CN-370000-LE811-4I71327C.pdf
PDF 131 KB Posted
- Contract number
- LE811
- Issued by
- Florida
About this file
This is a Work Authorization Form (OER_13) issued by the Florida Department of Environmental Protection's Office of Emergency Response. The document authorizes work to be performed by Cliff Berry Inc. (CBI) under Contract #2024-4I-7132-7C at the Quail Meadow Road site in Thonotossassa, Hillsborough County, Florida. The incident was reported on July 8, 2024, with on-site coordinator Jon Belcher overseeing the response efforts.
The work authorization covers the removal and transport of two 55-gallon drums suspected to contain used oil (one full and one three-quarters full) from the site. CBI will provide one supervisor and one recovery technician using a response truck, with drums appearing to be transportable. The authorized work is classified as a fixed-price assignment with a not-to-exceed estimate amount of $1,500. Analytical and disposal arrangements will be handled via the contractor. Funding is allocated from Project No. LE811 with an Object Code of 131545, Fund Category 099001, and is authorized for $1,500 from Fund 102577. The work authorization was approved and executed on July 9, 2024, with digital signatures from Jon Belcher (DEP Representative), Jon Sandora (Contractor Representative), Vickie Koenig (OER Budget Representative), and Samuel Graves (Approver).
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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-71327C
LE811 Jon Sandora 7/8/24
Quail Meadow Rd Jon Belcher
28.11267, -82.21734 813-470-5908
Thonotossassa Hillsborough 813-399-0581
(2) 55 gal drums suspected to be used oil. Full and 3/4 full.
C
Drums appear to be transportable.
1,500
LE811 3704 0100 000 FC 131545 099001 102577 1,500 00
Jon Belcher 7/9/2024
Vickie Koenig 7/9/2024
Samuel Graves
✔ 2
Vickie Koenig Digitally signed by Vickie Koenig Date: 2024.07.09 10:09:58 -04'00'
Jon Sandora Digitally signed by Jon Sandora Date: 2024.07.09 06:52:14 -04'00'
Jon Belcher Digitally signed by Jon Belcher Date: 2024.07.08 16:48:49 -04'00'
Samuel Graves Digitally signed by Samuel Graves Date: 2024.07.09 10:50:03 -04'00'
Belcher_J Inserted Text
File details come from the government source that posted it. Updated .