CN-370000-LE810-5I-65231.pdf
PDF 233 KB Posted
- Contract number
- LE810
- Issued by
- Florida
About this file
Work Authorization Form Summary
This is a Work Authorization Form (OER_13, effective 7-01-2017) issued by the Florida Department of Environmental Protection, Office of Emergency Response. The document authorizes Hulls Environmental to perform emergency spill response services related to incident 2020-5I-65231 at El Bethel Church Road in Grand Ridge, Jackson County, Florida. The primary contact for the Department of Environmental Response is C. Mark Sumner, and the contractor representative is Jesse Hixson. The incident involved a stolen tank spill occurring on 02/24/2010 containing approximately 75 gallons of diesel fuel.
The work authorization employs a fixed-price contract structure with a not-to-exceed estimate amount of $15,000, to be invoiced based on actual DEP daily sheets. Services include spill response activities with one supervisor, one recovery technician, and two equipment operators utilizing a pickup/van, backhoe, two roll-off containers, and personal protective equipment rated at Level 4. Analytical and disposal arrangements are handled via the contractor, with petroleum-impacted soils profiled as waste. Funding is allocated from Project No. LE810, Organization Code 37040000222, Object Code 139900, Fund Category/Year 10027, with the total authorized amount of $15,000.00. The work authorization was executed with approvals dated between February 28, 2020 and March 9, 2020.
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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 2020-5I-65231
LE810 Jesse Hixson 02/24/2010
El Bethal Church Road Stolen Tank Spill C. Mark Sumner
2427 El Bethel Church Rd 850-767-0046
Grand Ridge Jackson 850-251-1477
75 Gallons of Diesel Fuel
1 2
2 4
Estimate based on quote from Hulls. Actual invoicing from DEP daily sheets.
15,000
LE810 37040000222 ZC 139900 780001 10027 15000 00
C. mark Sumner 2/28/2020
Jesse Hixson 3/6/2020
Kristin Gousse 3/9/2020
Melissa Woehle
Petroleum impacted soils
Kristin Gousse Digitally signed by Kristin Gousse Date: 2020.04.09 14:21:11 -04'00'
Jesse Hixson Digitally signed by Jesse Hixson DN: cn=Jesse Hixson gn=Jesse Hixson c=US United States l=US United States o=Hull's Environmental Services, Inc ou=Panama City e=jhixson@hullsenvironmental.com Reason: I am the author of this document Location:
Date: 2020-03-06 07:24-06:00
C. Mark Sumner Digitally signed by C. Mark Sumner Date: 2020.02.28 09:48:03 -06'00'
Melissa Woehle Digitally signed by Melissa Woehle Date: 2020.04.09 14:25:57 -04'00'
File details come from the government source that posted it. Updated .