May 28, 2021), Contractor Representative Jason Huffman (June 1, 2021), and OER Budget Representative Precious Boatwright.
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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, Inc. 2021-4I-67635C
LE807 Jason Huffman 5/27/2021
Diesel fuel theft / discharge from leaking 250-gal. tote Domenic LetoBarone
Lake Shipp Drive at Camellia Dr. SW 813-470-5920
Winter Haven Polk 813-299-3608
Please call to coordinate
An estimated 100-gallons + of diesel fuel spilled from a box truck with a tote of diesel. The spill impacted the road & storm drain.
Work Clothes
ER Trailer
Sweep up contaminated absorbent and place into 55-gallon drums for disposal. Use a VacUnit to remove the soil from the bottom of the storm drain. Replace soil with clean backfill. *** The storm drain is not a concrete vault, and has soil sides and a soil bottom.*** OER will perform OVA-PID screening.
4,900.00
LE807 37040100000 JC 139900 212001 104132 4900 00
Domenic LetoBarone 5/28/2021
Jason Huffman 6/1/2021
Precious Boatwright
Cory Dilmore
Diesel impacted soils and absorbent material
Use VacUnit to remove soil bottoms from inside impacted storm drain
Precious Boatwright Digitally signed by Precious Boatwright Date: 2021.06.16 15:44:29 -04'00'
Jason Huffman Digitally signed by Jason Huffman DN: cn=Jason Huffman gn=Jason Huffman c=United States l=US o=ACT ou=Emergency Response e=jhuffman@act.com Reason: I have reviewed this document Location:
Date: 2021-06-01 10:15-04:00
Domenic LetoBarone Digitally signed by Domenic LetoBarone Date: 2021.05.29 19:25:16 -04'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2021.06.02 10:17:52 -04'00'
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