CN-370000-LE810-4I-71622.pdf
PDF 121 KB Posted
- Contract number
- LE810
- Issued by
- Florida
About this file
Work Authorization Form Summary
This is a Work Authorization Form (WAF) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER), authorizing work under Contract LE810 with Hulls Environmental Services, Inc. The form documents emergency response services for incident 2024-4I-71622, dated October 13, 2024, at a spill site located at 8316 Corney Drive in Port Richey, Pasco County, Florida. The incident was managed by On-Scene Coordinator (OSC) Jon Belcher, with contractor representative Jason Malluck and DEP representatives Michael Bevacqua and Vickie Koenig overseeing the authorization and funding.
The work authorization covers spill response operations involving the collection and transport of 3-4 drums (55 gallons each) of impacted absorbent materials. Personnel assigned include one supervisor and two recovery technicians, with equipment including a response truck, straight truck, and personal work clothes. Analytical and disposal arrangements were handled via the contractor. The work assignment was designated as fixed price with a not-to-exceed estimate amount of $3,000. Funding was allocated from Project LE 810, Organization Code 3704 0100 000, Object Code 131545, Fund Category 099001, with authorization code 102577. All required signatures were obtained, with final approval signed by Samuel Graves on December 2, 2024, completing the authorization chain from the DEP representative, contractor representative, and OER budget representative.
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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
Hulls Environmental Services, Inc. 2024-4I-71622
LE810 Jason Malluck 10/13/2024
Morehead Ln & Corney Dr Jon Belcher
8316 Corney Dr 813-470-5908
Port Richey Pasco 813-399-0581
3-4 (55) gal drums of impacted absorbent materials work clothes
3,000
LE 810 3704 0100 000 FC 131545 099001 102577 3,000 00
Jon Belcher 10/18/2024
Mike Bevacqua 10/18/2024
Vickie Koenig 11/22/2024
Samuel Graves
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.11.22 16:30:08 -05'00'
Michael Bevacqua Digitally signed by Michael Bevacqua Date: 2024.10.18 08:02:53 -04'00'
Jon Belcher Digitally signed by Jon Belcher Date: 2024.10.18 08:17:33 -04'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.12.02 13:44:12 -05'00'
File details come from the government source that posted it. Updated .