CN-370000-LE811-4C-69233.pdf
PDF 144 KB Posted
- Contract number
- LE811
- Issued by
- Florida
About this file
Work Authorization Form Summary
This is a Work Authorization Form (OER_13) issued by the Florida Department of Environmental Protection (FDEP), Office of Emergency Response (OER). The document authorizes Cliff Berry Inc to perform emergency response work under Contract LE811 for Incident 2022-4C-69233, dated August 3, 2022. The incident occurred at Beach Boulevard in Hudson, Pasco County, Florida. The On-Scene Coordinator (OSC) is Matthew Vincent, with direct contact at 813-470-5791. The work was authorized by DEP Representative Jonathan Belcher, Contractor Representative Nicole Collins, and OER Budget Representative Amanda Lanphere, with approvals signed between August 3 and September 9, 2022.
The work involves response to an abandoned drum containing beer line cleaner (full container) located at 6627 Beach Blvd, Hudson. The scope includes abandoned drum removal and utilization of 55-gallon drums for containment. Analytical and disposal arrangements are to be handled via the contractor. The work assignment is fixed price with a not-to-exceed estimate of $1,015. Funding is allocated from Project LE811, Organization Code 37040100000, with Object Code 139900, Fund Category 099001, Year 12577, and an amount of $1,015 with reference code 00. The deliverable will be reviewed and evaluated by the DEP Contract Manager to ensure complete, accurate, and timely documentation.
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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
Cliff Berry Inc 2022-4C-69233
LE811 John Sandora 8/3/22
Beach Blvd Hudson Drum Matthew Vincent
6627 Beach Blvd 813-470-5791
Hudson Pasco 813-267-3561
Beer line cleaner, full
LE811 37040100000 FL 139900 099001 12577 1015 00
Jonathan Belcher 8-3-22
Nicole Collins 8-8-22
Amanda Lanphere 8-9-22
Samuel Graves
✔ 1
Amanda Lanphere Digitally signed by Amanda Lanphere Date: 2022.09.09 09:28:47 -04'00'
Nicole Collins Digitally signed by Nicole Collins Date: 2022.08.09 08:44:10 -04'00'
Digitally signed by Jonathan Belcher Date: 2022.08.03 12:02:47 -04'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2022.09.08 15:14:16 -04'00'
File details come from the government source that posted it. Updated .