CN-370000-LE809-4I71565S.pdf
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- Contract number
- LE809
- Issued by
- Florida
About this file
Work Authorization Form Summary
This is a supplemental Work Authorization Form (WAF) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER), dated November 21, 2024. The form authorizes work for Cliff Berry Inc. under Contract #LE809 in response to DEP Incident #2024-4I-71565 (FD096). The incident occurred on September 29, 2024, at 7600 Block of Detroit Avenue in Hudson, Pasco County, Florida. Jon Belcher serves as the On-Scene Coordinator with primary contact at 813-470-5908. The supplemental authorization was issued to cover excess costs resulting from a second hurricane that increased the impacted area.
The work involves spill response and soil removal activities related to waste oil and PCW (polychlorinated waste) totaling over 100 gallons. The scope includes personnel deployment (equipment operator with work clothes), equipment mobilization (backhoe or similar equipment), and PPE Level work clothes. The work is assigned on a fixed-price basis with a not-to-exceed estimate of $1,700.00. Funding is allocated from Project LE 809, Organization Code 3704 0100 000, Object Code 131545, Fund Category 099001, with approval documented through digital signatures from Jonathan Belcher (DEP Representative), Kelly Brandenburg (Contractor Representative), and Vickie Koenig (OER Budget Representative), all executed on November 20-21, 2024.
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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. 2024-4I-71565 (FD096)
LE809 Kelly Brandenburg 9/29/24
7600 Block of Detroit Ave Jon Belcher
7505 Detroit Ave 813-470-5908
Hudson Pasco 813-399-0581
Waste Oil and PCW 100+ gals
1 work clothes
Supplemental WAF for excess costs due to second hurricane increasing impacted area.
1,700.00
LE 809 3704 0100 000 FC 131545 099001 101492 1,700 00
Jonathan Belcher
Kelly Brandenburg 11/20/2024
Vickie Koenig 11/21/2024
Samuel Graves
Supplemental WAF
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.11.21 11:54:28 -05'00'
Kelly Brandenburg Digitally signed by Kelly Brandenburg Date: 2024.11.20 21:39:17 -05'00'
Jon Belcher Digitally signed by Jon Belcher Date: 2024.11.19 14:09:59 -05'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.11.21 13:03:51 -05'00'
File details come from the government source that posted it. Updated .