CN-370000-LE810-4I65572C.pdf
PDF 175 KB Posted
- Contract number
- LE810
- 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, Office of Emergency Response. The form authorizes work under Contract LE810 with Hull's Environmental for incident 2020-4I-65572C. The On-Scene Coordinator is Domenic LetoBarone, and the incident occurred on April 17, 2020, in Lake Alfred, Polk County, Florida, at the corner of Clark Road and Lynchburg Road.
The authorized work involves excavation and remediation of approximately 25 gallons of used motor oil that was illegally dumped on a county right-of-way. Hull's Environmental will use a mini-excavator and roll-off container to remove oil-contaminated soils, backfill the excavation site, and install sod to prevent erosion due to roadway slope. The contaminated soils will be disposed of at Clark Environmental. The work is assigned as a fixed-price contract with a not-to-exceed amount of $3,500.00. Funding is allocated from Project LE810, Organization Code 3704000022, Object Code 139900, Fund 780001, Category/Year 10027. The work authorization was approved by DEP Representative Domenic LetoBarone, Contractor Representative Mike Bevacqua, and OER Budget Representative Kristin Gousse on April 24, 2020, and May 27, 2020, respectively.
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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
Hull's Environmental 2020-4I-65572C
LE810 Mike Bevacqua 4-17-2020
Lake Alfred used oil dumping Domenic LetoBarone
Corner of Clark Rd. at Lynchburg Rd. N 28.08758, W -81.75469 813-470-5920
Lake Alfred Polk 813-299-3608
Please call to schedule a date/time
~ 25 gallons of used motor oil was dumped on County Right-of-Way by an unknown party.
2 1
1 D
Equip. Op x 1 Mini-Excavator
Hull's will use a mini-excavator and a roll-off box to remove used oil impacted soils. The excavation will be back-filled and sod placed on top, due to the slope of the roadway to prevent washout. Impacted soils will be disposed of at Clark Env. *** Please call in locates*** tell them to look for the oil stain on the roadway near the above intersection.
3,500.00
LE810 3704000022 ZC 139900 780001 10027 $3,500.00
Domenic LetoBarone 4/24/2020
Mike Bevacqua 4/24/2020
Kristin Gousse 5/27/2020
Melissa Woehle
✔ Used oil contaminated soils
Excavate oil contaminated soils, backfill, sod area due to slope of road
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.05.27 12:06:10 -04'00'
Michael Bevacqua Digitally signed by Michael Bevacqua Date: 2020.04.24 10:13:44 -04'00'
Domenic LetoBarone Digitally signed by Domenic LetoBarone Date: 2020.04.24 16:36:47 -04'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.05.27 12:17:09 -04'00'
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