CN-370000-LE810-5I-72476.pdf
PDF 160 KB Posted
- Contract number
- LE810
- Issued by
- Florida
About this file
This Work Authorization Form (OER_13, effective July 1, 2017) is issued by the Florida Department of Environmental Protection's Office of Emergency Response to authorize emergency response work. Hull's Environmental Services is the contractor performing work under Contract #LE810, with Jesse Hixson serving as the contractor representative. The incident, identified as DEP Incident #2025-5I-72476, occurred on March 23, 2025, at 4347 FL-273 in Cottondale, Florida (Jackson County). Stephanie Kindos is the On-Scene Coordinator for the Florida Department of Environmental Protection, with contact information provided for both office and field coordination.
The authorized work consists of spill response activities, soil removal, and sampling related to a diesel spill of 50 gallons classified as petroleum-contaminated soil, non-hazardous. The scope includes one supervisor, two recovery technicians, and one field chemist, utilizing a response truck, pickup or van, backhoe or similar equipment, roll-off containers (2), vapor detector, and personal protective equipment (Level D). Analytical and disposal arrangements are managed via the contractor, with waste profiled as petroleum-contaminated soil, non-hazardous. The work assignment is designated as fixed price with a not-to-exceed estimate of $20,000. Funding is allocated from Project No. LE 810, Organization Code 3704 0100 000, Object Code 131545, Fund 099001, Category/Year 101492, with an approved amount of $20,000. All required signatures from the DEP Representative (Stephanie Kindos), Contractor Representative (Christina Hiers), and OER Budget Representative (Vickie Koenig) were executed on June 30, 2025.
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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
Christina Hiers 6/30/25
Hull's Environmental Services 2025-5I-72476
LE810 Jesse Hixson 3-23-25
30.88356724 x -85.47414456 Stephanie Kindos
4347 FL-273, Cottondale FL, 32431 850-767-0052
Cottondale Jackson 850-210-5945
By 4-23-25
Diesel, 50 gallons
2 2
D
PID/OVA
20,000
LE 810 3704 0100 000 FC 131545 099001 101492 20,000 00
Stephanie Kindos 6-30-25
Vickie Koenig 6/30/2025
Samuel Graves
✔ petroleum contaminated soil, non hazardous
Emergency Response Action per 62-780.500 F.A.C.
Vickie Koenig Digitally signed by Vickie Koenig Date: 2025.06.30 13:20:29 -04'00'
Christina Hiers Digitally signed by Christina Hiers DN: cn=Christina Hiers gn=Christina Hiers c=US United States l=US United States o=Hull's Environmental Services ou=PC Office e=chiers@hullsenvironmental.com Reason: I am the author of this document Location:
Date: 2025-06-30 11:58-05:00
Stephanie Kindos Digitally signed by Stephanie Kindos Date: 2025.06.30 09:20:51 -05'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2025.06.30 14:30:48 -04'00'
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