CN-370000-LE811-4I-71031.pdf
PDF 160 KB Posted
- Contract number
- LE811
- Issued by
- Florida
About this file
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 form authorizes work under an indefinite delivery contract between the DEP and Cliff Berry Inc (CBI), with Contract #LE811. The incident response is being managed by Jon Belcher (OSC) and Jon Sandora (Contractor Representative) for a site located at Saffold Road in Wimauma, Hillsborough County, Florida. The incident date is April 4, 2024, with DEP Incident #2024-4I-71031.
The work authorization addresses response and remediation services for an abandoned drum containing approximately less than 20 gallons of used motor oil in a damaged 200-gallon IBC tote at the specified location. The scope of work includes one supervisor and one recovery technician, one response truck, and one 55-gallon drum for offloading the damaged tote. The work is assigned as a fixed-price contract with a not-to-exceed estimate of $1,400. Analytical and disposal arrangements are handled via the contractor. Funding is allocated from Project LE 811, Organization Code 3704 0100 000, with Object Code 131545, Fund Category 0990001, and appropriation 102577. The total authorized amount is $1,400.00. The work authorization was approved and digitally signed by all required parties: DEP Representative Jon Belcher (April 10, 2024), Contractor Representative Jon Sandora (April 5, 2024), and OER Budget Representative Vickie Koenig (April 22, 2024).
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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) 2024-4I-71031
LE811 Jon Sandora 4/4/24
Saffold Rd Drum Jon Belcher
27.6585007, -82.3140462 813-470-5908
Wimauma Hillsborough 813-399-0581
<20 gallons used motor oil in IBC Tote.
D
Approximately less than 20 gallons of used oil in a 200 gal IBC tote. Tote is damaged but potentially transportable, 55 gal drum suggested to offload into.
1,400
LE 811 3704 0100 000 FC 131545 0990001 102577 1,400 00
Vickie Koenig 4/22/2024
Samuel Graves
✔ 1
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.04.22 10:24:01 -04'00'
Jon Sandora Digitally signed by Jon Sandora Date: 2024.04.05 07:28:12 -04'00'
Jon Belcher Digitally signed by Jon Belcher Date: 2024.04.10 11:13:21 -04'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.04.23 09:30:07 -04'00'
File details come from the government source that posted it. Updated .