CN-370000-LE810-5I-67282.pdf
PDF 131 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 (DEP), Office of Emergency Response (OER). The document authorizes work to be performed by Hull's Environmental Services, Inc. under Contract LE810 in response to DEP Incident #2021-5I-67282. The incident occurred on March 27, 2021, at the intersection of Douglas Ferry Road and Pate Pond Road in Caryville, Washington County, Florida, approximately 2,882 Pate Pond Road. The On-Scene Coordinator (OSC) is Joey Whibbs, with office contact at 850-595-0636 and cell contact at 850-258-4354.
The authorized work is classified as an abandoned drum response requiring immediate action with a scheduled date/time of March 28, 2021, at 10:00 a.m. The suspected material is diesel/herbicide in an amount of 60 gallons. The level of effort includes one recovery technician, a vacuum truck, and personal protective equipment (PPE) Level D. Analytical and disposal arrangements are managed via the contractor. The work assignment type is fixed price with a not-to-exceed estimate amount of $1,500. Funding is allocated from Project LE810, Organization Code 37040100000, Object Code 139900, Fund Category 099001, with a total amount of $1,500. All required signatures from the DEP representative, contractor representative, and OER budget representative were executed between March 28 and March 30, 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
Hull's Environmental 2021-5I-67282
LE810 Jesse Hixson 3/27/21
Intersection Douglas Ferry Road and Pate Pond Road Joey Whibbs
Approximately 2882 Pate Pond Road 850-595-0636
Caryville Washington 850-258-4354
3/28/21 10:00 am
Diesel/herbicide 60 gallons
D
1,500
LE810 37040100000 FL 139900 099001 102577 1500
Earl Whibbs 3/28/21
Jesse Hixon 3/28/21
Kristin Gousse 3/30/21
Cory Dilmore
Kristin Gousse Digitally signed by Kristin Gousse Date: 2021.03.30 12:17:41 -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: 2021-03-30 09:03-05:00
Earl J Whibbs Digitally signed by Earl J Whibbs Date: 2021.03.30 09:32:14 -05'00'
Cory Dewayne Dilmore Digitally signed by Cory Dewayne Dilmore Date: 2021.03.30 11:52:44 -04'00'
File details come from the government source that posted it. Updated .