CN-370000-LE809-21-0323.pdf
PDF 213 KB Posted
- Contract number
- LE809
- Issued by
- Florida
About this file
This is a Work Authorization Form (OER_13) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response. The document authorizes work to be performed by Cliff Berry, Inc. under Contract #LE809 in response to the Piney Point incident (EFO 21-0323, Mission 00091) located at 13300 U.S. Highway 41 in Palmetto, Manatee County, Florida. The incident was authorized on April 2, 2021, with the Work Authorization Form executed on April 23, 2021. The On-Scene Coordinator was Cory Dilmore, with Jon Sandora serving as the contractor representative.
The work involves the deployment of a 2,800-gallon vacuum truck and a 5,000-gallon tanker to the Piney Point site for immediate response to handle non-hazardous wastewater. The contract work is classified as a fixed-price assignment with a total authorized amount of $24,000.00. The work scope includes two supervisory personnel, one recovery technician, two drivers, and operational equipment including a vacuum truck and pickup/van. Funding was allocated from Project Number LE809, Organization Code 37040100000, Object Code 139900, Fund Category 09901, and funding year 102557. The work was approved by DEP Representative Cory Dewayne Dilmore, OER Budget Representative Kristin Gousse, and Contractor Representative Jon Sandora on April 23, 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
Cliff Berry, Inc. EFO 21-0323 - Piney Point - Mission 00091
LE809 Jon Sandora 4/2/2021
Piney Point Cory Dilmore
13300 U.S. Hwy 41 850-245-2875
Palmetto Manatee 850-274-7462
Respond Immediately wastewater
4 work clothes
2 Drivers semi tractor w/ tanker
2,800 gal vac truck and 5,000 gal tank requested to deploy to Piney Point site in Mantee Co.
24,000.00
LE809 37040100000 FL 139900 09901 102557 24,000
Cory Dewayne Dilmore 4/23/2021
Kristin Gousse 4.23.21
Cory Dewayne Dilmore non-haz wastewater
Deploy vac truck and tanker to the Piney Point site in Manatee County.
Digitally signed by Kristin Gousse
Jon Sandora Digitally signed by Jon Sandora Date: 2021.04.23 09:47:07 -04'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2021.04.23 11:17:37 -04'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2021.04.23 11:17:53 -04'00'
File details come from the government source that posted it. Updated .