CN-370000-LE811-4C-70856.pdf
PDF 160 KB Posted
- Contract number
- LE811
- 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 (OER), authorizing emergency response work under Contract #LE811 with Cliff Berry Inc (CBI). The incident, numbered 2024-4C-70856, occurred at Bay Aristocrat Village in Clearwater, Pinellas County, Florida. The On-Scene Coordinator is Jon Belcher, with primary contact through Jon Sandora at CBI.
The authorized work involves emergency response to an abandoned drum suspected to contain 30-40 gallons of seawater and release agent mixture. The scope of work requires one recovery technician, one response truck, one overpack drum, and PPE Level D equipment. The work is assigned as a fixed-price authorization with a not-to-exceed amount of $1,300.00. Analytical and disposal arrangements are to be handled via the contractor. Funding is allocated from Project LE811, Organization Code 3704 0100 000, with the amount of $1,300.00 charged to Fund Category 102577 (Object Code 131545, Fund 0990001). The Work Authorization Form was executed on February 13-14, 2024, with digital signatures from all required parties including DEP Representative Jon Belcher, Contractor Representative Jon Sandora, and OER Budget Representative Vickie Koenig.
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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 (CBI) 2024-4C-70856
LE811 Jon Sandora
Bay Aristocrat Village Jon Belcher
18675 US Hwy 19N 813-470-5908
Clearwater Pinellas 813-399-0581 suspected 30-40 gal of seawater and release agent mix
D
LE811 3704 0100 000 FC 131545 0990001 102577 1,300 00
Vickie Koenig 2/14/2024
Samuel Graves
✔ 1
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.02.14 11:11:32 -05'00'
Jon Sandora Digitally signed by Jon Sandora Date: 2024.02.13 13:44:41 -05'00'
Jon Belcher Digitally signed by Jon Belcher Date: 2024.02.13 13:39:40 -05'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.02.14 09:17:47 -05'00'
File details come from the government source that posted it. Updated .